The nature of medicine

Luanne Freer wrote the book on wilderness medicine. Truly. It’s called “Field Guide to Wilderness Medicine” and it’s a 950-page tome. Freer co-authored the latest edition in 2019.

In it are instructions for putting a patient with a broken bone in traction using a parachute cord, a trucker’s hitch knot and a trekking pole, and how to improvise a pelvic sling using jackets, tent poles and duct tape. You’ll find an illustration of exactly where to insert a pocket knife to open someone’s throat and deliver oxygen to an obstructed airway. There are instructions on how to make snowshoes out of sticks, how to use snow to create an emergency shelter and how to humanely euthanize an animal with a pistol.

Wilderness doctors are made in the field, not in the classroom. They practice the art of improvised medicine, and it’s practiced without the proper tools or environment in every kind of weather. There’s no triage department or nurses to start IVs (usually there are no IVs anyway), no blood tests or X-ray machines. There’s rarely electricity and there’s certainly no climate control.

“I really enjoy the challenge that is improvising, of figuring out a way to do something that isn’t prescribed,” Freer says. “That turns me on. In medicine, it’s wide open. There’s so much we don’t know about how to do this or that when we don’t have a CAT scan or a blood test. Professionally, that’s totally what I love doing — improvising a splint when somebody breaks their ankle on a trek.”

In the late 1980s, as Freer was finishing her degree at the VCU School of Medicine, she and her then-husband jumped in the car and drove from Richmond to Bozeman, stopping only to gas up and use the facilities. With just a few days off, she wanted to get out of the city and into the wilderness — someplace quiet, where a twig snapping in the dark betrays an approaching animal. It could be a ground squirrel; it could be a grizzly.

They’d been in the car for more than 30 hours when they spotted a sign on the side of the road. It was for a hospital in Yellowstone National Park. “I was like, are you kidding me?” Freer says. “They have doctors in Yellowstone Park?” She was stunned. In medical school, there had been no course in wilderness medicine. Freer wouldn’t hear the term until late in her residency at George Washington University Hospital. In training, she had any tool she could ever need within reach, plus peers to observe and mentors to advise. There would always be someone to help her decide which way to go. What if there were nothing to reach for, and no one to turn to?

The morning after her residency graduation in 1992, Freer climbed in her ragtop Jeep and drove west. “I might have looked like a Beverly Hillbilly,” she says. Her first job at Yellowstone was a staff physician at the hospital, and when she retired 30 years later, it was as the park’s medical director.

There’s no cure for Ebola; the only treatment is palliative care. Today, there are two vaccines, which provide immunity from some strands of the virus. But in 2014, the only preventive measure was to isolate patients in field hospitals.

The virus spreads through bodily fluids. It starts as a fever and progresses quickly, attacking the immune system and inflicting organ damage and uncontrollable bleeding. Roughly one in every two people who contract Ebola will die. During some outbreaks, the fatality rate has been as high as 90%. The few who survive often live with blindness and memory loss.

When Freer arrived in Sierra Leone in the depths of the 2014 Ebola outbreak, she started a journal while working in the emergency treatment unit. In her first entry, undated, she wrote:

“I’m working in an ETU repurposed from an old school into a makeshift hospital with about 80-100 bed capacity. Our unit is not sparkly clean and well-lit like some of the units in the news. In fact, there is mud between rooms and rats abound; packs of dogs break in at night, which can’t be a good public health situation. The work is beyond sweaty. I pour literal CUPS of sweat out of my boots after only 1½ hours in the PPE, and for some reason it’s just as bad in the dark as in the sun.”

Freer had treated bear attacks at Yellowstone and saved people from drowning in their own blood on Mount Everest, but it was the 2 1/2 months she spent treating Ebola victims in the small village of Maforki that shaped her the most. There was a time, before arriving in Sierra Leone, when she used to compartmentalize the pain and death she saw, achieving some distance from her patients.

This was different, she says. Ebola is vicious. Death by the virus is excruciating and gruesome. “To go from seeing them just feeling a little bit sick, having a sore throat and a fever, and then watching them progress through this terrible disease beside their brother or sister, dad or mom, and then die — that was something I’d never experienced before.”

“It was as happy as a confirmed ward could be for a few days,” she wrote in an entry about a family she grew particularly attached to. “Both infants nursing and feeding well, no vomiting or diarrhea, just occasional fevers. We all clung to the sliver of what we feared were unrealistic hopes.

“As [one baby’s] breathing turned labored and then agonal, his mom obsessed about his diaper rash. I put my hand on her shoulder, looked into her eyes, and big tears fell. I couldn’t let her miss her last few moments with him. I wanted her to know, without saying the words, that we had lost the battle and that she should soak up every moment with her waning spirit. As terrified older children looked on, both infants died in rapid succession. The room went silent. More staff sobbing, more unimaginable grief.  

“My brain says just stop getting involved, don’t attach. Perhaps time would help me insulate, but these scenes wreck me every time. Like waves in the ocean, I know one will wallop me if I dare to relax in the calm waters of hope.”

The most famous Luanne Freer story is from 2004. A climber named Joe Hughes was nearing Everest’s summit when he fell gravely ill. He was in the death zone, an altitude almost 5 miles above sea level where the air is so thin that living things begin to die. By the time his expedition dragged him into Freer’s medical tent at base camp, Hughes’ lungs had deteriorated to the porous consistency of a cheap garden hose and were quickly filling with blood. He was suffering from high-altitude pulmonary edema. The cure is more oxygen. But on Everest, more oxygen is often days away.

Freer and her team of medical volunteers worked double-quick to stabilize Hughes, but he wasn’t improving. What about Viagra? Freer thought. After all, sildenafil was originally designed to treat high blood pressure in the lungs. As the Viagra released the pressure in Hughes’ lungs, the electricity cut out. Hughes still needed IV fluids, but without any warmth, the liquid froze in the tube. Freer grabbed a nearby climber and threaded the IV tube through the sleeve of his down coat, the contact with his body warming the fluid. The next day, Hughes was evacuated. Nine months later, he named his daughter for the doctor who had saved his life.

Freer is blonde, nearly 6 feet tall and confident. She’s appeared on ABC News in the U.S. and “60 Minutes Australia.” Her picture has been in dozens of newspapers, and she’s been featured on Oprah.com and in Outside magazine many times over. She’s authored articles in The Lancet and Extreme Physiology and Medicine. In the mid-2000s, she was elected the first female president of the Wilderness Medical Society, and when the society was out of money and ready to lay off its chief administrator, Freer and a former president reached into their pockets to save it. Since that brush with extinction, the society has gone on to fund wilderness hospitals, publish research, train a new generation of wilderness doctors and set the first standards in the field.

“She’s a been-there, done-that person,” says Tony Islas, M.D., who practices wilderness medicine and teaches at the University of Nevada, Reno. “She hasn’t just talked about it or lectured about it or researched it. She’s worked it. She’s lived it. She did Everest ER. She worked in the Himalayas all those years. She’s been at altitude. She’s worked with climbers that have fallen down crevasses and got pulled back up. She has really good friends from all over the world because she’s worked as an international physician. She is probably one of the best and most well-known wilderness medicine practitioners in the world today.”

Wilderness medicine is a little unscientific at times. That’s because there’s little time to think. It attracts the unflappable and the even-keeled. Or perhaps it makes them. On Everest, Freer treated a climber who choked on his beef curry. Medical staff tried the Heimlich Maneuver, but it wasn’t helping; the chunk had lodged in his esophagus. He began drooling.

At Everest, Freer keeps nitroglycerin on hand, just in case someone has a heart attack. It’s a little pill that dissolves under the tongue; it relaxes the smooth muscles and sends more blood flow to the heart. Maybe that would free it, Freer thought. It did. Her colleagues were amazed, “but I was just guessing,” she says.

Deb Brown, a nurse who spent almost two decades at the medical clinics in Yellowstone, remembers the first season she spent working under Freer. The staff had arrived for training, and millions of campers were close behind. Right as Freer needed to prepare her teams for the long summer months, the power went out. There would be no PowerPoint presentations, no lecture notes. Freer lit candles and carried on.

“It set the tone for the whole summer,” Brown recalls. It was like saying, “‘Hey, guess what, you guys: This s--t is going to happen. You’re going to lose power. It may be a big storm in the summer, but you know what? This is what you do. You figure out ways to work around it. Instead of freaking out, she used it as a great example of how we have to be adaptable. Welcome to Yellowstone.”

“There are so many unknowns with this disease,” Freer wrote in a journal entry from her time in Maforki. “No expert or textbook to consult. We are living this outbreak patient by patient. We are writing this wretched history.”

The doctors and nurses who treat Ebola patients are covered from tip to toe in Tyvek suits, several layers of gloves, plus rubber boots and face masks — gear that looks more suited to the lunar surface than a West African village. To her patients, Freer was a tall figure covered in white, as anonymous as the next. “We all look the same,” she says, so hospital staff wrote their names on the chests of their protective suits. 

They called her Dr. Lulu, for a musician, DJ Lulu, popular among kids in the area. Eventually, patients at the hospital wanted to see the person in the white suit. Some, when they were recovering, and others, before they became too sick to move, would come to the chain-link fence that isolated them from the rest of the world, and say, “I want to see your face.” Freer, having doffed her PPE and face mask for the day, would stand on the opposite side and wave. They smiled at the woman who had been with them all this time.

“My stately friend died tonight,” she wrote in her journal about a local leader she deeply admired. “I cried at the sight of his body under the blanket. I’m not sure anyone else had bonded enough with him to get too worked up over it. After all, there are corpses every day. I asked a national nurse whether he cried when people died. He said no, there are too many. He said, ‘You will see. You can’t get attached.’ I hope I can still get attached to the ones I follow through. I don’t want that connection to be severed by the enormity of this pandemic.”

Before Luanne Freer founded Everest ER in 2003, doctors on the mountain were hired by private expeditions, and many hired them at great risk. 

Some brought medical students who hadn’t completed their training. Others assigned laymen to be in charge of medical care. Freer met one mountain guide in 2002 whose only equipment was a shoebox full of prescription drugs and a key identifying which pills to dole out for a skin infection or a stomachache.

Seeing the disasters waiting to happen, Freer returned to the States a few months later to raise money and solicit donations for equipment. Then she enlisted the help of the Himalayan Rescue Association and a few Sherpas to set up a medical clinic on a mountain that’s a 12-day hike from the nearest village. The wealthy mountaineers and trekkers who come to climb Everest pay to see the doctors, who are volunteers, and that money is used to fund low- or no-cost medical care for the local Sherpa community.

Freer is hardly a thrill-seeker. She’s never been interested in summiting Everest, but she did once begin the ascent. Her plan: Make it to Camp Three, roughly halfway between base camp and the summit, and look down. 

But on the ascent, Freer says, she didn’t feel right, like her brain was too big for her skull. “Dude, you’re blue,” a fellow climber told her. It was high-altitude pulmonary edema, and by the time Freer decided to turn around, it was too late in the day to begin the long descent: As the sun warms the ice and snow, the melt can send it tumbling down the mountain, along with climbers. 

Freer spent a terrible night without sleep. She made it back to base camp and spent days recovering. That attempt was enough for her.

When she left Sierra Leone in early 2015, Freer was a different person. “I became much more interested in mental health in general, talking more to my patients about what they were going through rather than just that they broke their arm,” she says. “I softened a lot, and that has persisted.”

By the spring, she was back at Everest base camp, treating pulmonary and cerebral edema, setting broken bones, and MacGyvering treatments for whatever arrived at the door of her heavy-duty tent. A call came from the States: A friend’s husband had been killed in a plane accident. Freer flew home to Bozeman to help. 

She wasn’t stateside for a full day when another call came, this one from Nepal. It was one of her colleagues at base camp. “He said, ‘There’s been an earthquake, and my phone’s going to go dead,’” Freer recalls. “I turned on the news and I went, ‘Holy crap.’” She repacked her bags and returned to Nepal, missing her friend’s memorial service.

The earthquake killed 9,000 people and injured some 21,000. In the following weeks, scientists counted 4,000 landslides that devastated villages surrounding the epicenter. In the Langtang Valley, more than 350 were killed, or simply never found, from a single avalanche. The quake also triggered an avalanche on Everest, killing at least 19. 

Freer didn’t go straight to the mountain. She headed for the communities where hundreds of Nepali people lined up for medical help. Some arrived with wounds from falling rocks. One man suffered a broken back under a collapsed building and had been pinned there for days. Another patient told Freer that she’d had a persistent stomachache for months, long before the earthquake. Is there anything else wrong? Freer asked. Yes, she had a backache, too. That pain started while she dug graves for her children, both of whom had died in the quake. 

When Freer tells stories like this one, she pauses and presses her palms against her eyes or her temples. These memories don’t come out easily. It takes time. She cries. 

“I felt like 90% of what we were seeing was people who didn’t know how to say, ‘I’ve been traumatized. I don’t know where my uncle is or my brother. Are they lost? Are they dead?’ The thing that really sticks out to me was the mental, the emotional trauma that these people went through.” It’s staggering, Freer says, how many medical problems are rooted in mental or emotional health. That, too, she learned on the job.

The people Freer admires most aren’t usually famous physicians or wilderness experts.

There’s the laborer in Sierra Leone who dug graves, a job easily overlooked in the shadow of the doctors who hold people’s hands while they die. But without quick and proper burial, the disease cannot be contained. Freer also likes the story of a nail technician who painted daisies on the toenails of children displaced by Hurricane Katrina. “During the time it took her to do that, she listened to their stories,” Freer says. “Listening to their stories was a witness to their tragedy.”

Then there’s Wongchhu Sherpa, a longtime friend who was deeply involved in setting up Everest ER. Wongchhu, who could neither read nor write, built a successful portering business and used the money to set up a school in his remote village. He built roads and took in children who needed a home. He helped bring electricity to his community. 

His charm was infectious, Freer says. And he was adventurous. He was the sirdar — the leader in charge of all Sherpas working on expeditions — during the 1996 disaster famously chronicled in Jon Krakauer’s book, “Into Thin Air.” Freer recalls that Wongchhu once phoned her late at night to say he was in London, hanging out with Sting and Trudie Styler.

When he died of colon cancer in 2015, Wongchhu still hadn’t realized his plans to build a permanent hospital in his village. Freer worked with Wongchhu’s daughter Lakpa, the Himalayan Yokpu Foundation and the Wilderness Medical Society, among others, and in 2022, the Wongchhu Sherpa Memorial Hospital opened to serve 30,000 people in the lower Solukhumbu region in Nepal. 

Freer retired as Yellowstone’s medical director in 2022. The biggest difference now, she laughs, is that she’s no longer drawing a paycheck. She snaps on gloves to volunteer at a spay-neuter clinic at the local animal hospital near her home on Fidalgo Island, part of a sparsely populated, wildlife-rich archipelago in the Salish Sea between Canada and the mainland of Washington state. She gets to sleep in.

Freer goes to morning barre classes and takes long vacations with friends. She spent a month in Portugal and a few weeks hiking the Dingle Peninsula in Ireland. While in Dublin for a few days, she and her friend Deb Brown, who worked with her in Yellowstone, took a shine to a doughnut shop and visited repeatedly. Freer is giving motivational speeches at corporate events, exhorting an audience dressed in business casual to combine their skills with their passions. She sends the money she earns to the hospital built in Wongchhu’s memory. She’s planning a return trip to Nepal in the spring, hoping to transition the hospital’s operations to local doctors.

It’s not danger that she’s after in the wilderness; it’s peace. “My shoulders go down,” she says, “I’m relaxed. I’m able to relax enough to take in the smells and the sounds that I would miss if I was rushing through my day. The feeling that you just don’t know what’s around the next bend, because you never do. 

“I can sit on my back porch and look at the water and feel that feeling. But there’s something different when you know that you don’t have cell service and you’re really out in it. That amplifies those feelings.” Freer is always looking for something new, and that’s the irresistible draw of the wilderness. There could be “a new flower or a bird I’ve never seen before,” she says. “Or maybe the river has a new way for it to flow.”