Spotlight: Part 3

A Note to the Reader  This is a book review. It is not a guide to diagnosis and treatment. Moreover, the art of medicine is constantly evolving. Whatever medical handbook you bring into the backcountry — be it one of the books reviewed here or another of your own choosing — your best source of information on medical matters is always your own doctor. If you value your life and health, consult her before you head for the put-in.

Canoeing and kayaking are great fun. That goes without saying. Like all physically demanding sports, however, they can also be hazardous. Happily, most illnesses and injuries in the backcountry are minor. But some are not. Padders drown, fall victim to heat illnesses, suffer heart attacks, and succumb to dehydration. Paddling, wading, tracking, and portaging can lead to infected blisters, disabling sprains and strains, dislocations, and fractures. Bad water can sicken even the healthiest paddler, and a single moment's carelessness may end with an ax blade driven deep into a foot. Nor is nature always kind. Lightning, cold water, and falling trees kill without warning, and there are still a few animals left on earth who don't recognize human beings as the top of the food chain.

Then there are the usual run of everyday aches, pains, and ailments. An abscessed tooth, a bad headache, or a bout of diarrhea — each of these can put an end to the fun in a hurry.

What to do? At home, help is as close as your telephone. In the backcountry, however, you're on your own, whatever your health plan. Sure, modern technology can lend a helping hand. A cell phone or VHF radio can put you in touch with the outside world in seconds, and GPS will provide your exact coordinates to Search and Rescue personnel. But that doesn't guarantee a happy ending. Cell phone networks have gaps. Radio transmission is affected by atmospheric conditions and terrain. Batteries fail. And there are some days when even the boldest pilots won't fly.

There's also cost to consider. If you call out Air-Sea Rescue when you lose a filling, you'll soon have more than a toothache to worry about.

The answer? Knowledge is power. A first-aid course is a start, but it isn't enough. Anyone traveling into the backcountry needs to know more. You owe it to yourself, your companions, and your loved ones. So talk to your doctor. Take a wilderness medicine course. And always pack a good medical handbook in the dry bag, along with your splints and bandages.

But what, exactly, is a "good medical handbook"? I like to start with the criteria laid down in a nineteenth-century testimonial for The Young Sea Officer's Sheet Anchor, an early textbook for naval officers-in-training: "We can recommend Mr. Lever's Work as containing nothing that is superfluous, and all things that are useful." That's simple, isn't it? "Nothing that is superfluous, and all things that are useful." Now let's see how an old standby and a new contender measure up.

The old standby first. I came to paddling by way of mountaineering. When my climbing trips took me farther afield than the road-cuts, hills, and frozen waterfalls near my rural home, a copy of James A. Wilkerson'sMedicine for Mountaineering (The Mountaineers Books, Seattle, Washington) went along with me. It was a good choice, and others must have thought so, too: the fifth edition is already in its second printing. I've changed in the last thirty years, of course. I no longer climb frozen waterfalls, for one thing. And Medicine for Mountaineering has changed with the times, as well. The title now adds the welcome phrase And Other Wilderness Activities. Canoeists and kayakers take heart!

The title says it all. Medicine for Mountaineering is not your ordinary first-aid text. It's a true "handbook of medicine." The names of twelve physicians appear in the list of contributors, and the text is detailed, comprehensive, and authoritative. Preventative medicine, diagnosis, and treatment — they're all here, along with a handy (and necessary) glossary, a wilderness pharmacopeia, and a guide to a number of therapeutic procedures, including intravenous fluid therapy, urethral catheterization, and tube thoracostomy (a "severely hazardous procedure," yet one which, when properly performed, "may be lifesaving").

The information is presented pretty well, too. The new, larger format insures plenty of space for marginal notes, even if it doesn't pack as handily as the older editions. And the illustrations are well drawn and clear. So far, so good. But Medicine for Mountaineering is not without its faults, and some are troubling. Aging eyes may have difficulty with the tiny print, particularly in dim light. The book needs more illustrations, too. Worst of all, however, is the index. Although somewhat improved from earlier editions, it's still poor.

A case in point: Suppose you've got a pain in your belly. It's been getting worse for a couple of hours and now it's got you worried. So you look under "pain." Nope. Burns and fractures only. You try "belly" next. Nope again. Then another spasm of cramp assails you. When the pain lets up, you start playing guessing games with the index, hoping to find the Magic Word that will unlock the secrets of the text. "Gut"? No. "Abdomen"? No luck there, either, but.… Just below the place in the index where you were looking for "abdomen" you see "abdominal pain." Eureka! But you'll probably wish the search had been easier — and quicker.

Is this important? Probably not. If you're so familiar with the book that you know where to go without using the index. But what if you're so sick that someone else — your kid say, or a companion with minimal training — has to find the right section in a hurry? If mommy's too sick to be much help, will her ten-year-old daughter be able to guess the Magic Word in time? I hope so.

Nor is the index the only obstacle in your path. Even when you hit the Magic Word on the first try, your problems may not be over. This, or something like it, is likely to confront you:

A definitive diagnosis may be impossible during the early phases of a disease, but a tentative or working diagnosis, with the understanding that it may be altered as signs or symptoms change, is appropriate because it provides the guidance for the next step.

Makes sense to me. It might not to make much sense to a ten-year-old, though. And it's definitely excess baggage for anyone in a hurry. "Signs or symptoms"? What's the difference? The glossary will help, but that's even more time lost. And later — you've gotten farther along in the section on "Acute Abdominal Pain," now — just how do you palpate an abdomen? You'll find no illustrations to help you.

There are curious omissions in the text, too. Have you ever lost a filling in the backcountry? It isn't exactly a rare problem. Want to learn how to plug the hole the next time it happens? OK. Let's see if we can guess the Magic Word. "Fillings"? No. "Dental problems"? No. "Teeth"? Nope. How about "toothache," then? At last! There's nothing about lost fillings in the text, but at least we're told that "mild or moderate analgesics every four hours … help relieve discomfort." That's always nice to know.

Now let's go back to our starting point and see how Medicine for Mountaineering stacks up. Remember the ideal? "Nothing that is superfluous, and all things that are useful." Well, I'm afraid there's a lot that is superfluous in Medicine. Like chatty disquisitions on the utility of working diagnoses, for example. And a lot of other things that would be useful — a little more help in dealing with tooth troubles, say — simply can't be found at all. My conclusion? There's room for improvement. Still, despite its shortcomings, Medicine for Mountaineering remains the gold standard for wilderness medical guides. If you're going high or planning an expedition to the back of beyond, it's your best bet. Just be sure that everybody in your group — even your ten-year-old daughter — is thoroughly familiar with the book's layout and organization before you leave home.

But what if you're not planning an expedition or going high? What if you just want an accessible, easy to use handbook, one that addresses common problems while also helping you decide when it's time to call for help. Then you might want to consider David Werner's Where There Is No Doctor: A Village Health Care Handbook (Hesperian Foundation, Berkeley, California), instead.

First published in English in 1977, Where There Is No Doctor was last revised in 1992, with the help of Carol Thuman and Jane Maxwell. This edition is now in its sixth printing. Originally intended as a handbook for health-care workers in isolated rural villages, Where There Is No Doctor is very different from Medicine for Mountaineering. It's written in the language of everyday life, for one thing: colloquial, blunt, and matter-of-fact. Moreover, every page is embellished with simple but strikingly effective line drawings. (CAUTION. These graphics are frequently graphic, but then sickness doesn't often show a pretty face, does it?) And the index — the book's "Yellow Pages," in fact as well as function — is superb. Our hypothetical patient with a pain in her belly won't have to waste time guessing the Magic Word. She need only turn to "Pain: in the belly." (Or just "belly." Or "abdomen." There are entries under all three.) There she'll find a list of page references, the second of which will bring her to an excellent, copiously-illustrated, hands-on guide to the technique of abdominal examination. And it gets even better. The accompanying diagnostic chart can be understood at a glance, while cross-references make it easy to find related sections of the text.

Is the book perfect, then? No. Dental problems get short shrift in Where There Is No Doctor, too, though the coverage is still better than in Medicine for Mountaineering, and a slim companion volume, Murray Dickson'sWhere There Is No Dentist, fills the…er…cavity admirably. (Lost filling? See Dickson's index under "Fillings, lost or broken: diagnosis and treatment.") Of more importance, perhaps, Where There Is No Doctor is starting to show its age. With the rapid evolution of resistant strains of common bacterial and protozoan pathogens, revision of the book's "Green Pages" ("Information on Medicines") is now overdue.

What's the bottom line? Where There Is No Doctor is reasonably comprehensive, well-organized, easy to understand, and accessible. It was not intended as a handbook for wilderness travelers, however, and it contains much that they may find superfluous. Few paddling parties will need to deal with outbreaks of sexually transmitted disease, after all, and not many canoeists and kayakers will ever have to cope with a breech birth on the riverbank. (The section entitled "Health and Sicknesses of Children" will be welcomed by many paddling parents, though.) And does Where There Is No Doctor have "all that is useful"? No. While its coverage of tropical diseases is understandably thorough, Medicine for Mountaineering does a better job on some subjects: environmental injuries and fractures, for example.

That said, when illness or injury strikes, I now turn first to Where There Is No Doctor, both in the field and at home. But which book will suit you best? That's for you to decide. Canoeists and kayakers who combine climbing and paddling will probably find that Medicine for Mountaineering is still king of the hill. On the other hand, folks who frequently paddle in the tropics, or whose children often accompany them into the backcountry, may give the edge to Where There Is No Doctor. (Large groups can carry both, of course. They probably should.)

Do you need a little help coming to a decision? Perform a simple test. Use each book to look for information about problems that you and your paddling companions have already encountered. Then ask yourself…

• How easy was it to find what I was looking for? In the light of my own experience, did what I read make sense?
• Was the index helpful? Could I go directly to the proper place in the text, or did I have to hunt for information, returning to the index again and again?
• If I needed to use this book for help in an emergency, would I be able to find what I needed quickly, and would I understand what I read, the first time I read it?

Be guided accordingly.

It's also a good idea to take your medical handbook to your doctor and ask her opinion. You'll need prescriptions for many medications, anyway. And remember that no single medical guide can be relied on absolutely. Where There Is No Doctor, for instance, recommends treating some life-threatening conditions with both tetracycline and penicillin, taken together. This runs directly counter to the advice of other authorities. You'll need an expert's help to resolve such conflicts.

*

In the final analysis, few books ever live up to the proud boast of that nineteenth century testimonial: "nothing that is superfluous, and all things that are useful." But both Medicine for Mountaineering and Where There Is No Doctor come about as close as is humanly possible. Whichever medical handbook you choose, get to know it well. Read it before you need it. Pay special attention to the introduction and any appendices, and heed the authors' advice on using their book. Make notes in the margins, and annotate the index if required. (It will be required with Medicine for Mountaineering.)

Remember, too, that no book, however good, can substitute for a physician's care. But you can't carry a doctor in your pack, can you? So find a medical handbook you can use and bring it along with you on every trip. It's a decision you'll find easy to live with.

Wilkerson, James A., M.D.., ed. Medicine for Mountaineering & Other Wilderness Activities, 5th ed.. The Mountaineers Books, Seattle, Washington; 2001 (second printing, 2002). ISBN 0-89886-799-1.

Werner, David, with Carol Thuman and Jane Maxwell. Where There Is No Doctor: A Village Health Care Handbook, rev. ed.. The Hesperian Foundation, Berkeley, California; 1992 (sixth printing, January 2002). ISBN 0-942364-15-5.

Dickson, Murray. Where There Is No Dentist. The Hesperian Foundation, Berkeley, California; 1983 (tenth printing, January 2000). ISBN 0-942364-05-8.

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