Wheezing in the Wilderness

December 1, 2011

Asthma is a big problem in the United States, and one which is growing annually. Somewhere between 3000 and 4000 people die from the disease in this country annually; this figure includes about 200 to 300 children. While I am unaware of confirmed asthma deaths in the setting of backcountry treks, the disease is so common it is inevitable that some folks with asthma will have difficulty in the wilderness.

Most specialists in asthma believe that the bulk of these deaths are unnecessary. Many of them result not from the lack of appropriate therapy but from failure to use well-established therapies in the appropriate fashion and time.

There is a major national initiative ongoing to improve all of this. One big component of it is the development of personal “asthma action plans” (AAPs). These are documents which are developed for individual patients with their physicians, which provide specific directions for treatment depending upon actual symptoms. There are several versions of AAPs, but all are predicated on the individual’s assessment of his or her condition as “green” (good), “yellow” (not good), or “red” (awful). The plan provides specific medication suggestions for each zone. Here’s a link to a nice example of an AAP:

How does this relate to the wilderness? Although this system has become state-of-the-art for asthma care in the US, it has largely not penetrated first aid courses–any courses, not just wilderness ones. I recently reviewed over a dozen wilderness first aid textbooks and none even mentioned the AAP. Instead, they had a variety of generic recommendations regarding inhalers, perhaps enhanced by some attempt at explaining esoteric lung physiology, none of which were particularly useful. I guess that I shouldn’t find this too surprising, since at a panel discussion in which I took part a while ago the representative of a major provider of wilderness first aid training commented that he had asthma himself and never heard of an asthma action plan!

Is there an “action item” for the wilderness educator here? You bet there is. Part of the pre-trek process in most programs is some sort of medical history/screening/release. I firmly believe that if any prospective participants provide a history of asthma, they must have an up to date personal AAP, a copy of which accompanies them on the expedition. Of course, there is also a need to be sure that the individual has an adequate supply of any or all drugs called for in the AAP.

What if someone does not have this? Although I hardly ever criticize fellow physicians (I know you’ll find that hard to believe!), this is a time when it is appropriate to do so. Simply put, a physician caring for a patient with asthma in the 21st century who does not provide an asthma action plan is providing substandard care. This isn’t just me–the Center for Medicare and Medicaid Services (CMS) has a standard for hospitals that patients with asthma must be provided with AAPs upon discharge. Failure to do so can actually result in hospital sanctions.

Therefore, I believe that programs have an obligation to their participants to notify them that they must discuss with their physician the development of an AAP and must bring one along with them.