WILDERNESS & ENVIRONMENTAL MEDICINE, 25, 56–59 (2014)
CASE REPORT
Where Wilderness, Medicine, Technology, and Religion Collide Lori Weichenthal, MD; Sameir Alhadi, MD From the Medical Education and Research Center, University of California-San Francisco, Fresno, CA.
We report a case of a man injured in Yosemite National Park (YNP) whose use of technology and refusal of medical care, based on his Christian Science religious beliefs, created multiple challenges to the providers working to rescue and care for him. This case illustrates how our increasingly diverse and complex world requires flexibility and openness to provide the optimal care, both in the wilderness and in the front country. Key words: search and rescue, technology, trauma, ethics, refusal of care, religion
Introduction Yosemite Search and Rescue (YOSAR) was formally established in 1974 to respond to emergencies within Yosemite National Park (YNP).1,2 In 2012, YOSAR responded to more than 245 incidents, including 15 major search and rescue incidents.3 One of these major incidents occurred in June 2012, when YOSAR came to the aid of a man who sustained traumatic injuries while hiking near Illilouette Falls in YNP. The subject’s refusal of medical care because of his Christian Science religious beliefs created many challenges to those seeking to help him, both in the wilderness setting and once he reached definitive medical care. We hope to shed light on the quarrels that can sometimes arise when the wilderness, medicine, technology, and religion collide. Case Report On June 28, 2012, a 65-year-old man set out alone to hike in Yosemite. The subject was a regular visitor to the park and was reportedly in excellent physical condition. Before setting off on his trek, he left a voice mail for his wife indicating his planned route. As a backup method of communication, he also sent a text to his wife with his plans for the day. She was in the valley of YNP, Corresponding author: Lori Weichenthal, MD, Medical Education and Research Center, University of California-San Francisco, 155 N. Fresno Street, Suite 206, Fresno, CA 93701 (e-mail: [email protected]. edu).
attending an art class. He then set off from the Lower Pines Campground in Yosemite Valley (Figure 1). Starting his off-trail hike at the junction of the Merced River and Illilouette Creek he began his ascent toward Illilouette Falls. Four hours into his hike, he encountered steep Class 5 terrain (technical climbing requiring the use of rope and belaying) near Glacier Point. When climbing over a large boulder, he lost his footing and fell down a rock wall, tumbling approximately 30.5 m (100 feet). He came to a halt on a granite ridge near the base of the Illilouette Falls. The subject landed on his right side and suffered intense pain in his neck, right hip, and lower back. He lay on his back, and could not move. The subject quickly surmised that his choice to venture off standard trails lessened his chance of being discovered by fellow hikers. At some point, he checked his cell phone, and upon discovering that he had service, he first attempted to call his wife. In a 30-minute period, he left 3 messages for her, all without an answer. He also sent an “SOS” as a text message to 911 during this time period. In reply, he received a standardized text message asking him to make a voice call to 911 as text services were not available. The subject never accessed 911 via a voice call. Our subject’s wife never received any of his calls as she had turned her phone off during her art class. When she finally turned her phone on, nearly an hour after his fall, she discovered she had messages from her husband but could not access them because of her cell phone coverage. She called her son, who was able to access her cell phone voice mail remotely and determine that our
Where Wilderness, Medicine, Technology, and Religion Collide
57
Figure 1. Map of Yosemite Valley. Red squares illustrate the start of subject’s hike and where he became injured.
subject was in need of assistance. His wife was then able to contact volunteers at the Lower Pines Campground who notified park rangers and YOSAR. Rescuers were then able to talk with our subject on his cell phone, and near sunset, a team of 3, including a park medic, headed up the Illilouette drainage in search of him. Park medics are park rangers with specialty medical training that is similar to an Advanced Emergency Medical Technician (AEMT) but with an expanded pharmacological and procedural scope of practice.4 When the rescuers made contact with our subject, it was after 8:00 PM and nearly dark. On initial survey they noted he had severe back and leg pain and an open finger fracture avulsion. Owing to the severity of his injuries and the impending nightfall, rangers were unable to transport the patient and made the decision to camp overnight. They placed him in a vacuum body splint to maintain motion restriction and to help stabilize his injuries (Figure 2). Rangers stayed with him overnight. During this time, the subject refused all medical treatment outside of the stabilization provided by the vacuum body splint, citing his Christian Science religious beliefs. Care that he refused included the placement of an IV and parenteral administration of isotonic fluids, antibiotics, and pain medications. He also refused all oral medications but did accept food and water. At sunrise, a flight crew short hauled the subject out of the backcountry via helicopter. A short haul is defined as a transport of one or more persons suspended beneath a helicopter (Figure 3). Crews then rendezvoused with a ground ambulance unit, and he was transported to the
Yosemite Medical Clinic where a medical evaluation was performed. At the Yosemite Medical Clinic, the subject continued to refuse medical interventions such as blood work, monitoring, antibiotics, wound care, and further splinting. Care providers at the clinic offered him the option of signing out against medical advice. However, when he attempted to stand up and walk, he was unable to do so, and the staff convinced him to accept transport to the closest Level 1 trauma center, Community Regional Medical Center (CRMC), in Fresno, California. During the 2-hour transport to CRMC, the subject continued to refuse most medical interventions including an IV or analgesics. Agreeing to only be immobilized and have basic wound dressings, he repeatedly conveyed to his
Figure 2. Example of a vacuum body splint.
58
Figure 3. Demonstration of a short haul rescue, Sequoia Kings Canyon National Park (used with permission by Dr Weichenthal).
medical providers that he was a devout Christian Scientist and that any other interventions went against his religious beliefs. The subject was a Glasgow Coma Scale (GCS) of 15 throughout his prehospital course, and his vital signs were stable. On arrival to CRMC, the emergency medicine and trauma surgery teams evaluated him. His airway, breathing, and circulation were intact, and he had a GCS of 15. His vital signs included a heart rate of 62 beats/min, a blood pressure of 116/62 mm Hg, and a respiratory rate of 14 breaths/min. He was afebrile. He denied loss of consciousness. He also denied any allergies to medications, and stated he had no prior medical or surgical history. His examination revealed several deep scalp lacerations, midline cervical tenderness, an open avulsion fracture to his left fourth digit, and an abrasion with moderate sized hematoma to his right flank and hip. He was unable to flex or extend his right lower extremity because of pain and could not ambulate. The subject continued to refuse placement of an IV and also refused a tetanus injection or antibiotics for his visibly open finger fracture. He stated to one provider after refusing closure of his scalp wounds and finger avulsion that through prayer his body would heal itself and that his fractures will heal and his infections would clear. Despite his refusal of any therapeutic intervention, our subject was agreeable to have any necessary imaging studies performed and was open to consultation with specialists, but wanted to have an active role in deciding what, if any, treatments or interventions were to be done.
Weichenthal and Alhadi His head computed tomography (CT) scan was negative for acute hemorrhage. His CT cervical spine was notable for a fifth cervical vertebral fracture at the right posterior pedicle that extended into the inferior facet and lamina. Abdominal and pelvic scans were negative for solid organ injury but did show a comminuted fracture of his right sacral iliac wing. A magnetic resonance image of his lumbar spine was ordered to evaluate right lower extremity weakness and was notable for a contusion along his sacral bone. Plain radiographs of his left hand showed an open tuft fracture of his fourth digit. At this point neurosurgery, orthopedic surgery, hand surgery, and social work were consulted, and the patient was admitted to the trauma surgery service. The subject refused many commonly used evaluations for trauma patients including serial hemoglobin blood draws, enoxaparin for deep vein thrombosis prophylaxis, and general nursing wound care. During his hospital stay, providers worked with him to provide the best possible care within the limits of his religious beliefs. He did participate with physical therapy and was discharged on hospital day 4 with a front wheel walker and follow-up with care providers in his hometown. Our subject was lost to follow-up once he returned to his home outside of the state of California. He was not billed for the search and rescue effort, as YOSAR does not charge for their services, but he was billed for the emergency medical services (EMS) care, his visit to the Yosemite Clinic, and his stay at CRMC. His healthcare insurance covered the majority of the costs for his hospitalization at CRMC; we do not have access to information regarding whether the costs of his EMS and clinic care were covered. Discussion This case represents a unique intersection of the wilderness, medicine, technology, and religion. Our subject, who was reportedly an experienced hiker, made the decision to hike off-trail with minimal supplies and, when he became injured, reached for his cell phone. He was extremely lucky to have cell phone service at the location where he was injured, but even so, the way he sought to access help (calling family and texting 911) delayed officials’ awareness of his accident. He and his rescuers had to spend the night in the wilderness before transport to definitive care. Many recent papers have sought to define the relationship between technology and the wilderness.5–7 These documents have suggested that we need to be aware of the dangers of technology damaging the very qualities that we seek from our experience in the wilderness including the opportunity to revel in natural awe, beauty,
Where Wilderness, Medicine, Technology, and Religion Collide and solitude. At the same time, it has shown that people who believe that technology increases safety in the wilderness may be more willing to take risks.8 Layered on top of this debate regarding the appropriate interaction between the wilderness and technology was our subject’s religious beliefs. He described himself as a devout Christian Scientist. Based on his personal beliefs, he refused multiple treatments that he was offered in the wilderness, prehospital, and hospital settings. Christian Science is a system of religious thought first described in 1875 by Mary Baker Eddy in her book Science and Health, which continues to be one of the religion’s central texts. Adherents espouse a radical form of philosophical idealism in which spiritual reality is the only reality and the material world, including sickness and death, is an illusion.9 Given this belief that sickness is an error of the mind, Christian Scientists have traditionally turned to prayer and spiritual healers for the treatment of illness or injury.10 This belief has come in conflict with mainstream society, as evidenced by several high-profile cases in which parents refused medical care for their children.11 Autonomy is one of the fundamental guidelines of medical ethics and includes a patient’s right to refuse medical treatment that the care provider may believe is essential. Whereas in the hospital setting such refusal of care does not usually endanger the care providers or other patients, in austere settings with limited resources it has the potential to do so. On the same day that our subject was being rescued, there were 16 other 911 calls for medical service in YNP. During that same 24-hour period, there were only 7 park medics on duty. Three rescuers, including 1 park medic, spent 14 hours with our subject and placed themselves at risk to locate, stabilize, spend the night with, and ultimately extricate him. The advanced medical skills of the park medic were all refused by the patient. This care provider’s abilities might have been better used by other people who found themselves injured or ill in YNP during that period.
59
This case displays the complexity of all human interactions. We may view the wilderness as a place of simplicity and clarity, but as human beliefs and technology become more entwined in these regions that we have reserved as austere sanctuaries, we will need to be more aware of how humans, the wilderness, medicine, technology, and our personal religious beliefs interact. References 1. Boore SM, Bock D. Ten years of search and rescue in Yosemite National Park: examining the past for future prevention. Wilderness Environ Med. 2013;24:2–7. 2. Fimrite P. United States honors Yosemite search and rescue ranger. San Francisco Chronicle. October 30, 2008. 3. Search and Rescue: Lessons from the Field. Available at: http://www.nps.gov/yose/blogs/psarblog.htm. Accessed January 28, 2013. 4. Kaufman TI, Knopp R, Webster T. The Parkmedic Program: prehospital care in the national parks. Ann Emerg Med. 1981;10:156–160. 5. Shultis J. The impact of technology on the wilderness experience: a review of common themes and approaches in three bodies of literature. USDA Forest Service Proceedings. 2012:110–118. 6. Borrie WT. The impacts of technology on the meaning of wilderness. Proceeding of Sixth World Congress Symposium on Research, Management, and Allocation. 1998: 87–88. 7. Pohl S. Technology and wilderness experience. Environ Ethics. 2006;28:147–163. 8. Pope K, Martin SR. Visitor perceptions of technology, risk and rescue in wilderness. Int J Wilderness. 2011;17:19–26, 48. 9. Schoepflin RB. Christian Science on Trial: Religious Healing in America. 1st ed. Baltimore, MD: Johns Hopkins University Press; 2002. 10. Benson H, Dusek JA. Self-reported health and illness and the use of conventional and unconventional medicine and mind/body healing by Christian Scientists and others. J Nerv Ment Dis. 1999;187:539–548. 11. May L. Challenging medical authority: the refusal of treatment by Christian Scientists. Hastings Cent Rep. 1995;25:15–21.
CASE REPORT
Where Wilderness, Medicine, Technology, and Religion Collide Lori Weichenthal, MD; Sameir Alhadi, MD From the Medical Education and Research Center, University of California-San Francisco, Fresno, CA.
We report a case of a man injured in Yosemite National Park (YNP) whose use of technology and refusal of medical care, based on his Christian Science religious beliefs, created multiple challenges to the providers working to rescue and care for him. This case illustrates how our increasingly diverse and complex world requires flexibility and openness to provide the optimal care, both in the wilderness and in the front country. Key words: search and rescue, technology, trauma, ethics, refusal of care, religion
Introduction Yosemite Search and Rescue (YOSAR) was formally established in 1974 to respond to emergencies within Yosemite National Park (YNP).1,2 In 2012, YOSAR responded to more than 245 incidents, including 15 major search and rescue incidents.3 One of these major incidents occurred in June 2012, when YOSAR came to the aid of a man who sustained traumatic injuries while hiking near Illilouette Falls in YNP. The subject’s refusal of medical care because of his Christian Science religious beliefs created many challenges to those seeking to help him, both in the wilderness setting and once he reached definitive medical care. We hope to shed light on the quarrels that can sometimes arise when the wilderness, medicine, technology, and religion collide. Case Report On June 28, 2012, a 65-year-old man set out alone to hike in Yosemite. The subject was a regular visitor to the park and was reportedly in excellent physical condition. Before setting off on his trek, he left a voice mail for his wife indicating his planned route. As a backup method of communication, he also sent a text to his wife with his plans for the day. She was in the valley of YNP, Corresponding author: Lori Weichenthal, MD, Medical Education and Research Center, University of California-San Francisco, 155 N. Fresno Street, Suite 206, Fresno, CA 93701 (e-mail: [email protected]. edu).
attending an art class. He then set off from the Lower Pines Campground in Yosemite Valley (Figure 1). Starting his off-trail hike at the junction of the Merced River and Illilouette Creek he began his ascent toward Illilouette Falls. Four hours into his hike, he encountered steep Class 5 terrain (technical climbing requiring the use of rope and belaying) near Glacier Point. When climbing over a large boulder, he lost his footing and fell down a rock wall, tumbling approximately 30.5 m (100 feet). He came to a halt on a granite ridge near the base of the Illilouette Falls. The subject landed on his right side and suffered intense pain in his neck, right hip, and lower back. He lay on his back, and could not move. The subject quickly surmised that his choice to venture off standard trails lessened his chance of being discovered by fellow hikers. At some point, he checked his cell phone, and upon discovering that he had service, he first attempted to call his wife. In a 30-minute period, he left 3 messages for her, all without an answer. He also sent an “SOS” as a text message to 911 during this time period. In reply, he received a standardized text message asking him to make a voice call to 911 as text services were not available. The subject never accessed 911 via a voice call. Our subject’s wife never received any of his calls as she had turned her phone off during her art class. When she finally turned her phone on, nearly an hour after his fall, she discovered she had messages from her husband but could not access them because of her cell phone coverage. She called her son, who was able to access her cell phone voice mail remotely and determine that our
Where Wilderness, Medicine, Technology, and Religion Collide
57
Figure 1. Map of Yosemite Valley. Red squares illustrate the start of subject’s hike and where he became injured.
subject was in need of assistance. His wife was then able to contact volunteers at the Lower Pines Campground who notified park rangers and YOSAR. Rescuers were then able to talk with our subject on his cell phone, and near sunset, a team of 3, including a park medic, headed up the Illilouette drainage in search of him. Park medics are park rangers with specialty medical training that is similar to an Advanced Emergency Medical Technician (AEMT) but with an expanded pharmacological and procedural scope of practice.4 When the rescuers made contact with our subject, it was after 8:00 PM and nearly dark. On initial survey they noted he had severe back and leg pain and an open finger fracture avulsion. Owing to the severity of his injuries and the impending nightfall, rangers were unable to transport the patient and made the decision to camp overnight. They placed him in a vacuum body splint to maintain motion restriction and to help stabilize his injuries (Figure 2). Rangers stayed with him overnight. During this time, the subject refused all medical treatment outside of the stabilization provided by the vacuum body splint, citing his Christian Science religious beliefs. Care that he refused included the placement of an IV and parenteral administration of isotonic fluids, antibiotics, and pain medications. He also refused all oral medications but did accept food and water. At sunrise, a flight crew short hauled the subject out of the backcountry via helicopter. A short haul is defined as a transport of one or more persons suspended beneath a helicopter (Figure 3). Crews then rendezvoused with a ground ambulance unit, and he was transported to the
Yosemite Medical Clinic where a medical evaluation was performed. At the Yosemite Medical Clinic, the subject continued to refuse medical interventions such as blood work, monitoring, antibiotics, wound care, and further splinting. Care providers at the clinic offered him the option of signing out against medical advice. However, when he attempted to stand up and walk, he was unable to do so, and the staff convinced him to accept transport to the closest Level 1 trauma center, Community Regional Medical Center (CRMC), in Fresno, California. During the 2-hour transport to CRMC, the subject continued to refuse most medical interventions including an IV or analgesics. Agreeing to only be immobilized and have basic wound dressings, he repeatedly conveyed to his
Figure 2. Example of a vacuum body splint.
58
Figure 3. Demonstration of a short haul rescue, Sequoia Kings Canyon National Park (used with permission by Dr Weichenthal).
medical providers that he was a devout Christian Scientist and that any other interventions went against his religious beliefs. The subject was a Glasgow Coma Scale (GCS) of 15 throughout his prehospital course, and his vital signs were stable. On arrival to CRMC, the emergency medicine and trauma surgery teams evaluated him. His airway, breathing, and circulation were intact, and he had a GCS of 15. His vital signs included a heart rate of 62 beats/min, a blood pressure of 116/62 mm Hg, and a respiratory rate of 14 breaths/min. He was afebrile. He denied loss of consciousness. He also denied any allergies to medications, and stated he had no prior medical or surgical history. His examination revealed several deep scalp lacerations, midline cervical tenderness, an open avulsion fracture to his left fourth digit, and an abrasion with moderate sized hematoma to his right flank and hip. He was unable to flex or extend his right lower extremity because of pain and could not ambulate. The subject continued to refuse placement of an IV and also refused a tetanus injection or antibiotics for his visibly open finger fracture. He stated to one provider after refusing closure of his scalp wounds and finger avulsion that through prayer his body would heal itself and that his fractures will heal and his infections would clear. Despite his refusal of any therapeutic intervention, our subject was agreeable to have any necessary imaging studies performed and was open to consultation with specialists, but wanted to have an active role in deciding what, if any, treatments or interventions were to be done.
Weichenthal and Alhadi His head computed tomography (CT) scan was negative for acute hemorrhage. His CT cervical spine was notable for a fifth cervical vertebral fracture at the right posterior pedicle that extended into the inferior facet and lamina. Abdominal and pelvic scans were negative for solid organ injury but did show a comminuted fracture of his right sacral iliac wing. A magnetic resonance image of his lumbar spine was ordered to evaluate right lower extremity weakness and was notable for a contusion along his sacral bone. Plain radiographs of his left hand showed an open tuft fracture of his fourth digit. At this point neurosurgery, orthopedic surgery, hand surgery, and social work were consulted, and the patient was admitted to the trauma surgery service. The subject refused many commonly used evaluations for trauma patients including serial hemoglobin blood draws, enoxaparin for deep vein thrombosis prophylaxis, and general nursing wound care. During his hospital stay, providers worked with him to provide the best possible care within the limits of his religious beliefs. He did participate with physical therapy and was discharged on hospital day 4 with a front wheel walker and follow-up with care providers in his hometown. Our subject was lost to follow-up once he returned to his home outside of the state of California. He was not billed for the search and rescue effort, as YOSAR does not charge for their services, but he was billed for the emergency medical services (EMS) care, his visit to the Yosemite Clinic, and his stay at CRMC. His healthcare insurance covered the majority of the costs for his hospitalization at CRMC; we do not have access to information regarding whether the costs of his EMS and clinic care were covered. Discussion This case represents a unique intersection of the wilderness, medicine, technology, and religion. Our subject, who was reportedly an experienced hiker, made the decision to hike off-trail with minimal supplies and, when he became injured, reached for his cell phone. He was extremely lucky to have cell phone service at the location where he was injured, but even so, the way he sought to access help (calling family and texting 911) delayed officials’ awareness of his accident. He and his rescuers had to spend the night in the wilderness before transport to definitive care. Many recent papers have sought to define the relationship between technology and the wilderness.5–7 These documents have suggested that we need to be aware of the dangers of technology damaging the very qualities that we seek from our experience in the wilderness including the opportunity to revel in natural awe, beauty,
Where Wilderness, Medicine, Technology, and Religion Collide and solitude. At the same time, it has shown that people who believe that technology increases safety in the wilderness may be more willing to take risks.8 Layered on top of this debate regarding the appropriate interaction between the wilderness and technology was our subject’s religious beliefs. He described himself as a devout Christian Scientist. Based on his personal beliefs, he refused multiple treatments that he was offered in the wilderness, prehospital, and hospital settings. Christian Science is a system of religious thought first described in 1875 by Mary Baker Eddy in her book Science and Health, which continues to be one of the religion’s central texts. Adherents espouse a radical form of philosophical idealism in which spiritual reality is the only reality and the material world, including sickness and death, is an illusion.9 Given this belief that sickness is an error of the mind, Christian Scientists have traditionally turned to prayer and spiritual healers for the treatment of illness or injury.10 This belief has come in conflict with mainstream society, as evidenced by several high-profile cases in which parents refused medical care for their children.11 Autonomy is one of the fundamental guidelines of medical ethics and includes a patient’s right to refuse medical treatment that the care provider may believe is essential. Whereas in the hospital setting such refusal of care does not usually endanger the care providers or other patients, in austere settings with limited resources it has the potential to do so. On the same day that our subject was being rescued, there were 16 other 911 calls for medical service in YNP. During that same 24-hour period, there were only 7 park medics on duty. Three rescuers, including 1 park medic, spent 14 hours with our subject and placed themselves at risk to locate, stabilize, spend the night with, and ultimately extricate him. The advanced medical skills of the park medic were all refused by the patient. This care provider’s abilities might have been better used by other people who found themselves injured or ill in YNP during that period.
59
This case displays the complexity of all human interactions. We may view the wilderness as a place of simplicity and clarity, but as human beliefs and technology become more entwined in these regions that we have reserved as austere sanctuaries, we will need to be more aware of how humans, the wilderness, medicine, technology, and our personal religious beliefs interact. References 1. Boore SM, Bock D. Ten years of search and rescue in Yosemite National Park: examining the past for future prevention. Wilderness Environ Med. 2013;24:2–7. 2. Fimrite P. United States honors Yosemite search and rescue ranger. San Francisco Chronicle. October 30, 2008. 3. Search and Rescue: Lessons from the Field. Available at: http://www.nps.gov/yose/blogs/psarblog.htm. Accessed January 28, 2013. 4. Kaufman TI, Knopp R, Webster T. The Parkmedic Program: prehospital care in the national parks. Ann Emerg Med. 1981;10:156–160. 5. Shultis J. The impact of technology on the wilderness experience: a review of common themes and approaches in three bodies of literature. USDA Forest Service Proceedings. 2012:110–118. 6. Borrie WT. The impacts of technology on the meaning of wilderness. Proceeding of Sixth World Congress Symposium on Research, Management, and Allocation. 1998: 87–88. 7. Pohl S. Technology and wilderness experience. Environ Ethics. 2006;28:147–163. 8. Pope K, Martin SR. Visitor perceptions of technology, risk and rescue in wilderness. Int J Wilderness. 2011;17:19–26, 48. 9. Schoepflin RB. Christian Science on Trial: Religious Healing in America. 1st ed. Baltimore, MD: Johns Hopkins University Press; 2002. 10. Benson H, Dusek JA. Self-reported health and illness and the use of conventional and unconventional medicine and mind/body healing by Christian Scientists and others. J Nerv Ment Dis. 1999;187:539–548. 11. May L. Challenging medical authority: the refusal of treatment by Christian Scientists. Hastings Cent Rep. 1995;25:15–21.
