January 12, 2025 • 45 mins
Ketamine Use in Wilderness Pain Management: An Interview with Dr. Chris Van Tilburg
In this episode of Wilderness Medicine Updates, host Patrick Fink discusses wilderness pain control with guest Dr. Chris Van Tilburg, focusing on the effective use of ketamine. The episode delves into how ketamine serves as a versatile medication for pain management, sedation, and intubation in emergency and wilderness environments.
Dr. Van Tilburg, an expert in wilderness medicine with extensive field experience, shares insights on administering ketamine in challenging rescue scenarios, the limitations and benefits of various medications, and practical considerations for field use. The conversation touches on dose ranges, administration techniques, and patient management during rescues. Additionally, Dr. Van Tilburg talks about his soon-to-be-released book, 'Crisis on Mount Hood: Stories from 100 Years of Mountain Rescue,' celebrating the centennial of the Crag Rats, America's oldest mountain rescue team.
Links
WMS Guideline: Avalanche and Nonavalanche Snow Burial
WMS Guideline: Pain Management in Austere Environments
Chris’s Linktree
Contact Chris through LinkedIn
Preorder Chris’s book “Crisis on Mt Hood”
Chris on Wikipedia
Crag Rats Mountain Rescue
Chapters:
00:00 Welcome and New Year Greetings
00:29 Introducing Today's Guest: Dr. Chris Van Tilburg
03:07 Podcast Shoutouts and Listener Appreciation
03:37 In Conversation with Dr. Chris Van Tilburg
05:58 Challenges of Wilderness Pain Management
09:37 Pain Management Strategies
14:23 Ketamine vs. Other Pain Medications
18:01 Ketamine Dosage and Administration
22:16 Nitty Gritty Tactics: Needle Sizes and Administration
23:02 Intramuscular Injection Sites and Techniques
24:22 Timing and Dosage of Ketamine Administration
25:16 Challenges in Mountain Rescue Situations
27:17 Case Study: Seizure Patient and Ketamine Use
29:18 Considerations for Head Injuries and Ketamine
33:03 Medications in Wilderness Medical Kits
34:02 The Art of Wilderness Medicine
37:54 Protecting Medications in the Field
38:55 Wrapping Up: Upcoming Book and Final Thoughts
As always, thanks for listening to Wilderness Medicine Updates, hosted by Patrick Fink MD FAWM.
Connect with us by email at wildernessmedicineupdates@gmail.com.
You can pay us a compliment and share the show with a new listener on any popular platform here.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Patrick (00:05):
Welcome back to Wilderness Medicine Updates.
The show for providers at theedges and happy new year to you
all.
This is our first episode for2025.
And I'm very happy to be wishingyou a happy new year from Bend,
Oregon, where we have aridiculously deep snowpack and
somehow haven't really gottenany snow in town.
It's pretty nice to live nearthe mountains and not in them
(00:28):
sometimes.
Today, I'm super excited towelcome a guest to the show.
Chris Van Tilburg.
I'm gonna talk to you a littlebit about Chris in just a
second, but our topic for todayis going to be approach to
wilderness pain control, andimportantly, we're gonna make a
deep dive on ketamine.
Ketamine is a medication thatyou may be familiar with because
(00:50):
of the news, has killed somecelebrities recently, or maybe
you've heard of people gettingketamine infusions for treatment
resistant depression orsubstance abuse.
Well, for us in the emergencydepartment, ketamine.
Is a wonder drug of sortsbecause it can be used for pain
control.
It can be used for sedation.
It can be used to intubatepeople.
(01:10):
It can be used to control thedangerously agitated, but it has
some special features thatdifferentiate it from opioids or
NSAIDs and then make itparticularly well suited to use
in unmonitored or minimallymonitored environments, such as
out in the wilderness or thesearch and rescue context.
(01:30):
First, a little bit about Chrisstraight from his Wikipedia
page.
He's a cool enough doctor tohave a Wikipedia page.
Chris van Tilburg is an Americanphysician and author
specializing in emergencywilderness travel, environmental
occupational and public healthmedicine.
He is the author of 11 books onoutdoor recreation, wilderness
(01:51):
medicine, and internationaltravel.
Including a couple of memoirs,one called mountain rescue
doctor, wilderness medicine inthe extremes of nature and
search and rescue a wildernessdoctors life and death tales of
risk and reward.
He has a forthcoming book, whichwe discuss at the end of this
podcast, crisis on Mount hoodstories from 100 years of
(02:13):
mountain rescue.
And that comes from Chris'sbackground as a deployable
member of the crag rats, whichis a search and rescue team on
the North side.
Of Mount hood.
And I believe that the longestcontinuously operating search
and rescue team in the UnitedStates.
Chris is also a family medicinetrained emergency medicine doc
(02:36):
working out of hood river,Oregon, and he's a medical
director to a number of mountainrescue and search and rescue
teams.
And this podcast, you can expectto hear about Chris's approach
to search and rescue painmanagement.
You're also going to hear whyketamine is his drug of choice
and why we both shy fromwilderness use of intranasal
(02:57):
medications.
We're going to talk about whichmedications he brings with him
on a SAR deployment and whichones he does not and why and so
much more.
Before we dive in, I also wantto thank those of you who have
given the podcast a writtenrating on Apple podcasts, I'm
looking at you lions, Leo,Haley, one eight, eight, and my
(03:19):
favorite name on there.
Sorry to the other two charterspatula.
I appreciate the comments thatwent along with your five star
reviews.
It really warms my heart and itdefinitely helps get the This
podcast out to other people whenyou drop those reviews.
So thank you.
And if you want to be mentionedon the show, keep them rolling.
Without further ado, let's jumpinto my conversation with Dr.
(03:41):
Chris Van Tilburg.
It's great to have you on theshow, Chris, I really appreciate
you coming.
When someone asks you at adinner party, what you do, how
do you elevator pitch yourself?
Cause you have a lot of balls inthe air,
Chris Van Tillburg (03:57):
Well, it's, it's easiest to explain to
people that I'm a and wildernessdoctor, but of my job now I do
administration, administrativemedicine.
but that's the easiest thing totell people is kind of
encompasses my entire career.
Patrick (04:18):
but Chris, what's a wilderness doctor.
Chris Van Tillburg (04:21):
A wilderness physician is generally anybody
who's practicing medicine inrural, remote, or wild areas,
and for me, that means mostlymountain rescue, but I've also
worked in Haiti.
I've been to Haiti five times.
I've been a cruise ship pilot.
(04:42):
Doctor, I've been an expeditiondoctor but most of my time now
is in mountain rescue.
Patrick (04:48):
Okay.
And is that predominantly orexclusively with the crag rats?
Chris Van Tillburg (04:54):
No, I'm a field deployable member of the
Craig rats.
Last year I went on 35 missionsor something like that.
But I'm also field deployableand medical director of Portland
mountain rescue, which is thoseare the two teams that cover
mountain hood.
Craig rats generally cover the.
North and east portal MountainRescue covers the south.
(05:15):
I'm also a medical director forClackamas County, SAR and
Pacific Northwest SAR.
Those are the two ground teamsthat cover Mount Hood.
Patrick (05:24):
You're a busy guy.
That's a lot of run reviews andtraining.
Chris Van Tillburg (05:28):
Well, I got, a great medical lead for every
team.
So it's, it's fabulous.
I got really great help.
Patrick (05:34):
Awesome.
So the reason that I wanted toreach out to you to talk about
wilderness pain control, andspecifically ketamine, was the
expertise that you brought toour group when we were putting
together the pain managementguideline for the Wilderness
Medicine Society.
And it seems like you have aparticular knack with ketamine,
(05:54):
which is where I want to get toeventually.
For the purposes of thisdiscussion, let's table the
language and you can say remote,austere wilderness when we're
talking about like, Well,outside the hospital
environment, what do you thinkof as the challenges of managing
pain in those settings that areunique to wilderness or austere
(06:18):
settings?
Chris Van Tillburg (06:19):
Great question.
The two probably the two biggestchallenges.
One is a medical provider issueand one's a patient issue for
medical providers.
Our biggest challenges.
We just can't take very much.
Very many up on the table.
the mountain or up the trail.
We just have a limited space inour pack and we have to make
(06:42):
really hard decisions sometimeswhat we take up the trail.
So that is one of the biglimitations.
The other big limitations is thepatient is in a oftentimes in a
remote or rural or area and sothat Even if we did have
equipment up the trail, it justmakes delivery of medical care
(07:04):
very, very challenging.
Patrick (07:06):
So, when you're thinking about constraints on
your pack, are you thinkingabout, you know, the range of
medications you can bring?
Are we talking monitoringequipment?
what do you typically have inthe hospital that you find that
you do not have when you're upon the north side of mount hood,
for example?
Chris Van Tillburg (07:22):
Well, I have a like 40 liter pack.
And then I generally in theAlpine, I take an airbag pack.
So in that pack, I have to takemy personal safety equipment, my
spare clothing, food, water, mytechnical climbing equipment for
the South side of Mount Hood.
That's going to be like a PetzlRAD line.
And.
Set of boot crampons and aharness I'm usually wearing.
(07:47):
And then.
that stuff fills up, you know,most of my pack.
And so I have limitations ofwhat I can bring.
So typically, I bring a sixliter bag zippered pouch that
has my advanced life support kitand oftentimes, depending on the
situation, I'll bring it.
An AED I'll bring a heat blanketor two, and we might spread
(08:11):
those out amongst the teammembers, depending if I'm on the
ready, I'm on the hasty team, orif I'm coming after some gears
already up the mountain.
So, just situationallydependent, but those are the
things I bring.
I don't bring IV fluids.
I don't bring a twelve leadmonitor.
bring kit, you know, all thosethings that we have available to
(08:34):
us in the emergency department.
Patrick (08:35):
Okay, so a limited subset Of both medication tools,
but then also physical tools.
Do you have the capacity tomonitor blood pressure and, uh,
to monitor oxygenation,
Chris Van Tillburg (08:48):
I carry a pulse oximeter, which is mostly
helpful, I've found.
Bringing somebody down themountain.
It's a quick, easy way to, foranybody, any BLS rescuer can
glance at the pulse oximeter andsay, yeah, we still got a pulse
and we still got O2 sat at theappropriate.
So it's a great tool to monitorsomebody.
(09:11):
I don't bring a blood pressurecuff because it's just 1 of the
things I've decided, you know, Ihave to cut something out.
I only have 6 liter bags.
So it's 1 of the things I justdecided, it's, it's useful, but
not gonna make, not gonna employmedical decision making that I
can't use other tools and skillsfor.
Patrick (09:29):
right?
When you see a low bloodpressure, what are you going to
do?
You're going to walk out faster.
Chris Van Tillburg (09:35):
Yeah, right.
Patrick (09:37):
So when you're thinking about your role as the physician
or the medical provider on atechnical rescue team, what are
your goals when you're,Delivering pain control to a
patient.
that seems like a reallystraightforward question, right?
You're like to get rid of pain.
I want them to have less pain,but everything has a downside to
it So what are yourconsiderations when you're
(09:58):
thinking about should I use thismedication?
Should I not will this?
Enhance our action here, or isthis just gonna impede us?
Chris Van Tillburg (10:08):
Right.
Probably an important goal,maybe not the most important,
but an important goal is to makejob of the rescuers easier.
We had a ankle fracturedislocation.
Last summer, four miles up thetrail combined with the elbow
(10:30):
non dislocation, and it wasuntil I got there, it was just
impossible to even move thisperson, this patient, even get,
get that person out of us into asafe zone.
We were up by a waterfall.
There's water sprayingeverywhere.
So, a really important job ofpain control is to make the job,
allow the rescuers to do theirjob.
Patrick (10:49):
that's like packaging and moving the patient in that
setting.
Chris Van Tillburg (10:53):
Yeah, correct.
It was like, they couldn't evenmove her.
For Into a safe spot withoutpaying control, and then we had
to move her into the litter andget her down the trail.
So, yes yeah, pack moving andpackaging.
Patrick (11:03):
Okay.
And obviously there's, you know,kind of multiple levels to pain
control that we can apply and wemight go straight to higher
levels in that setting wheresomeone is clearly in
excruciating pain.
But can you march me through thelevels that you think of in
terms of like, this is thelowest level or the base level
of care that I've essentiallydelivered to almost everybody.
(11:25):
And then this is how I escalatemy.
Pain management tactics,depending on what's in front of
me.
Chris Van Tillburg (11:34):
Yeah, I think in my situation, there's
really three levels of paintreatment.
One is just getting somebody.
Immobilizing a fracture orgetting them into a litter off
the trail, straighten theirfractured extremity or
immobilizing it.
That's probably the quickest andeasiest and one of the most
(11:57):
essential things to do.
And then the next step would besome kind of oral over the
counter.
And then the third step would beprescription medication.
Patrick (12:05):
So, immobilization first, because If that broken
wrist stops flapping in the windthat addresses a significant
pain driver
Chris Van Tillburg (12:16):
Yeah.
And a lot of people, we get thempackaged in a litter and they're
immediately, the two effectshappen.
One is kind of alleviates theirpain because they're off the
ground and they're stabilized.
And then it provides a fair bitof anxiety relief because all of
a sudden they realize I'm goingto be taking care of them in
this package.
And I got a bunch of rescuersaround me.
Patrick (12:37):
That's an interesting effect to think about kind of
ties into the psychologicalfirst aid side of things you
know, we always talk abouttrying to Empower the patient or
involve them in their care Butat times they're perfectly happy
to be wrapped up in a blanketand say take it from here
Chris Van Tillburg (12:56):
Right?
Patrick (12:59):
I feel safe now
Chris Van Tillburg (13:01):
Yeah.
Patrick (13:03):
What is your over the counter pain strategy or oral
pain control?
What's that level 2 look like?
Chris Van Tillburg (13:10):
Usually that's, you know, Tylenol is the
safest.
Ibuprofen is the mostubiquitous.
Somebody's usually got that intheir pack, or I have both.
once in a while I'll use whichisn't over the counter, but it's
maybe a little bit safer to usethan Ibuprofen in some
situations.
But yeah, it's Tylenol andIbuprofen.
Patrick (13:29):
Remind me, is it meloxicam that's in the military
pill packs?
Chris Van Tillburg (13:34):
Yeah, exactly.
Patrick (13:35):
Okay.
For those who aren't familiar,that's like a self administered
pain pack that the militaryuses, which has immediate
administration pain meds as wellas an antibiotic.
So if you sustain some kind ofwound in the field, they can
treat themselves immediately.
Um, so you, you start off withan NSAID and Tylenol of some
(13:56):
form, and then let's say that,that lady you've just pulled out
from underneath the waterfallwith the elbow fracture, the
ankle fracture.
She's in the litter, she'sstabilized, you managed to get
her to swallow some NSAIDs.
She's still screaming.
You clearly would like to kindof March to that next level.
What is your first line kind ofprescription or show physician
(14:20):
level medication?
Chris Van Tillburg (14:24):
I should mention that sometimes I go
straight to the the good drugs.
Like, I don't even mess withibuprofen.
Sometimes if somebody's insignificant pain, or if I want
to make sure I keep them withouttaking anything by mouth, like
I've had that a few times withhead injuries, but I only carry.
Ketamine and oxycodone.
That's all I carry those twothings.
(14:45):
So if I can't give somebody, Irarely use oxycodone because of.
the risk of, respiratorycompromise and it just takes
longer to work.
I usually go right to ketamine.
Patrick (14:59):
Okay.
I think a lot of us on thispodcast and people listening,
perhaps with an EMS backgroundor saying, where's the fentanyl?
Chris Van Tillburg (15:09):
Yeah, I don't carry it.
I don't carry it for a couple ofreasons.
One is I can do almosteverything with ketamine that I
would do with fentanyl two isit's a little.
More challenging to carrybecause of the higher level of
controlled substance by the D.
E.
A.
That's kind of a minor issue.
Um, and then, um, you know, theside effects of fentanyl are are
(15:32):
more pronounced and ketamine.
So I don't even I've nevercarried it.
I don't carry it.
I just carry ketamine.
Patrick (15:37):
Those side effects being respiratory depression and
potentially altered mentalstatus, depending on the
patient.
Chris Van Tillburg (15:44):
Correct.
Patrick (15:47):
I have always used fentanyl as a first line, but
my, wilderness operationalcontext is usually ski hill
medicine.
If I've had one issue with it,it's that.
Delivering it intranasally ispretty variable in that setting
because people's noses are coldand runny and intramuscular
(16:08):
fentanyl doses to be effectiveneed to be probably up above 100
micrograms, which means thatwe're talking about four
milliliters plus of a standardmixture of fentanyl.
I have been hesitant to useketamine.
I'll admit that.
You seem very comfortable, andthis is like where I want to dig
in a little deeper.
Can you anticipate why I wouldbe hesitant to use ketamine?
Chris Van Tillburg (16:34):
Well, I'm not sure exactly your
perspective, but I have somepeople are hesitant to use it
because it hasn't been used aslong as a parental opioids.
It has it's it's a drug ofabuse.
So there's all is that stigmataabout it.
But so is fentanyl.
And just, you know, maybe inunfamiliarity with it.
(16:55):
I mean, I use it somewhat rarelyin the emergency department when
I work, or especially at the skiclinic we have a minor or major
procedure to do.
That's pretty straightforward,but maybe unfamiliarity might be
part of it too.
Patrick (17:09):
Okay, it was unfair to ask you to read my mind.
I think, as you know, I'm alsoan emergency physician, and so I
use it a ton in the emergencydepartment,, often in people who
have experience with opioids,who have significant pain.
It can be opioid sparing in thatcontext, but I'm usually
administering it.
IV in that setting at a doserange of 1 to 3 milligrams per
(17:33):
kilogram, which we don't need todive too much into the math here
today, but it's a relatively lowdose.
And even at those doses, Ioccasionally have people who get
weird, um, you know, if it's notpushed slowly or hung in a bag,
I get people who startexperiencing hallucinations.
So let's contextualize this alittle bit for our audience,
(17:55):
because probably a number ofthem might not have as much
familiarity with ketamine as wedo.
talk with me or explain the doserange that exists within
ketamine, how we get from likenothing up to we're using it as
an RSI drug.
Chris Van Tillburg (18:13):
Right.
Well, I use it.
Pain management dosage.
I don't use it yet.
The dissociative sedation dosageexcept the occasion would be at
the mountain ski resort clinicwhere we have a nurse full code
card.
(18:33):
Sometimes they're there for adifficult shoulder reduction or
something or a.
you know, pediatric, polysfracture reduction.
I may use it, but generally Ionly use it in a pain dose.
I carry a nasal atomizer, butI've never given ketamine
intranasally for the exact sameissue you've already mentioned.
Patrick (18:55):
That's kind of variable effect and absorption.
Chris Van Tillburg (18:57):
Yeah, if somebody's on the side of a
mountain shivering and they'recold and they're trying, you're
telling them to hold theirbreath and then snort through
their nose.
And it's just, I've never doneit just for that reason.
So I give it.
I am, um, and I give, you know,one, two milligrams per
kilogram.
I am.
So, um, a hundred milligrams ispretty safe for most adults for
(19:20):
the pain dose.
I have had people, okay.
Um, not get great pain controlwith that.
I've also had people that aregetting slightly loopy and
slightly dissociative with thatdose.
So to err on the side of maybe alittle less to start see what
happens.
The half life is like, in myexperience, 30 to 40 minutes.
So it's, you know, you got toredose in 30 to 40 minutes or
(19:42):
hopefully you're off themountain.
Patrick (19:43):
Okay.
So I think of ketamine as havingbasically three dosing ranges.
The first being the one thatyou're trying to stay inside of,
which is where it's providingpain control.
And then if we get up higherabove that, that's probably what
we could call the recreational.
where people who are abusingthis drug are tending to use it
for that effect, where at thatpoint people are starting to
(20:06):
hallucinate, but have notreached zone three, which I
would call dissociative doseketamine, which is where mind
and body are not in relationshipwith one another.
And that's the level at which weuse it in the emergency
department when we'reintubating.
So you don't get too muchexperience with people.
starting to have hallucinationswhen you're giving it at two
(20:27):
milligrams per kilogramintramuscularly.
Chris Van Tillburg (20:31):
I've had it happen once.
I give it roughly four to fivetimes a year, either on the
mountain or up a trail in aremote location.
And so I've had that happen.
I had that happen once last yearthen it wore off and I just
backed off on the dose a littlebit.
But, um, I have that happenwith, two milligrams per
kilogram.
Patrick (20:51):
Because when you say two milligrams per kilogram, my
mind immediately goes to whenketamine has been studied for
management of the dangerouslyagitated psychiatric patient,
the dose range For putting thosepeople down is three to five
milligrams per kilogram.
So it's really not that muchfarther away, but it sounds like
(21:14):
you don't have a lot of troublewith, strapping people into that
litter and getting halfway downtowards cloud cap.
And they're seeing machine elvesor strange hallucinations.
Chris Van Tillburg (21:26):
Yeah.
And that that does pass fairlyquickly.
And probably I use more like oneto one point five milligrams per
kilogram.
Because basically theformulation I buy it in is, um,
one hundred per M.
L.
And it's in a five M.
L.
Bottle.
So, um, You know, we're notweighing people
Patrick (21:46):
Right.
Chris Van Tillburg (21:47):
Sometimes you can ask people what they
weigh and sometimes you got toguess probably more often than
not, I just give a hundredmilligrams.
So it's one CC, one ML.
It's easy for somebody to helpme draw it up.
If they're a paramedic or, um,you know, if there's two of us,
or sometimes I draw it up andgive it to our awesome critical
care nurse who's on our team.
So, yeah.
(22:07):
So oftentimes I just go straightto a hundred milligrams
Patrick (22:10):
Okay, and for most people, that's going to land
between one and two milligramsper kilogram for an adult size
human.
Chris Van Tillburg (22:16):
Right.
Patrick (22:17):
let's just talk nitty gritty tactics.
Obviously, you're going to drawit up with a large gauge needle
when you give it.
I am what size needle are youcaring for that?
Chris Van Tillburg (22:28):
Well, that's a great question.
You know, so typically I carry,two eighteens and two twenty
sevens, but I think the lasttime I used it, which was on a
trail up on Mount hood forwhatever reason, I couldn't find
any 27 gauge needles, so I drewit up with an 18 and gave it an
(22:48):
18.
Not the best, but this lady, shewas in bad shape and we couldn't
even move her at all.
So, that's just, but yeah,generally, I like to just carry
an 18 and a 27.
Patrick (22:59):
Yeah, that's a small biopsy.
when you're administering itintramuscularly, do you prefer
shoulder versus thigh versusglued?
Or is it just what you can getaccess to?
Chris Van Tillburg (23:11):
I think I've only given it in the shoulder in
the deltoid because gettingaccess to any other muscle is
very challenging, especiallypeople have lower extremity
injuries and you got to taketheir clothes off.
It's pretty easy to somehow getto a deltoid.
Um, and so that's where I'vealways given it.
Patrick (23:31):
Okay.
I'm going to share my nonevidence based tactic for the
lower extremity, which is mostpeople have pockets.
And so you can go through thelining of the pocket into the
thigh without Exposing the leg.
That's something I came up withwhen people got tired of me
poking holes in their Gore Texpants.
I was just administering itstraight through the arcteryx
(23:52):
and it made some people a littlefrosty, but through the pocket
works pretty well if you don'thave access to the shoulder.
Chris Van Tillburg (23:59):
That's a great idea.
Fabulous idea.
Patrick (24:02):
Yeah, because that's why we're not giving IV meds,
right?
Both the fussiness of the IV andbecause we don't want to expose
people.
So there's always the side zipon the pants or the pocket where
there's the thin nothingmaterial and you can usually
find some thigh muscle throughthere.
Chris Van Tillburg (24:20):
Yeah, that's a great idea.
Patrick (24:22):
So when you administer it intramuscularly, how long
Before peak effect, generallyspeaking.
Chris Van Tillburg (24:29):
In my experience, it's usually pretty
quick, five or six, sevenminutes, something like that.
And then, peaks, in 20 or 30minutes and then wears off by 40
minutes.
So, oftentimes, know, it's twoor three hour trail excavation.
I'm doing multiple doses.
Patrick (24:44):
Okay, and do you carry just the single vial of five
milliliters?
Chris Van Tillburg (24:49):
Yep, that's it.
So, and then I get home, I wasteit and, you know, put a new one
in my kit.
But yeah, I just carry one, fiveml bottle.
Patrick (25:00):
Okay.
How do you decide at that sevento ten minute mark whether or
not to up the dose or re dose?
Are you just waiting a fulltwenty to forty minute cycle and
saying the next time I dose, I'mgoing to give more if pain
control was not adequate?
Chris Van Tillburg (25:17):
No, because the rescues in the mountain
rescue situation are, you know,I wouldn't say chaotic, but
there's so many different thingsgoing on.
do I have somebody who couldkeep track of time.
I try to have somebody on theirphone, either myself or somebody
else start a little chart noteand just document times, but,
(25:37):
you know, we're wheeling thepatient down a litter, down the
trail.
We get to bridge, get the wheeloff, haul him across the bridge,
put the wheel back on thelitter.
there's just so many thingsgoing on that I just kind of
wait till the patient says, Hey,I'm having pain again, which
usually happens.
Patrick (25:52):
Okay, yeah, 20 minutes or even 40 could go by
relatively quickly in thatsetting.
Chris Van Tillburg (26:00):
Right.
Patrick (26:01):
you're never really giving say your a hundred
milligrams or one milliliter andthen 10 minutes later saying,
well, that obviously wasn'tenough and redosing right then.
Chris Van Tillburg (26:11):
Uh, I think I've done that maybe once or
twice where, know, we've had toredose before 30 or minutes went
by.
But in general, I just kind ofgive him the shot and wait five
minutes for the edge to go awayof the pain.
And then we package them.
I mean, there's so many otherthings we got to do.
We got to extremity.
(26:31):
Package them in a hypothermiawrap, get them in the litter,
somebody might be working on therope raising system, especially
if they're up high on themountain.
We got to get them out of thefemoral, which is where a lot of
people land.
And it's about a, you've been upthere, it's about
Patrick (26:44):
Yeah,
Chris Van Tillburg (26:45):
know, 200 vertical raise to get back to
the hogs back.
Uh, so there's just so muchgoing on that I don't, it's, not
as prescribed as it is in thehospital.
Patrick (26:56):
the fumaroles on the south side of Mount Hood always
reminded me of those things youwould see in kids arcades where
you like feed a quarter in andit does circles and circles and
circles down the drain.
It just seems to pull people inno matter where you fall from
off the top of the south side ofMount Hood.
They just funnel into thefumarole.
Chris Van Tillburg (27:13):
yeah,
Patrick (27:14):
Oh, what an awful place to be.
So are there patients with whomyou would say, ketamine is not
the right drug here.
I am not going to give youketamine to manage your pain.
Chris Van Tillburg (27:26):
well, it does go through my mind.
Occasionally.
we had a patient who had ageneralized tonic clonic seizure
right in front of us, sevenmiles up the trail.
And I didn't, I don't carry,benzodiazepine in my kit.
So, after.
The seizure that we witnessed,was postictal maybe five minutes
or so we got her and startedbringing her down and three hour
(27:48):
ride down in a wheeled, youknow, cascade toboggan.
And so kind of did think twice.
I talked to a pretty skilledparamedic that's on our team
about giving that personketamine for pain because, you
know, there's the some reportsof it, lowering the seizure
threshold and so it's not ideal.
(28:11):
But, you know, it's just, thoseare the kind of some of the
decisions that we make inmedicine.
You make them all the time,right?
You're just, uh, weighing risksand benefits.
We had a two hour extricationdown the trail, so I gave her
ketamine.
I did think twice about it.
Patrick (28:24):
Had this patient sustained traumatic injuries?
Chris Van Tillburg (28:29):
No, was just bouncing around in the litter.
Patrick (28:31):
Okay.
So, I guess, break down for mewhy you were considering pain
control in that setting anyway.
Just for the comfort of theride?
Chris Van Tillburg (28:42):
Yeah, she was in significant pain, just
bouncing around in the litter.
We were seven and a half milesup.
We had two bridges to getacross, one washout.
The wheels got to come off forthose situations.
Um, you know, it's a ruggedtrail and she was complaining of
pain and she said, this isreally awful.
I don't like this and I'mhurting.
So yeah, I was, you know,atrogenic pain, pain caused by
(29:04):
the extrication basically.
So I talked to her about it andtalked to her with my paramedic
and I was like, you know, here'sthe options.
I gave her probably a smallishdose, but yeah, that's just pain
from just extrication.
Patrick (29:16):
Yeah.
Okay.
And then classically, there'sthe concern about increased
intracranial pressure, possiblywhen we administer ketamine.
Um, do you?
Hold any concerns about givingit to people who have sustained
a head injury.
And let's refine that to say,you know, I've hit my head, but
I'm not yet altered, you know,because an altered patient, we
(29:39):
might hold back or be cautiousabout administering centrally
acting medications because wedon't want to make them more
altered.
We don't want to make them stopprotecting their airway or stop.
respiring spontaneously, butlet's say there's that person
who's fallen off the south sideof Mount Hood and they took a
bouncing ride down to thefuneral, hit their head,
(29:59):
obviously wearing a helmet, butmaybe brief loss of
consciousness and that nowthey're talking to you.
Do you have any concerns aboutketamine in that patient?
Chris Van Tillburg (30:08):
Yeah, like I would probably with any altering
pain medicine.
And I think we've had a coupleof those where the,
Patrick (30:15):
Okay.
Chris Van Tillburg (30:23):
that's their fentanyl because they carry it.
So we have had a couple ofsituations where that's a
consideration.
I mean, it's just we got to justweigh the pros and cons.
If we just get the patientpackage in a hypothermia wrap
and bundled in the litter,sometimes that's adequate pain
control and sometimes it isn't.
Patrick (30:44):
And I'm presuming you've never seen the mythical
side effects of laryngospasm orpronounced hypersalivation when
you're administering this paindose ketamine.
Chris Van Tillburg (30:55):
No, but we did have a patient.
It wasn't my patient, but we didhave a patient at the Mountain
Hood Meadows Ski Resort Clinicwho had a, um, airway compromise
because of ketamine, you know,couldn't hold his neck up
straight and kinked his head Thenurses, the doc on duty straight
(31:15):
down his neck and, um, Okay.
But yeah, there, there's thatcase of positional or near
asphyxia.
Patrick (31:24):
And that based on what you said earlier, you were
probably giving a higher dose inthat setting to facilitate a
reduction.
Chris Van Tillburg (31:31):
Yeah, I think that was a case.
It wasn't my patient.
It was one of the other docs,but yeah, I think that was the
case.
it was a joint.
Production,
Patrick (31:38):
And just to quell maybe some of the concerns of the
listeners who have lessfamiliarity with ketamine.
I mean, one of the reasons thatwe so love ketamine in the
emergency department andelsewhere It has the effect of
sedating or dissociating thepatient, providing pain control,
yet they continue to breathe forthemselves, even if you go
completely into thatdissociative zone.
(32:01):
So what you're saying in thispatient is they essentially
became too relaxed and toosedate and it was a mechanical
level obstruction.
They, you know, slumped theirhead and the hose got kinked.
But not that they stoppedbreathing on their own, correct?
Chris Van Tillburg (32:14):
Yes.
A good clarification.
That's correct.
Patrick (32:17):
Yeah, it is such a magical drug for that reason and
fairly neutral on the bloodpressure if anything like a
little bump in the bloodpressure in young healthy people
when we give it.
So those are some significantupsides in comparison to opioids
specifically or our othersedating medications Propofol or
Versed, for example.
(32:39):
I think that's a pretty goodmarch through your approach to
ketamine.
I'm definitely going to try Thisintramuscular ketamine.
I think I'm going to start inthe emergency department using
this for pain control to gainsome familiarity with how folks
look after one to 200 milligramsof intramuscular ketamine.
You said you're thinking aboutadding some benzodiazepines to
(33:02):
your kit.
Are there other medications thatyou have tried carrying with you
in the past and no longer founduseful or ran into problems with
them?
Chris Van Tillburg (33:13):
I don't think so.
And I'm giving a talk at theWilderness Medical Society,
Crested Butte Conference onadvanced life support kits.
So, anybody who attends thatwill get my full, List of what I
bring, but I think, you know, Ibring kind of very basic stuff,
epi, nitro, aspirin, glucagon, acouple types of antihistamine,
(33:40):
one sedating, one non sedating,and decadron, and ketamine.
And I think I have somelidocaine too with me, and
that's about it.
So it's not a huge list, andit's pretty compact.
all the meds fit into like abaggie.
that's designed like a snacksized Ziploc.
Patrick (33:58):
It's quite a snack.
Chris Van Tillburg (34:00):
Yeah.
Yeah.
you know, the challenge really,as you know, in wilderness
medicine is like, especially Irealized when we were sitting
there doing the, pain managementguidelines for WMS, the big
challenge is there's multiplethings happening.
on the side of the mountain oron a trail above a creek.
people are cold.
It's windy.
(34:22):
You're on a dirt trail or onsnow and we, can't literally
just measure out exactly 2milligrams per kilogram, for
example, or we're just, youknow, doing the best we can, as
you know, to try to, getsomebody.
reasonable pain control, evenjust bring it down to a moderate
(34:42):
level from a severe level andthen get them packaged and get
out of there.
Um, so every, there's a lot ofthings happening at once.
And oftentimes, if it's me orour other physician mountain
rescuer, or our highly skilledparamedics, we're often doing
two jobs because we're maybe,Team lead in medical or we're
medical and we're also in chargeof putting in a rope anchor just
(35:04):
because we have limitedresources.
Patrick (35:05):
Right.
Chris Van Tillburg (35:07):
we're doing multiple jobs,
Patrick (35:08):
You don't have the luxury of being the staff
physician inserted by helicopterlike Dominique Zermatt.
Chris Van Tillburg (35:16):
right?
Patrick (35:17):
Which would be fantastic with a big duffel bag
full of tools.
Chris Van Tillburg (35:21):
Yeah,
Patrick (35:22):
Yeah, it definitely falls into the art of medicine
realm where that experience thatyou've garnered in the emergency
department and other caresettings over the course of
years helps you make thosedecisions.
So it's tough if someone is newto this setting where they're A
paramedic who, is just enteringa rescue setting, for example,
(35:44):
or, even worse, a physician whois just entering a rescue
setting.
you want more monitoring tools.
You feel a little bit naked andyou have to fall back on
judgment a lot more, which canbe challenging.
it feels a little bit morevulnerable when you're out in
that setting and you're.
Actions have more consequencebecause you have fewer rescue
(36:06):
tools available at yourdisposal, like less ability to
manage airway.
I don't have a constant cardiacand pulse oximetry monitor.
So I would be more than happy tobe rescued by you, Chris, with
your years of experience.
Chris Van Tillburg (36:23):
but I think our corollary to that really,
you know, really greatobservation.
The corollary is we, the Craigrats, you know, we're the oldest
mountain rescue team in the U.
S.
And we have gone through variouscycles of personnel and.
Just all of a sudden, three orfour years, we have nine ALS
(36:44):
rescuers, paramedics, a criticalcare nurse, three doctors,
including me.
So we are starting an ALSprogram, and I leaned on my good
friend, A.
J.
Wheeler from Teton County tosort of put it together.
In the ALS program, we are onlymedication for those ALS might
(37:06):
be ketamine.
It would be useful to bringother things, but I think the
advantages of ketamine were theydon't cause respiratory
depression, as you mentioned.
And, uh, If you err a little biton the the pain dosing, not, not
going to put somebody into acritical state.
So there are a number of reasonswhere I think that will be the
(37:29):
only pain medicine we carry.
at least when we start, we'rejust starting this program, so
we'll see how it goes.
Patrick (37:36):
Yeah, that's interesting.
We should stay in conversationabout that.
Not bachelors in the position oftrying to expand their ALS
program as well Just wanting todeliver a higher level of care
to their guests And so goingthrough the same kind of
considerations as well.
that brings to mind one lastquestion about ketamine, which
(37:57):
is, do you think about in termsof the viable operating
temperatures, how do youactually protect the physical
integrity of that medication inthe field?
Chris Van Tillburg (38:08):
Yeah, I just have it in my ALS kit buried in
my pack, but I don't do anythingspecial, for it in the field
because usually, we're able toget to a patient in, 1, 2, 3
hours, something like that.
So, I just put it in my pack andgo and hopefully it doesn't
freeze.
I suppose if I was worried aboutit, throw a chemical hand warmer
in my ALS kit.
Patrick (38:28):
so you've never had that vial freeze.
Okay.
Now most, most of the meds, itseems like, have an operating
temperature that is similar tothat of a reasonably comfortable
human.
So, uh, it's, it's always alittle bit off label when you're
like, I'm gonna take this out in30 degree temperatures for six
hours.
(38:48):
Yeah, it's hard to imagine itdenaturing in the cold, but I
have worried aboutprecipitation, for example,
having it come out of solution.
Well, I think let's wrap uphere.
I want you to give us a littleblurb about your upcoming book.
You have a truly impressive listof your bibliography, not
(39:09):
bibliography, your, your opus isextensive.
You have written quite a numberof books, both pertaining to
wilderness medicine and toTravel in the backcountry,
backcountry ski and snowboardroutes, Oregon.
It's really impressive.
And I actually, when looking atyour upcoming book, I'm quite
interested to pick up a copy.
(39:30):
Why don't you let us know what,what we have in store.
Chris Van Tillburg (39:35):
Well, I've been a member of the Craig Rats
Mountain Rescue Team based inHood River, Oregon since, 2000
and, we were the oldest rescueteam in the nation formed in
1926, so our, centennialanniversary is coming up next
year.
I said about, Documenting the100 year history of the Craig
rats.
(39:55):
And after, you know, I've beenworking on this project for 3 or
4 years and after going over itwith my agent and my editor,
really about a 3rd of it isabout the 100 year history of
the Craig rats and about 2 3rdsof it is the changing landscape
of Mount Hood and how, you know,in 2022 during the pandemic, we
(40:19):
had this surge of outdoorrecreation and it, expanded all
of the typical problems we have.
So, it's really, it's a historynarrative, but also grounded in
modern day.
Patrick (40:34):
So it's a hundred years of rescue history on Mount Hood.
from the very early days up tonow,
Chris Van Tillburg (40:43):
Yeah, and the Craig Rats have very
detailed archives date back to1926.
I mean, it took me a year justto go through the meeting
minutes and news clips and, um,yeah, they, Craig Rats have
maintained detailed archives.
Patrick (40:57):
that's very cool.
If our listeners are interestedin learning about that or diving
into more of your works, whereshould they connect with you?
Where can they find Chris VanTilburg?
Chris Van Tillburg (41:10):
Uh, the best way is probably just to go to,
um, either Wikipedia or, linktree, has links to my recent
articles in an outside magazine,and it has a WMS practice
guideline.
So my link tree or my Wikipediapage have probably is the best
place to start.
Patrick (41:29):
Perfect.
And for the listeners, we'll putthose in the show notes.
So you don't have to go diggingaround for those.
And he just put in a subtle plugfor our wilderness medicine
clinical practice guidelines.
Chris is the lead author on theavalanche and snow burial.
Guideline, but also, as Imentioned earlier, joined us on
the pain management in austeresettings, which is, it's a tome.
(41:52):
it's not an easy read because ofthe expansiveness of the
document.
But if you are interested indiving deeper, we have different
sections on differentmedications.
And also, I think the kind ofgeneral approach to.
Pain management in there coversa lot of the art side of what
we're talking about here.
The many considerations that gointo wilderness pain control.
(42:13):
So you can look in the shownotes to find a link to that as
well.
It is open access, so anyone canread it.
Thank you again, Chris, forjoining us.
A really.
Enjoyed chatting about this andI'm personally looking forward
to giving some ketamine to somefolks starting tomorrow in the
ER for pain control.
Going to build my experiencearound this one.
Chris Van Tillburg (42:32):
Okay.
Good luck.
Thanks a lot for having
Patrick (42:42):
All right, everybody.
I hope you enjoyed thatconversation with Dr.
Chris Van Tilburg.
Physician, author, rescuer,mountaineer, athlete.
He's an interesting guy.
I know Chris from our worktogether on the Wilderness
Medical Society guideline forpain management in the austere
environment, but he's also thelead author on the avalanche and
(43:04):
snow burial guideline.
And both of those are linkeddown in the show notes as well
as links to Chris's personalpage on His link tree, his
Wikipedia, anything you can wantto do to reach out to Chris, as
well as the link where you canpre order his upcoming book, I
don't get any kickbacks if youorder his books, but it looks
like an awesome book and he'sbeen going through some really,
really cool archives and puttingtogether some awesome history.
(43:28):
So I hope you enjoyed ourconversation as always.
If you have questions, comments,Suggestions for future episodes.
Want to delve into things moreor just have a personal
clarifying question.
You want to reach out to me andwe can chat about how you are
approaching pain management foryour search and rescue your ski
patrol or just your personaluse.
(43:48):
Don't hesitate to reach out atwilderness medicine updates at
gmail.
com right now.
I am not on social media withany of this stuff because I just
can't handle it.
The real world happenselsewhere.
So if you want to support theshow.
Because this is a passionproject and I just pay for it
out of pocket.
We don't have any sponsors yet.
(44:10):
The best thing you can do ismake sure you are subscribed on
your listening platform ofchoice, be that Apple podcasts
or Spotify and whatever platformyou're on.
Do give us a review.
Give us five stars because thathelps get this out to other
people.
It helps get us into thatsuggestions box where it says,
Hey, You listen to this podcast.
(44:31):
Maybe you'd like wildernessmedicine updates.
And if you have another friend,a skier, a climber, a boater, a
wilderness traveler, explorer,rescuer, Mountaineer, another
athlete, maybe a med student, aPA, a nurse, an EMT paramedic.
SAR member, ski patrol memberwho you know, hasn't heard this
podcast and you know, they wouldbenefit from hearing about
(44:54):
wilderness pain control orupdates to avalanche rescue
protocols or the physiology ofthe buried avalanche victim, or
all of the other stuff I'm goingto be pushing out this year,
share an episode with them andinvite them to join the crowd.
I really appreciate all thepositive feedback that I get
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(45:16):
reviews.
I see all of them and Iappreciate all of them and I do
reply to all the emails that Ireceive.
So until next time, stay fit,stay focused, have fun.
Welcome back to Wilderness Medicine Updates.
The show for providers at theedges and happy new year to you
all.
This is our first episode for2025.
And I'm very happy to be wishingyou a happy new year from Bend,
Oregon, where we have aridiculously deep snowpack and
somehow haven't really gottenany snow in town.
It's pretty nice to live nearthe mountains and not in them
(00:28):
sometimes.
Today, I'm super excited towelcome a guest to the show.
Chris Van Tilburg.
I'm gonna talk to you a littlebit about Chris in just a
second, but our topic for todayis going to be approach to
wilderness pain control, andimportantly, we're gonna make a
deep dive on ketamine.
Ketamine is a medication thatyou may be familiar with because
(00:50):
of the news, has killed somecelebrities recently, or maybe
you've heard of people gettingketamine infusions for treatment
resistant depression orsubstance abuse.
Well, for us in the emergencydepartment, ketamine.
Is a wonder drug of sortsbecause it can be used for pain
control.
It can be used for sedation.
It can be used to intubatepeople.
(01:10):
It can be used to control thedangerously agitated, but it has
some special features thatdifferentiate it from opioids or
NSAIDs and then make itparticularly well suited to use
in unmonitored or minimallymonitored environments, such as
out in the wilderness or thesearch and rescue context.
(01:30):
First, a little bit about Chrisstraight from his Wikipedia
page.
He's a cool enough doctor tohave a Wikipedia page.
Chris van Tilburg is an Americanphysician and author
specializing in emergencywilderness travel, environmental
occupational and public healthmedicine.
He is the author of 11 books onoutdoor recreation, wilderness
(01:51):
medicine, and internationaltravel.
Including a couple of memoirs,one called mountain rescue
doctor, wilderness medicine inthe extremes of nature and
search and rescue a wildernessdoctors life and death tales of
risk and reward.
He has a forthcoming book, whichwe discuss at the end of this
podcast, crisis on Mount hoodstories from 100 years of
(02:13):
mountain rescue.
And that comes from Chris'sbackground as a deployable
member of the crag rats, whichis a search and rescue team on
the North side.
Of Mount hood.
And I believe that the longestcontinuously operating search
and rescue team in the UnitedStates.
Chris is also a family medicinetrained emergency medicine doc
(02:36):
working out of hood river,Oregon, and he's a medical
director to a number of mountainrescue and search and rescue
teams.
And this podcast, you can expectto hear about Chris's approach
to search and rescue painmanagement.
You're also going to hear whyketamine is his drug of choice
and why we both shy fromwilderness use of intranasal
(02:57):
medications.
We're going to talk about whichmedications he brings with him
on a SAR deployment and whichones he does not and why and so
much more.
Before we dive in, I also wantto thank those of you who have
given the podcast a writtenrating on Apple podcasts, I'm
looking at you lions, Leo,Haley, one eight, eight, and my
(03:19):
favorite name on there.
Sorry to the other two charterspatula.
I appreciate the comments thatwent along with your five star
reviews.
It really warms my heart and itdefinitely helps get the This
podcast out to other people whenyou drop those reviews.
So thank you.
And if you want to be mentionedon the show, keep them rolling.
Without further ado, let's jumpinto my conversation with Dr.
(03:41):
Chris Van Tilburg.
It's great to have you on theshow, Chris, I really appreciate
you coming.
When someone asks you at adinner party, what you do, how
do you elevator pitch yourself?
Cause you have a lot of balls inthe air,
Chris Van Tillburg (03:57):
Well, it's, it's easiest to explain to
people that I'm a and wildernessdoctor, but of my job now I do
administration, administrativemedicine.
but that's the easiest thing totell people is kind of
encompasses my entire career.
Patrick (04:18):
but Chris, what's a wilderness doctor.
Chris Van Tillburg (04:21):
A wilderness physician is generally anybody
who's practicing medicine inrural, remote, or wild areas,
and for me, that means mostlymountain rescue, but I've also
worked in Haiti.
I've been to Haiti five times.
I've been a cruise ship pilot.
(04:42):
Doctor, I've been an expeditiondoctor but most of my time now
is in mountain rescue.
Patrick (04:48):
Okay.
And is that predominantly orexclusively with the crag rats?
Chris Van Tillburg (04:54):
No, I'm a field deployable member of the
Craig rats.
Last year I went on 35 missionsor something like that.
But I'm also field deployableand medical director of Portland
mountain rescue, which is thoseare the two teams that cover
mountain hood.
Craig rats generally cover the.
North and east portal MountainRescue covers the south.
(05:15):
I'm also a medical director forClackamas County, SAR and
Pacific Northwest SAR.
Those are the two ground teamsthat cover Mount Hood.
Patrick (05:24):
You're a busy guy.
That's a lot of run reviews andtraining.
Chris Van Tillburg (05:28):
Well, I got, a great medical lead for every
team.
So it's, it's fabulous.
I got really great help.
Patrick (05:34):
Awesome.
So the reason that I wanted toreach out to you to talk about
wilderness pain control, andspecifically ketamine, was the
expertise that you brought toour group when we were putting
together the pain managementguideline for the Wilderness
Medicine Society.
And it seems like you have aparticular knack with ketamine,
(05:54):
which is where I want to get toeventually.
For the purposes of thisdiscussion, let's table the
language and you can say remote,austere wilderness when we're
talking about like, Well,outside the hospital
environment, what do you thinkof as the challenges of managing
pain in those settings that areunique to wilderness or austere
(06:18):
settings?
Chris Van Tillburg (06:19):
Great question.
The two probably the two biggestchallenges.
One is a medical provider issueand one's a patient issue for
medical providers.
Our biggest challenges.
We just can't take very much.
Very many up on the table.
the mountain or up the trail.
We just have a limited space inour pack and we have to make
(06:42):
really hard decisions sometimeswhat we take up the trail.
So that is one of the biglimitations.
The other big limitations is thepatient is in a oftentimes in a
remote or rural or area and sothat Even if we did have
equipment up the trail, it justmakes delivery of medical care
(07:04):
very, very challenging.
Patrick (07:06):
So, when you're thinking about constraints on
your pack, are you thinkingabout, you know, the range of
medications you can bring?
Are we talking monitoringequipment?
what do you typically have inthe hospital that you find that
you do not have when you're upon the north side of mount hood,
for example?
Chris Van Tillburg (07:22):
Well, I have a like 40 liter pack.
And then I generally in theAlpine, I take an airbag pack.
So in that pack, I have to takemy personal safety equipment, my
spare clothing, food, water, mytechnical climbing equipment for
the South side of Mount Hood.
That's going to be like a PetzlRAD line.
And.
Set of boot crampons and aharness I'm usually wearing.
(07:47):
And then.
that stuff fills up, you know,most of my pack.
And so I have limitations ofwhat I can bring.
So typically, I bring a sixliter bag zippered pouch that
has my advanced life support kitand oftentimes, depending on the
situation, I'll bring it.
An AED I'll bring a heat blanketor two, and we might spread
(08:11):
those out amongst the teammembers, depending if I'm on the
ready, I'm on the hasty team, orif I'm coming after some gears
already up the mountain.
So, just situationallydependent, but those are the
things I bring.
I don't bring IV fluids.
I don't bring a twelve leadmonitor.
bring kit, you know, all thosethings that we have available to
(08:34):
us in the emergency department.
Patrick (08:35):
Okay, so a limited subset Of both medication tools,
but then also physical tools.
Do you have the capacity tomonitor blood pressure and, uh,
to monitor oxygenation,
Chris Van Tillburg (08:48):
I carry a pulse oximeter, which is mostly
helpful, I've found.
Bringing somebody down themountain.
It's a quick, easy way to, foranybody, any BLS rescuer can
glance at the pulse oximeter andsay, yeah, we still got a pulse
and we still got O2 sat at theappropriate.
So it's a great tool to monitorsomebody.
(09:11):
I don't bring a blood pressurecuff because it's just 1 of the
things I've decided, you know, Ihave to cut something out.
I only have 6 liter bags.
So it's 1 of the things I justdecided, it's, it's useful, but
not gonna make, not gonna employmedical decision making that I
can't use other tools and skillsfor.
Patrick (09:29):
right?
When you see a low bloodpressure, what are you going to
do?
You're going to walk out faster.
Chris Van Tillburg (09:35):
Yeah, right.
Patrick (09:37):
So when you're thinking about your role as the physician
or the medical provider on atechnical rescue team, what are
your goals when you're,Delivering pain control to a
patient.
that seems like a reallystraightforward question, right?
You're like to get rid of pain.
I want them to have less pain,but everything has a downside to
it So what are yourconsiderations when you're
(09:58):
thinking about should I use thismedication?
Should I not will this?
Enhance our action here, or isthis just gonna impede us?
Chris Van Tillburg (10:08):
Right.
Probably an important goal,maybe not the most important,
but an important goal is to makejob of the rescuers easier.
We had a ankle fracturedislocation.
Last summer, four miles up thetrail combined with the elbow
(10:30):
non dislocation, and it wasuntil I got there, it was just
impossible to even move thisperson, this patient, even get,
get that person out of us into asafe zone.
We were up by a waterfall.
There's water sprayingeverywhere.
So, a really important job ofpain control is to make the job,
allow the rescuers to do theirjob.
Patrick (10:49):
that's like packaging and moving the patient in that
setting.
Chris Van Tillburg (10:53):
Yeah, correct.
It was like, they couldn't evenmove her.
For Into a safe spot withoutpaying control, and then we had
to move her into the litter andget her down the trail.
So, yes yeah, pack moving andpackaging.
Patrick (11:03):
Okay.
And obviously there's, you know,kind of multiple levels to pain
control that we can apply and wemight go straight to higher
levels in that setting wheresomeone is clearly in
excruciating pain.
But can you march me through thelevels that you think of in
terms of like, this is thelowest level or the base level
of care that I've essentiallydelivered to almost everybody.
(11:25):
And then this is how I escalatemy.
Pain management tactics,depending on what's in front of
me.
Chris Van Tillburg (11:34):
Yeah, I think in my situation, there's
really three levels of paintreatment.
One is just getting somebody.
Immobilizing a fracture orgetting them into a litter off
the trail, straighten theirfractured extremity or
immobilizing it.
That's probably the quickest andeasiest and one of the most
(11:57):
essential things to do.
And then the next step would besome kind of oral over the
counter.
And then the third step would beprescription medication.
Patrick (12:05):
So, immobilization first, because If that broken
wrist stops flapping in the windthat addresses a significant
pain driver
Chris Van Tillburg (12:16):
Yeah.
And a lot of people, we get thempackaged in a litter and they're
immediately, the two effectshappen.
One is kind of alleviates theirpain because they're off the
ground and they're stabilized.
And then it provides a fair bitof anxiety relief because all of
a sudden they realize I'm goingto be taking care of them in
this package.
And I got a bunch of rescuersaround me.
Patrick (12:37):
That's an interesting effect to think about kind of
ties into the psychologicalfirst aid side of things you
know, we always talk abouttrying to Empower the patient or
involve them in their care Butat times they're perfectly happy
to be wrapped up in a blanketand say take it from here
Chris Van Tillburg (12:56):
Right?
Patrick (12:59):
I feel safe now
Chris Van Tillburg (13:01):
Yeah.
Patrick (13:03):
What is your over the counter pain strategy or oral
pain control?
What's that level 2 look like?
Chris Van Tillburg (13:10):
Usually that's, you know, Tylenol is the
safest.
Ibuprofen is the mostubiquitous.
Somebody's usually got that intheir pack, or I have both.
once in a while I'll use whichisn't over the counter, but it's
maybe a little bit safer to usethan Ibuprofen in some
situations.
But yeah, it's Tylenol andIbuprofen.
Patrick (13:29):
Remind me, is it meloxicam that's in the military
pill packs?
Chris Van Tillburg (13:34):
Yeah, exactly.
Patrick (13:35):
Okay.
For those who aren't familiar,that's like a self administered
pain pack that the militaryuses, which has immediate
administration pain meds as wellas an antibiotic.
So if you sustain some kind ofwound in the field, they can
treat themselves immediately.
Um, so you, you start off withan NSAID and Tylenol of some
(13:56):
form, and then let's say that,that lady you've just pulled out
from underneath the waterfallwith the elbow fracture, the
ankle fracture.
She's in the litter, she'sstabilized, you managed to get
her to swallow some NSAIDs.
She's still screaming.
You clearly would like to kindof March to that next level.
What is your first line kind ofprescription or show physician
(14:20):
level medication?
Chris Van Tillburg (14:24):
I should mention that sometimes I go
straight to the the good drugs.
Like, I don't even mess withibuprofen.
Sometimes if somebody's insignificant pain, or if I want
to make sure I keep them withouttaking anything by mouth, like
I've had that a few times withhead injuries, but I only carry.
Ketamine and oxycodone.
That's all I carry those twothings.
(14:45):
So if I can't give somebody, Irarely use oxycodone because of.
the risk of, respiratorycompromise and it just takes
longer to work.
I usually go right to ketamine.
Patrick (14:59):
Okay.
I think a lot of us on thispodcast and people listening,
perhaps with an EMS backgroundor saying, where's the fentanyl?
Chris Van Tillburg (15:09):
Yeah, I don't carry it.
I don't carry it for a couple ofreasons.
One is I can do almosteverything with ketamine that I
would do with fentanyl two isit's a little.
More challenging to carrybecause of the higher level of
controlled substance by the D.
E.
A.
That's kind of a minor issue.
Um, and then, um, you know, theside effects of fentanyl are are
(15:32):
more pronounced and ketamine.
So I don't even I've nevercarried it.
I don't carry it.
I just carry ketamine.
Patrick (15:37):
Those side effects being respiratory depression and
potentially altered mentalstatus, depending on the
patient.
Chris Van Tillburg (15:44):
Correct.
Patrick (15:47):
I have always used fentanyl as a first line, but
my, wilderness operationalcontext is usually ski hill
medicine.
If I've had one issue with it,it's that.
Delivering it intranasally ispretty variable in that setting
because people's noses are coldand runny and intramuscular
(16:08):
fentanyl doses to be effectiveneed to be probably up above 100
micrograms, which means thatwe're talking about four
milliliters plus of a standardmixture of fentanyl.
I have been hesitant to useketamine.
I'll admit that.
You seem very comfortable, andthis is like where I want to dig
in a little deeper.
Can you anticipate why I wouldbe hesitant to use ketamine?
Chris Van Tillburg (16:34):
Well, I'm not sure exactly your
perspective, but I have somepeople are hesitant to use it
because it hasn't been used aslong as a parental opioids.
It has it's it's a drug ofabuse.
So there's all is that stigmataabout it.
But so is fentanyl.
And just, you know, maybe inunfamiliarity with it.
(16:55):
I mean, I use it somewhat rarelyin the emergency department when
I work, or especially at the skiclinic we have a minor or major
procedure to do.
That's pretty straightforward,but maybe unfamiliarity might be
part of it too.
Patrick (17:09):
Okay, it was unfair to ask you to read my mind.
I think, as you know, I'm alsoan emergency physician, and so I
use it a ton in the emergencydepartment,, often in people who
have experience with opioids,who have significant pain.
It can be opioid sparing in thatcontext, but I'm usually
administering it.
IV in that setting at a doserange of 1 to 3 milligrams per
(17:33):
kilogram, which we don't need todive too much into the math here
today, but it's a relatively lowdose.
And even at those doses, Ioccasionally have people who get
weird, um, you know, if it's notpushed slowly or hung in a bag,
I get people who startexperiencing hallucinations.
So let's contextualize this alittle bit for our audience,
(17:55):
because probably a number ofthem might not have as much
familiarity with ketamine as wedo.
talk with me or explain the doserange that exists within
ketamine, how we get from likenothing up to we're using it as
an RSI drug.
Chris Van Tillburg (18:13):
Right.
Well, I use it.
Pain management dosage.
I don't use it yet.
The dissociative sedation dosageexcept the occasion would be at
the mountain ski resort clinicwhere we have a nurse full code
card.
(18:33):
Sometimes they're there for adifficult shoulder reduction or
something or a.
you know, pediatric, polysfracture reduction.
I may use it, but generally Ionly use it in a pain dose.
I carry a nasal atomizer, butI've never given ketamine
intranasally for the exact sameissue you've already mentioned.
Patrick (18:55):
That's kind of variable effect and absorption.
Chris Van Tillburg (18:57):
Yeah, if somebody's on the side of a
mountain shivering and they'recold and they're trying, you're
telling them to hold theirbreath and then snort through
their nose.
And it's just, I've never doneit just for that reason.
So I give it.
I am, um, and I give, you know,one, two milligrams per
kilogram.
I am.
So, um, a hundred milligrams ispretty safe for most adults for
(19:20):
the pain dose.
I have had people, okay.
Um, not get great pain controlwith that.
I've also had people that aregetting slightly loopy and
slightly dissociative with thatdose.
So to err on the side of maybe alittle less to start see what
happens.
The half life is like, in myexperience, 30 to 40 minutes.
So it's, you know, you got toredose in 30 to 40 minutes or
(19:42):
hopefully you're off themountain.
Patrick (19:43):
Okay.
So I think of ketamine as havingbasically three dosing ranges.
The first being the one thatyou're trying to stay inside of,
which is where it's providingpain control.
And then if we get up higherabove that, that's probably what
we could call the recreational.
where people who are abusingthis drug are tending to use it
for that effect, where at thatpoint people are starting to
(20:06):
hallucinate, but have notreached zone three, which I
would call dissociative doseketamine, which is where mind
and body are not in relationshipwith one another.
And that's the level at which weuse it in the emergency
department when we'reintubating.
So you don't get too muchexperience with people.
starting to have hallucinationswhen you're giving it at two
(20:27):
milligrams per kilogramintramuscularly.
Chris Van Tillburg (20:31):
I've had it happen once.
I give it roughly four to fivetimes a year, either on the
mountain or up a trail in aremote location.
And so I've had that happen.
I had that happen once last yearthen it wore off and I just
backed off on the dose a littlebit.
But, um, I have that happenwith, two milligrams per
kilogram.
Patrick (20:51):
Because when you say two milligrams per kilogram, my
mind immediately goes to whenketamine has been studied for
management of the dangerouslyagitated psychiatric patient,
the dose range For putting thosepeople down is three to five
milligrams per kilogram.
So it's really not that muchfarther away, but it sounds like
(21:14):
you don't have a lot of troublewith, strapping people into that
litter and getting halfway downtowards cloud cap.
And they're seeing machine elvesor strange hallucinations.
Chris Van Tillburg (21:26):
Yeah.
And that that does pass fairlyquickly.
And probably I use more like oneto one point five milligrams per
kilogram.
Because basically theformulation I buy it in is, um,
one hundred per M.
L.
And it's in a five M.
L.
Bottle.
So, um, You know, we're notweighing people
Patrick (21:46):
Right.
Chris Van Tillburg (21:47):
Sometimes you can ask people what they
weigh and sometimes you got toguess probably more often than
not, I just give a hundredmilligrams.
So it's one CC, one ML.
It's easy for somebody to helpme draw it up.
If they're a paramedic or, um,you know, if there's two of us,
or sometimes I draw it up andgive it to our awesome critical
care nurse who's on our team.
So, yeah.
(22:07):
So oftentimes I just go straightto a hundred milligrams
Patrick (22:10):
Okay, and for most people, that's going to land
between one and two milligramsper kilogram for an adult size
human.
Chris Van Tillburg (22:16):
Right.
Patrick (22:17):
let's just talk nitty gritty tactics.
Obviously, you're going to drawit up with a large gauge needle
when you give it.
I am what size needle are youcaring for that?
Chris Van Tillburg (22:28):
Well, that's a great question.
You know, so typically I carry,two eighteens and two twenty
sevens, but I think the lasttime I used it, which was on a
trail up on Mount hood forwhatever reason, I couldn't find
any 27 gauge needles, so I drewit up with an 18 and gave it an
(22:48):
18.
Not the best, but this lady, shewas in bad shape and we couldn't
even move her at all.
So, that's just, but yeah,generally, I like to just carry
an 18 and a 27.
Patrick (22:59):
Yeah, that's a small biopsy.
when you're administering itintramuscularly, do you prefer
shoulder versus thigh versusglued?
Or is it just what you can getaccess to?
Chris Van Tillburg (23:11):
I think I've only given it in the shoulder in
the deltoid because gettingaccess to any other muscle is
very challenging, especiallypeople have lower extremity
injuries and you got to taketheir clothes off.
It's pretty easy to somehow getto a deltoid.
Um, and so that's where I'vealways given it.
Patrick (23:31):
Okay.
I'm going to share my nonevidence based tactic for the
lower extremity, which is mostpeople have pockets.
And so you can go through thelining of the pocket into the
thigh without Exposing the leg.
That's something I came up withwhen people got tired of me
poking holes in their Gore Texpants.
I was just administering itstraight through the arcteryx
(23:52):
and it made some people a littlefrosty, but through the pocket
works pretty well if you don'thave access to the shoulder.
Chris Van Tillburg (23:59):
That's a great idea.
Fabulous idea.
Patrick (24:02):
Yeah, because that's why we're not giving IV meds,
right?
Both the fussiness of the IV andbecause we don't want to expose
people.
So there's always the side zipon the pants or the pocket where
there's the thin nothingmaterial and you can usually
find some thigh muscle throughthere.
Chris Van Tillburg (24:20):
Yeah, that's a great idea.
Patrick (24:22):
So when you administer it intramuscularly, how long
Before peak effect, generallyspeaking.
Chris Van Tillburg (24:29):
In my experience, it's usually pretty
quick, five or six, sevenminutes, something like that.
And then, peaks, in 20 or 30minutes and then wears off by 40
minutes.
So, oftentimes, know, it's twoor three hour trail excavation.
I'm doing multiple doses.
Patrick (24:44):
Okay, and do you carry just the single vial of five
milliliters?
Chris Van Tillburg (24:49):
Yep, that's it.
So, and then I get home, I wasteit and, you know, put a new one
in my kit.
But yeah, I just carry one, fiveml bottle.
Patrick (25:00):
Okay.
How do you decide at that sevento ten minute mark whether or
not to up the dose or re dose?
Are you just waiting a fulltwenty to forty minute cycle and
saying the next time I dose, I'mgoing to give more if pain
control was not adequate?
Chris Van Tillburg (25:17):
No, because the rescues in the mountain
rescue situation are, you know,I wouldn't say chaotic, but
there's so many different thingsgoing on.
do I have somebody who couldkeep track of time.
I try to have somebody on theirphone, either myself or somebody
else start a little chart noteand just document times, but,
(25:37):
you know, we're wheeling thepatient down a litter, down the
trail.
We get to bridge, get the wheeloff, haul him across the bridge,
put the wheel back on thelitter.
there's just so many thingsgoing on that I just kind of
wait till the patient says, Hey,I'm having pain again, which
usually happens.
Patrick (25:52):
Okay, yeah, 20 minutes or even 40 could go by
relatively quickly in thatsetting.
Chris Van Tillburg (26:00):
Right.
Patrick (26:01):
you're never really giving say your a hundred
milligrams or one milliliter andthen 10 minutes later saying,
well, that obviously wasn'tenough and redosing right then.
Chris Van Tillburg (26:11):
Uh, I think I've done that maybe once or
twice where, know, we've had toredose before 30 or minutes went
by.
But in general, I just kind ofgive him the shot and wait five
minutes for the edge to go awayof the pain.
And then we package them.
I mean, there's so many otherthings we got to do.
We got to extremity.
(26:31):
Package them in a hypothermiawrap, get them in the litter,
somebody might be working on therope raising system, especially
if they're up high on themountain.
We got to get them out of thefemoral, which is where a lot of
people land.
And it's about a, you've been upthere, it's about
Patrick (26:44):
Yeah,
Chris Van Tillburg (26:45):
know, 200 vertical raise to get back to
the hogs back.
Uh, so there's just so muchgoing on that I don't, it's, not
as prescribed as it is in thehospital.
Patrick (26:56):
the fumaroles on the south side of Mount Hood always
reminded me of those things youwould see in kids arcades where
you like feed a quarter in andit does circles and circles and
circles down the drain.
It just seems to pull people inno matter where you fall from
off the top of the south side ofMount Hood.
They just funnel into thefumarole.
Chris Van Tillburg (27:13):
yeah,
Patrick (27:14):
Oh, what an awful place to be.
So are there patients with whomyou would say, ketamine is not
the right drug here.
I am not going to give youketamine to manage your pain.
Chris Van Tillburg (27:26):
well, it does go through my mind.
Occasionally.
we had a patient who had ageneralized tonic clonic seizure
right in front of us, sevenmiles up the trail.
And I didn't, I don't carry,benzodiazepine in my kit.
So, after.
The seizure that we witnessed,was postictal maybe five minutes
or so we got her and startedbringing her down and three hour
(27:48):
ride down in a wheeled, youknow, cascade toboggan.
And so kind of did think twice.
I talked to a pretty skilledparamedic that's on our team
about giving that personketamine for pain because, you
know, there's the some reportsof it, lowering the seizure
threshold and so it's not ideal.
(28:11):
But, you know, it's just, thoseare the kind of some of the
decisions that we make inmedicine.
You make them all the time,right?
You're just, uh, weighing risksand benefits.
We had a two hour extricationdown the trail, so I gave her
ketamine.
I did think twice about it.
Patrick (28:24):
Had this patient sustained traumatic injuries?
Chris Van Tillburg (28:29):
No, was just bouncing around in the litter.
Patrick (28:31):
Okay.
So, I guess, break down for mewhy you were considering pain
control in that setting anyway.
Just for the comfort of theride?
Chris Van Tillburg (28:42):
Yeah, she was in significant pain, just
bouncing around in the litter.
We were seven and a half milesup.
We had two bridges to getacross, one washout.
The wheels got to come off forthose situations.
Um, you know, it's a ruggedtrail and she was complaining of
pain and she said, this isreally awful.
I don't like this and I'mhurting.
So yeah, I was, you know,atrogenic pain, pain caused by
(29:04):
the extrication basically.
So I talked to her about it andtalked to her with my paramedic
and I was like, you know, here'sthe options.
I gave her probably a smallishdose, but yeah, that's just pain
from just extrication.
Patrick (29:16):
Yeah.
Okay.
And then classically, there'sthe concern about increased
intracranial pressure, possiblywhen we administer ketamine.
Um, do you?
Hold any concerns about givingit to people who have sustained
a head injury.
And let's refine that to say,you know, I've hit my head, but
I'm not yet altered, you know,because an altered patient, we
(29:39):
might hold back or be cautiousabout administering centrally
acting medications because wedon't want to make them more
altered.
We don't want to make them stopprotecting their airway or stop.
respiring spontaneously, butlet's say there's that person
who's fallen off the south sideof Mount Hood and they took a
bouncing ride down to thefuneral, hit their head,
(29:59):
obviously wearing a helmet, butmaybe brief loss of
consciousness and that nowthey're talking to you.
Do you have any concerns aboutketamine in that patient?
Chris Van Tillburg (30:08):
Yeah, like I would probably with any altering
pain medicine.
And I think we've had a coupleof those where the,
Patrick (30:15):
Okay.
Chris Van Tillburg (30:23):
that's their fentanyl because they carry it.
So we have had a couple ofsituations where that's a
consideration.
I mean, it's just we got to justweigh the pros and cons.
If we just get the patientpackage in a hypothermia wrap
and bundled in the litter,sometimes that's adequate pain
control and sometimes it isn't.
Patrick (30:44):
And I'm presuming you've never seen the mythical
side effects of laryngospasm orpronounced hypersalivation when
you're administering this paindose ketamine.
Chris Van Tillburg (30:55):
No, but we did have a patient.
It wasn't my patient, but we didhave a patient at the Mountain
Hood Meadows Ski Resort Clinicwho had a, um, airway compromise
because of ketamine, you know,couldn't hold his neck up
straight and kinked his head Thenurses, the doc on duty straight
(31:15):
down his neck and, um, Okay.
But yeah, there, there's thatcase of positional or near
asphyxia.
Patrick (31:24):
And that based on what you said earlier, you were
probably giving a higher dose inthat setting to facilitate a
reduction.
Chris Van Tillburg (31:31):
Yeah, I think that was a case.
It wasn't my patient.
It was one of the other docs,but yeah, I think that was the
case.
it was a joint.
Production,
Patrick (31:38):
And just to quell maybe some of the concerns of the
listeners who have lessfamiliarity with ketamine.
I mean, one of the reasons thatwe so love ketamine in the
emergency department andelsewhere It has the effect of
sedating or dissociating thepatient, providing pain control,
yet they continue to breathe forthemselves, even if you go
completely into thatdissociative zone.
(32:01):
So what you're saying in thispatient is they essentially
became too relaxed and toosedate and it was a mechanical
level obstruction.
They, you know, slumped theirhead and the hose got kinked.
But not that they stoppedbreathing on their own, correct?
Chris Van Tillburg (32:14):
Yes.
A good clarification.
That's correct.
Patrick (32:17):
Yeah, it is such a magical drug for that reason and
fairly neutral on the bloodpressure if anything like a
little bump in the bloodpressure in young healthy people
when we give it.
So those are some significantupsides in comparison to opioids
specifically or our othersedating medications Propofol or
Versed, for example.
(32:39):
I think that's a pretty goodmarch through your approach to
ketamine.
I'm definitely going to try Thisintramuscular ketamine.
I think I'm going to start inthe emergency department using
this for pain control to gainsome familiarity with how folks
look after one to 200 milligramsof intramuscular ketamine.
You said you're thinking aboutadding some benzodiazepines to
(33:02):
your kit.
Are there other medications thatyou have tried carrying with you
in the past and no longer founduseful or ran into problems with
them?
Chris Van Tillburg (33:13):
I don't think so.
And I'm giving a talk at theWilderness Medical Society,
Crested Butte Conference onadvanced life support kits.
So, anybody who attends thatwill get my full, List of what I
bring, but I think, you know, Ibring kind of very basic stuff,
epi, nitro, aspirin, glucagon, acouple types of antihistamine,
(33:40):
one sedating, one non sedating,and decadron, and ketamine.
And I think I have somelidocaine too with me, and
that's about it.
So it's not a huge list, andit's pretty compact.
all the meds fit into like abaggie.
that's designed like a snacksized Ziploc.
Patrick (33:58):
It's quite a snack.
Chris Van Tillburg (34:00):
Yeah.
Yeah.
you know, the challenge really,as you know, in wilderness
medicine is like, especially Irealized when we were sitting
there doing the, pain managementguidelines for WMS, the big
challenge is there's multiplethings happening.
on the side of the mountain oron a trail above a creek.
people are cold.
It's windy.
(34:22):
You're on a dirt trail or onsnow and we, can't literally
just measure out exactly 2milligrams per kilogram, for
example, or we're just, youknow, doing the best we can, as
you know, to try to, getsomebody.
reasonable pain control, evenjust bring it down to a moderate
(34:42):
level from a severe level andthen get them packaged and get
out of there.
Um, so every, there's a lot ofthings happening at once.
And oftentimes, if it's me orour other physician mountain
rescuer, or our highly skilledparamedics, we're often doing
two jobs because we're maybe,Team lead in medical or we're
medical and we're also in chargeof putting in a rope anchor just
(35:04):
because we have limitedresources.
Patrick (35:05):
Right.
Chris Van Tillburg (35:07):
we're doing multiple jobs,
Patrick (35:08):
You don't have the luxury of being the staff
physician inserted by helicopterlike Dominique Zermatt.
Chris Van Tillburg (35:16):
right?
Patrick (35:17):
Which would be fantastic with a big duffel bag
full of tools.
Chris Van Tillburg (35:21):
Yeah,
Patrick (35:22):
Yeah, it definitely falls into the art of medicine
realm where that experience thatyou've garnered in the emergency
department and other caresettings over the course of
years helps you make thosedecisions.
So it's tough if someone is newto this setting where they're A
paramedic who, is just enteringa rescue setting, for example,
(35:44):
or, even worse, a physician whois just entering a rescue
setting.
you want more monitoring tools.
You feel a little bit naked andyou have to fall back on
judgment a lot more, which canbe challenging.
it feels a little bit morevulnerable when you're out in
that setting and you're.
Actions have more consequencebecause you have fewer rescue
(36:06):
tools available at yourdisposal, like less ability to
manage airway.
I don't have a constant cardiacand pulse oximetry monitor.
So I would be more than happy tobe rescued by you, Chris, with
your years of experience.
Chris Van Tillburg (36:23):
but I think our corollary to that really,
you know, really greatobservation.
The corollary is we, the Craigrats, you know, we're the oldest
mountain rescue team in the U.
S.
And we have gone through variouscycles of personnel and.
Just all of a sudden, three orfour years, we have nine ALS
(36:44):
rescuers, paramedics, a criticalcare nurse, three doctors,
including me.
So we are starting an ALSprogram, and I leaned on my good
friend, A.
J.
Wheeler from Teton County tosort of put it together.
In the ALS program, we are onlymedication for those ALS might
(37:06):
be ketamine.
It would be useful to bringother things, but I think the
advantages of ketamine were theydon't cause respiratory
depression, as you mentioned.
And, uh, If you err a little biton the the pain dosing, not, not
going to put somebody into acritical state.
So there are a number of reasonswhere I think that will be the
(37:29):
only pain medicine we carry.
at least when we start, we'rejust starting this program, so
we'll see how it goes.
Patrick (37:36):
Yeah, that's interesting.
We should stay in conversationabout that.
Not bachelors in the position oftrying to expand their ALS
program as well Just wanting todeliver a higher level of care
to their guests And so goingthrough the same kind of
considerations as well.
that brings to mind one lastquestion about ketamine, which
(37:57):
is, do you think about in termsof the viable operating
temperatures, how do youactually protect the physical
integrity of that medication inthe field?
Chris Van Tillburg (38:08):
Yeah, I just have it in my ALS kit buried in
my pack, but I don't do anythingspecial, for it in the field
because usually, we're able toget to a patient in, 1, 2, 3
hours, something like that.
So, I just put it in my pack andgo and hopefully it doesn't
freeze.
I suppose if I was worried aboutit, throw a chemical hand warmer
in my ALS kit.
Patrick (38:28):
so you've never had that vial freeze.
Okay.
Now most, most of the meds, itseems like, have an operating
temperature that is similar tothat of a reasonably comfortable
human.
So, uh, it's, it's always alittle bit off label when you're
like, I'm gonna take this out in30 degree temperatures for six
hours.
(38:48):
Yeah, it's hard to imagine itdenaturing in the cold, but I
have worried aboutprecipitation, for example,
having it come out of solution.
Well, I think let's wrap uphere.
I want you to give us a littleblurb about your upcoming book.
You have a truly impressive listof your bibliography, not
(39:09):
bibliography, your, your opus isextensive.
You have written quite a numberof books, both pertaining to
wilderness medicine and toTravel in the backcountry,
backcountry ski and snowboardroutes, Oregon.
It's really impressive.
And I actually, when looking atyour upcoming book, I'm quite
interested to pick up a copy.
(39:30):
Why don't you let us know what,what we have in store.
Chris Van Tillburg (39:35):
Well, I've been a member of the Craig Rats
Mountain Rescue Team based inHood River, Oregon since, 2000
and, we were the oldest rescueteam in the nation formed in
1926, so our, centennialanniversary is coming up next
year.
I said about, Documenting the100 year history of the Craig
rats.
(39:55):
And after, you know, I've beenworking on this project for 3 or
4 years and after going over itwith my agent and my editor,
really about a 3rd of it isabout the 100 year history of
the Craig rats and about 2 3rdsof it is the changing landscape
of Mount Hood and how, you know,in 2022 during the pandemic, we
(40:19):
had this surge of outdoorrecreation and it, expanded all
of the typical problems we have.
So, it's really, it's a historynarrative, but also grounded in
modern day.
Patrick (40:34):
So it's a hundred years of rescue history on Mount Hood.
from the very early days up tonow,
Chris Van Tillburg (40:43):
Yeah, and the Craig Rats have very
detailed archives date back to1926.
I mean, it took me a year justto go through the meeting
minutes and news clips and, um,yeah, they, Craig Rats have
maintained detailed archives.
Patrick (40:57):
that's very cool.
If our listeners are interestedin learning about that or diving
into more of your works, whereshould they connect with you?
Where can they find Chris VanTilburg?
Chris Van Tillburg (41:10):
Uh, the best way is probably just to go to,
um, either Wikipedia or, linktree, has links to my recent
articles in an outside magazine,and it has a WMS practice
guideline.
So my link tree or my Wikipediapage have probably is the best
place to start.
Patrick (41:29):
Perfect.
And for the listeners, we'll putthose in the show notes.
So you don't have to go diggingaround for those.
And he just put in a subtle plugfor our wilderness medicine
clinical practice guidelines.
Chris is the lead author on theavalanche and snow burial.
Guideline, but also, as Imentioned earlier, joined us on
the pain management in austeresettings, which is, it's a tome.
(41:52):
it's not an easy read because ofthe expansiveness of the
document.
But if you are interested indiving deeper, we have different
sections on differentmedications.
And also, I think the kind ofgeneral approach to.
Pain management in there coversa lot of the art side of what
we're talking about here.
The many considerations that gointo wilderness pain control.
(42:13):
So you can look in the shownotes to find a link to that as
well.
It is open access, so anyone canread it.
Thank you again, Chris, forjoining us.
A really.
Enjoyed chatting about this andI'm personally looking forward
to giving some ketamine to somefolks starting tomorrow in the
ER for pain control.
Going to build my experiencearound this one.
Chris Van Tillburg (42:32):
Okay.
Good luck.
Thanks a lot for having
Patrick (42:42):
All right, everybody.
I hope you enjoyed thatconversation with Dr.
Chris Van Tilburg.
Physician, author, rescuer,mountaineer, athlete.
He's an interesting guy.
I know Chris from our worktogether on the Wilderness
Medical Society guideline forpain management in the austere
environment, but he's also thelead author on the avalanche and
(43:04):
snow burial guideline.
And both of those are linkeddown in the show notes as well
as links to Chris's personalpage on His link tree, his
Wikipedia, anything you can wantto do to reach out to Chris, as
well as the link where you canpre order his upcoming book, I
don't get any kickbacks if youorder his books, but it looks
like an awesome book and he'sbeen going through some really,
really cool archives and puttingtogether some awesome history.
(43:28):
So I hope you enjoyed ourconversation as always.
If you have questions, comments,Suggestions for future episodes.
Want to delve into things moreor just have a personal
clarifying question.
You want to reach out to me andwe can chat about how you are
approaching pain management foryour search and rescue your ski
patrol or just your personaluse.
(43:48):
Don't hesitate to reach out atwilderness medicine updates at
gmail.
com right now.
I am not on social media withany of this stuff because I just
can't handle it.
The real world happenselsewhere.
So if you want to support theshow.
Because this is a passionproject and I just pay for it
out of pocket.
We don't have any sponsors yet.
(44:10):
The best thing you can do ismake sure you are subscribed on
your listening platform ofchoice, be that Apple podcasts
or Spotify and whatever platformyou're on.
Do give us a review.
Give us five stars because thathelps get this out to other
people.
It helps get us into thatsuggestions box where it says,
Hey, You listen to this podcast.
(44:31):
Maybe you'd like wildernessmedicine updates.
And if you have another friend,a skier, a climber, a boater, a
wilderness traveler, explorer,rescuer, Mountaineer, another
athlete, maybe a med student, aPA, a nurse, an EMT paramedic.
SAR member, ski patrol memberwho you know, hasn't heard this
podcast and you know, they wouldbenefit from hearing about
(44:54):
wilderness pain control orupdates to avalanche rescue
protocols or the physiology ofthe buried avalanche victim, or
all of the other stuff I'm goingto be pushing out this year,
share an episode with them andinvite them to join the crowd.
I really appreciate all thepositive feedback that I get
from you guys both in person,through the emails, through the
(45:16):
reviews.
I see all of them and Iappreciate all of them and I do
reply to all the emails that Ireceive.
So until next time, stay fit,stay focused, have fun.
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