May 3, 2024

Balance in the Wilderness: Consequences and Likelihood

Patrick Burns MD
Chair Elect, ACEP Wilderness Medicine Section

As emergency physicians, we are constantly balancing risk vs benefit in our on shift decision-making. For those of us that serve as medical support for expeditions and other adventures, we meticulously comb through health records, obtain supplies and medications, and try to prepare for different scenarios based on risk. When serving in these roles, we often lean towards being more risk-averse in our preparations, however, our risk tolerance seems to shift when we go on our own adventures.

I recently completed the Tour Aotearoa, a 3000 km gravel bike ride from Cape Reinga at the top of the North Island of New Zealand to Bluff at the bottom of the South Island, in 20 days. It was an aggressive attempt by four friends (two EM physicians, one general surgeon, and a non-medical friend) and we were unsure if it was even possible. The trip averaged nearly 92 miles daily with a mix of paved road, gravel, dirt, and mud traversing some of the most remote parts of the country. Since our timeline was tight, we needed to go fast, which meant we had to take the most minimal gear, weighing every item to the gram. To avoid bringing camping gear, we booked rentals at interval distances in advance, which meant that we had to make it to our destination every day.

At the heart of our preparation was the debate over what we might need in a worst-case situation versus the additional weight that would slow us down.

As an example, while none of us has ever had anaphylaxis, I thought we should bring epinephrine in case we had to contend with this low likelihood but high consequence event. Though New Zealand does not carry Australia’s risk of poisonous creatures, allergens exist, including hymenoptera (bees). According to Auerbach’s Wilderness Medicine textbook, “epinephrine is indicated for use in the medical kit for those who are medically trained when there is a high risk for arthropod envenomation or allergies.” Most medical professionals would recommend bringing epinephrine if there was significant risk of an anaphylactic event. The question before us was simple: how much risk were we willing to take on?

The immediate response from the group was that an EpiPen was far too heavy and would add significant weight to our minimalist group medical kit which only consisted of 4 x 500 mg acetaminophen, 4 x 200 mg ibuprofen, 3 x 500mg azithromycin, 4 x 20 mg famotidine, 2 x 4 mg Zofran ODT, 4 x 10mg cetirizine, 2 x 4mg dexamethasone, 2 x 25 mg benadryl, 2 x bacitracin packets, 2 gauze 4x4, a small bit of rock tape, and some paper tape. In response, I created a minimalist Epi Kit weighing 20 grams.

The arguments against bringing this 20g epinephrine kit were reasonable and well-thought-out. Though 20g is not a great deal of weight, every additional gram would slow us down, and our plan was aggressive with minimal room for error. No one in our group has ever had anaphylaxis, making the need very unlikely. New Zealand has a wonderful medical system and infrastructure should we run into trouble. There were no rest days planned, and there was no room for not making our daily goals.

However, the high consequence of anaphylaxis in the wilderness was a risk I wasn’t willing to gamble on. My Epi Kit consisted of a 1ml vial of 1:1000 epinephrine, 1 ml syringe, a filter needle, a 22 gauge needle, 2 alcohol prep pads, and a 2x2 piece of gauze which was vacuum sealed into a small bag. Many things can be improvised, but epinephrine cannot and there were parts of the ride that placed us more than 40 miles from help on single track routes, without the ability to activate EMS services. If the need arose, help would be difficult to access and likely arrive too late.

How would you approach building a medical kit for this adventure? Would you bring epinephrine or leave it behind? Why or why not?

We documented our adventure on our blog, Aotearoa 2024. Take a look!

Minimalist Epi Kit – 20 grams