N. Stuart Harris, MD, MFA, practices medicine in two starkly different environments. In the Sumner M. Redstone Emergency Department at Massachusetts General Hospital, he is surrounded by some of the most sophisticated medical talent and technology in the world. Dr. Harris also has a passion for practicing medicine in the wilderness.
There, saving a life can mean providing treatment with the barest of essentials — bandages, aspirin and his own wits and skills.
As chief of the emergency department’s Division of Wilderness Medicine, he has worked on a search-and-rescue team on Alaska’s Mount McKinley, performed military research on Mount Kilimanjaro in Tanzania and provided care to victims of the tsunami and earthquake that devastated Japan in 2011. Dr. Harris also is director of the Wilderness Medicine Fellowship, which gives physicians the opportunity to practice medicine and perform research in remote settings like the Mount Everest region of Nepal.
Dr. Harris describes such efforts in modest terms. “There are a lot of areas where our skill set can be leveraged to help out,” he says. “I am convinced that every patient contains deep wells of strength and grace and poise — oftentimes completely unrecognized to them. A good physician bears witness to their suffering, whether patients are in the emergency room or atop a mountain, and helps them tap their own resiliency.”
Providing Care When Resources are Scarce
The wilderness medicine program is infused with the same spirit that prompts Mass General doctors and nurses to seek out underserved patients in Massachusetts community clinics and volunteer in field hospitals in earthquake-ravaged Haiti.
“Wilderness medicine is an important sub-specialty of emergency medicine,” explains David Brown, MD, vice chair of Emergency Medicine at Mass General. “When physicians have a clear understanding of how to provide care when resources are scarce, they are better prepared to provide timely, appropriate, compassionate and effective care to all patients in all settings.”
Interest is growing in providing medical care in extreme and austere environments where resources are limited. Wilderness medicine fellowships are offered by other medical schools and hospitals including the University of Utah and Stanford. Professionals gather for conferences at Harvard Medical School and London’s Royal Society of Medicine.
Wilderness medicine offers unique opportunities for research into common diseases and prepares physicians to provide care after natural disasters or in resource poor countries.
The art of wilderness medicine, Dr. Harris says, is being able to assess a situation quickly and determine what care is appropriate without the benefit of technology like EKG machines or lab testing. In these environments, listening to patients, carefully taking their medical histories and performing physical exams are crucial.
For the safety of their patients and teams, practitioners of wilderness medicine may need training in technical skills from whitewater navigation to dive medicine. And, in some environments, one of the most important abilities physicians can exhibit is knowing how to keep patients and themselves warm and dry.
“They may be very well intentioned and medically well-trained, but physicians who show up without the skill set and equipment to take care of themselves rapidly become a net negative to the situation,” Dr. Harris says.
Beyond providing care in remote and challenging locations, Dr. Harris and his wilderness-medicine colleagues at Mass General have specialized in research on the root cause of high altitude illnesses, a condition of having insufficient oxygen, called hypoxia. Hypoxia can affect climbers, skiers, military personnel and residents of mountainous regions. It can cause shortness of breath, headaches and alterations of consciousness. Some cases can lead to high altitude edema, a potentially deadly build-up of fluid in the lungs.
Specializing in High Altitude Illness
Hypoxia is also at the root of what happens when patients come to the emergency department suffering from a heart attack or stroke, Dr. Harris explains. To best address the broad range of threats that hypoxia poses, he founded and directs the High Altitude Medical Associates, a multispecialty group that cares for patients and collaborates on research projects.
His high altitude research is designed to broaden the understanding of these common conditions caused by organs being deprived of oxygen. By conducting the research in a controlled manner on younger, healthier individuals, factors such as age or pre-existing conditions that can complicate traditional research can be eliminated.
For more than seven years, Dr. Harris and his fellows have worked on projects with the U.S. Army Research Institute of Environmental Medicine in Natick, Mass. They use the army’s high-altitude chambers to artificially take people from sea level to heights above 14,000 feet.
In 2009, Dr. Harris traveled to Mount Kilimanjaro with a research group that included Stephen Muza, PhD, of the Army Research Institute. They studied a group of mountain climbers as they headed up to the 19,340-foot summit. Dr. Harris carried a 14-pound, solar-powered ultrasound machine and used it to examine pressure in the brain caused by swelling that can occur during such a climb. Dr. Muza, a research physiologist, says the recent need to acclimate U.S. troops for high-altitude service in Afghanistan is a good example of why such research is needed.
Recently, Dr. Harris has been steering Mass General’s wilderness medicine program toward another field of research. In 2012, he dispatched David Young, MD, Harvard Affiliated Emergency Medicine resident physician, to Siberia for a month to serve as the doctor for researchers from the Woods Hole Research Center. The group is studying the effects of global warming on a remote region near the Arctic Ocean. Dr. Young conducted independent research, testing mercury levels in the local population. Through such collaborations, Dr. Harris hopes to involve more Mass General physicians in medical research related to climate change.
Practicing Far and Wide
The wilderness has always called to Dr. Harris, who grew up in central Virginia near the Blue Ridge Mountains. As a boy, he learned how to whitewater canoe with his family. Later, he and his sister won a bronze medal for racing at the U.S. Whitewater Nationals. As an undergraduate, he learned how to cave, climb and survive desert heat during a 95-day course with the Wyoming-based National Outdoor Leadership School (NOLS). He traveled through Asia and spent time in the Everest region in Nepal, where he connected with the Himalayan Rescue Association, which operates out of a rudimentary stone clinic, educating trekkers and the Nepalese about high altitude sickness and treating their medical needs.
When Dr. Harris joined the Mass General emergency department staff, he continued to incorporate the wilderness into his career. He started a month-long wilderness medicine course for medical students in the Gila Wilderness of New Mexico in association with NOLS’s Wilderness Medicine Institute. Mass General’s fellowship began after Dr. Harris supervised then surgical resident Peter Fagenholz, MD, who spent months practicing medicine and performing research in Nepal. The result of his two-year fellowship: Dr. Fagenholz published groundbreaking high altitude research.
One of the program’s first fellows, Tracy Cushing, MD, went on to begin a wilderness medicine program at the University of Colorado. She says the three months she spent in Nepal through Mass General provided invaluable experience in trusting her own diagnostic skills. “It was sort of nice to practice medicine with just a stethoscope in your hands,” Dr. Cushing recalls.
Last summer, Dr. Harris worked as a volunteer physician in Denali National Park for a month with a climbing ranger patrol on Mount McKinley. In addition to performing ultrasound research, he provided medical care from a small tent at the medical presence centered at 14,000 feet. There, amid nighttime temperatures that sometimes dipped to minus 10, he made do with two cots, a few tanks of oxygen and a limited supply of medications.
He cared for conditions from blisters to pneumonia and high altitude lung edema and, after a prolonged search, the patrol retrieved the body of an Austrian climber.
One day, a military veteran began having chest pain during an expedition. The patrol hauled the man by sled to Dr. Harris. A storm had blown in, making a helicopter rescue impossible. Dr. Harris traded quiet conversation to keep his patient calm.
“As the veteran’s heart rate dropped to dangerously low levels, he asked me what I would do if he were at the emergency department at Mass General,” Dr. Harris recalls. “I had to tell him that the medication I most wanted — atropine — was ancient and inexpensive and might ultimately save his life — but was not available to us on Mount McKinley.”
The man told Dr. Harris that he appreciated the doctor staying by his side and knowing that whatever happened, he would not be alone.
“What he taught me that night, I carry with me as I see my patients in Boston,” Dr. Harris says. “The opportunity I have to comfort and cure another human being — especially under dire conditions — gives my life’s work meaning.”
Tsunami Response in Japan
Dr. Harris’ skills were tested in 2011, when he joined a medical team that traveled to Japan following the earthquake and tsunami that killed more than 15,000 people and destroyed vast swaths of the island’s northern shore. Other team members included Takashi Shiga, MD, and Kohei Hasegawa, MD, two Mass General emergency medicine colleagues who were born in Japan.
The group was dispatched to Kesennuma, a remote fishing port. Twenty years earlier, Dr. Harris had spent two years in the area teaching English as a second language, studying to earn his black belt in judo and climbing mountains. Many of the quiet villages he remembered had been destroyed. At one location, a fishing vessel was beached on top of a concrete building, tossed by the waters like a toy. A shellfish factory had been wiped from the landscape, leaving behind a mile and a half of broken shells pressed into mud.
The MGH team worked as embedded members of the Tokushukai Hospital’s disaster response team. “Tokushukai welcomed us in and provided expert logistics and support staff that made all of our work possible,” says Dr. Harris. “They remain invaluable friends and colleagues.”
During his week in Japan, Dr. Harris’s wilderness experience quietly came into play. Team members surveyed devastated coastal communities, reassuring displaced residents and tending to medical needs with whatever resources they could muster.
They worked out of a school nurse’s office assessing the needs of 1,200 refugees, many who had chronic conditions like heart failure or diabetes whose care had been disrupted by the storm. In the school gymnasium the displaced families curled up on futons to stay warm. The school had no heat, phone service or running water.
One day, a 38-year-old woman brought in her elderly mother. As Dr. Harris talked with the woman, she mentioned that one side of her own body ached. Additional questions prompted the woman to tell Dr. Harris she had tried to outrun the tsunami, but was caught and thrown against buildings and light poles before grabbing onto a floating tire and eventually pulled herself onto a rooftop. After repeated assurance that her mother would be OK, the woman allowed Dr. Harris to examine her. He was concerned about abdominal bruising, tenderness and her low blood pressure. He scanned her abdomen with an ultrasound machine he had used atop mountains. The woman had no internal injuries and she was able to continue to care for her mother.
“The ability to act thoughtfully and decisively in the face of uncertainty is something emergency medicine physicians do every day,” Dr. Harris says. “In the hospital, we very much take it for granted that a clean, well-lighted space is the starting point for good medicine. In wilderness medicine, we start with a human telling a story, and together, we move forward from there.”
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Photo at top by Menno Boermans