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Names: Hawkins, Seth, editor.
Title: Wilderness EMS / [edited by] Seth C. Hawkins.
Description: Philadelphia: Wolters Kluwer Health, [2018] | Includes bibliographical references.
Identifiers: LCCN 2017035251 | eISBN 9781496350442
Subjects: | MESH: Wilderness Medicine—methods | Emergency Medical Services | Rescue Work
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LWW.com
 This book is dedicated to my wife Kelly Collings Hawkins:
my lighthouse when I’m at sea, my lifeline when those seas rage fierce,
my diving mermaid should I sink to deeper depths, and the safe harbor
I steer toward after storm and struggle. You have my heart always
—tú, clara niña, pregunta de humo; eres la que iba formando
el viento con hojas iluminadas . . . eres hecha de todas las cosas.

The Life Line

Winslow Homer, American, 1836 - 1910
THE GEORGE W. ELKINS COLLECTION, 1924
T wo decades ago, I responded to my first mountain rescue callout high on Oregon’s iconic,
legendary Mount Hood. Back then we got the message via landline telephones and still
used lots of steel in our climbing gear. A crew of rescue mountaineers and ski patrollers searched
for a missing snowboarder in the middle of the night, in the middle of a storm. When one team
finally pulled the patient off the mountain, we treated the patient’s hypothermia and dehydration
in the ski patrol room of Timberline Lodge with the tools at hand: dry clothes and lukewarm hot
chocolate.
Little did I know back then that mountain rescue had a rich and vivid history on this
mountain.
On August 3, 1926, in Hood River, Oregon, a band of ski mountaineers were called upon by
the county sheriff to search for missing 7-year-old boy Jackie Strong. Strong was lost in the
north side of glacier-clad Mount Hood. The group found the boy in the remote Lost Creek
headwaters and when a reporter asked who they were, one member recalled his wife’s statement
about the men shucking household duties and being “rats for climbing crags every weekend.”
The men thus became simply Crag Rats. As described in Chapter 1 of this book, this was the
first organized team that provided mountain-specific search and rescue services in the country.1
In the early days, “the St. Bernards of North America” used waxed-cotton coats, wood skis,
hemp ropes, and alpenstocks, a long staff used for climbing glaciers before the ice axe came into
widespread popularity.1 Radios were the size of backpacks. Ipecac was the main poison antidote.
After several years, a need for teams to coalesce arose. On June 6 and 7, 1959, at Timberline
Lodge, Crag Rats, eight other volunteer rescue teams, and two military units met to organize a
national umbrella organization, the Mountain Rescue Association, also described in Chapter 1.2,3
The Mountain Rescue Association now comprises nearly 100 volunteer and government teams in
North America.
However, times have changed in the 90-year history of Crag Rats and my three-decade
involvement in wilderness medicine. Take my phone, for example. It now has a sophisticated
app for team callouts and a GPS app that’s better than a GPS unit. I carry a light-weight weather-
proof AED, an ultralight plastic laryngoscope, and rescue mountaineering gear crafted from
carbon fiber and aluminum.
In addition to better gear, we now have better personnel resources with multiple agencies
responding. Besides wilderness EMS crews built within traditional EMS agencies, often capable
of technical extrication and backcountry transport, it is not unusual for a mountain rescue team to
respond alongside fire department teams, private EMS staff, sheriff deputies, forest service trail
crews, ski patrollers, helicopter crews, park rangers, and military personnel. The oceans, rivers,
and lakes of the land have teams for dive, surf, open water, and swiftwater rescue. And even
guides and park staff with specialized wilderness medical training play a critical role in rendering
first aid, before further EMS arrival.
So, just as members from multiple agencies and organizations routinely work together with a
common goal, the teams have different protocols, equipment, and dynamics. This, it seems, is
now more frequent than not. This requires strong skills in multiagency interactions and
transitions of care, a topic discussed in great detail in Chapter 6 as well as the entire last third of
the book.
With the changing times—better gear, more resources, and personnel from multiple agencies
—the need is upon us for a specialized textbook specifically aimed at current EMS medical care
in wilderness settings. In wilderness rescues, EMS crews find themselves deploying to remote
locations with rugged terrain, limited communication, foul weather, and other challenges in
reaching, extricating, and transporting patients. The unique challenges of the wilderness
necessitate a stand-alone text. This book delivers. It’s the first of its kind to give special
instruction to wilderness EMS students and practitioners. In these pages Dr. Hawkins has
assembled an expert author group to give specialized instruction and best practices for
wilderness EMS, which is crucial for today’s rescue missions. This book will be a valuable
resource for students and an excellent resource for current practitioners. Importantly, these
techniques do not stand alone and should be coupled with formal training, plenty of practice, and
experience.

Christopher Van Tilburg, MD

Crag Rats Mountain Rescue
Providence Hood River Memorial Hospital
Occupational and Travel Medicine, Emergency Department
Mountain Clinic at Mount Hood Meadows
Hood River, Oregon

References
1. Annala, EE. The Crag Rats. Hood River, OR: Hood River News; 1977.
2. Grauer, J. Mount Hood: A Complete History. Vancouver, WA: Grauer; 1975.
3. Molenaar, D. Mountains Don’t Care, But We Do. San Diego: Mountain Rescue Association; 2009.
I first saw Winslow Homer’s The Life Line (reproduced on page v) in 2012 at the Philadelphia
Museum of Art. Although without a publisher, I had then already been working on this book
for half a decade.
Immediately and intuitively, I knew I wanted the painting to serve as a symbol for the
Wilderness EMS textbook.
Despite the strength of my visceral response to the painting, I was not sure of the reason for
this special conviction. It was not until an important conversation in Oregon with Bryan Simon
(author of Chapter 25) that I better understood my response.
Every author in this text is remarkable, and Bryan, a true Renaissance man, is no exception.
Besides his roles as a former US Army infantry officer with a brilliant military career, a talented
nurse, and a nationally known climbing and mountain rescue authority, Bryan is an art
aficionado who was accepted into a University of Oxford program in art history.
When I showed him this painting, he pointedly asked me, “Why does it speak to you that
way?”
I described its power and immediacy, the innate appeal of its illustration of human altruism
and the drama of rescue. I pointed out the way; although it depicted a water rescue, the pillowed
waves rose up like mountains, evoking the multiple environments discussed in the book. I talked
about how it captures themes of humanity, civilization, and the wilderness, and how wilderness
EMS sits precisely at the intersection of those same themes. I said that it captures a contention in
this book: more so than most medical specialties, all humans in a wilderness medical operation
are at some degree of risk, and are thus operating somewhere along the spectrum from potential
to actual patient. And getting far too technical, I even analyzed the characteristics of the breeches
buoy—cutting edge technology in the late 19th century and a predecessor to the contemporary
mountaineering Tyrolean traverse. Eventually, I ran out of things to say, but, clearly, he was
seeing something else.
He looked at me quizzically for a few moments, and then suggested, “Well, look at the
rescuer’s face.”
“You can’t,” I said, “it’s covered by…. Oh.” I paused for a moment. “Oh. Right.”
“I think you have your Preface,” said Bryan. And I did.
The painting is one of the true masterpieces of American art. I do think it has all the elements
I originally saw, but Bryan had pointed out one of its most potent features: You cannot see the
rescuer’s face. This rescuer could be anyone: any gender, any race, any age. Indeed, although
this rescuer could be anyone, in fact I suggest it is only one very specific person.
The rescuer in the painting is you.
The rescuer in the painting is you because you have chosen to pick up this book, and to read
more about wilderness rescue. And the rescuer is you because you have chosen a book about its
medical rather than technical aspects. You are not the rigger of the breeches buoy or the crew
standing by on the shore. You are the provider on the end of the rope, your vision obscured by
your patient’s flapping scarf and your face lashed by the rain. You are completely and personally
engaged in the rescue with your own body inextricably dedicated to the patient, ensuring by your
personal action, and at your own personal risk, safe delivery of this woman to the shore. In a
professional field where manikins are increasingly used to simulate an actual patient, the reality
and humanity of this patient, and the compassionate care being taken by the rescuer in
acknowledgment of that, cannot be denied.
That interpretation captures the soul of this book. Wilderness EMS, like Homer’s The Life
Line, is not primarily about the technical rigging, or the drama and fury of the surrounding
environment. It is not about the outcome, which is unknown. It is not even really about the
rescuer, who is obscured and intentionally rendered anonymous and universal.
It is about the patient.
With precisely that goal—the delivery of patient-centered care in the wilderness—this
textbook introduces many innovations to wilderness medicine, EMS, and their conjoined
subspecialty, wilderness EMS. Like the lesson of universality in Homer’s painting, we have
written this textbook for all types of providers. For this reason, we have implemented an
innovative technique of dividing care recommendations for each chapter into four categories:
First Aid, BLS, ALS, and Clinician. In Chapter 1, we introduce the first comprehensive timeline
of wilderness EMS history, and even invent a new word for the English language, not finding an
appropriate one already in existence. We pioneer the concept that “words matter,” explaining, in
Chapter 1, why this is so important, and describing, in Chapters 10 and 23, how our words affect
clinical management and patient outcome, and, in Chapters 16 and 25, how poor use of words
can complicate operations and medical care. We introduce a new concept of “horizontal
hierarchy” and its benefit for operational medical care. In every chapter, we prioritize medical
science and evidence-based medicine over medical dogma and tradition. In those places where
medical science did not adequately address a topic, we applied contemporary anthropologic
theory. Although this is quite unusual for a medical textbook, it seems very intuitive as an
underlying theoretical basis; anthropology, when defined literally, is the study of human beings.
The book’s clinical innovations range from medical management (for example, Chapter 20 takes
the evidence-based management of sepsis into the wilderness) to trauma management (for
example, Chapter 21 includes the groundbreaking statement that rigid cervical collars are not
required for trauma patients with suspected spinal cord injury, and throughout the book we state
there is no medical role for long spine boards as immobilization tools in the wilderness). Entire
chapters are unique simply in bringing their topic to an EMS textbook with a wilderness context
for the first time. Despite broad innovation and scope, as Christopher Van Tilburg points out in
the Foreword, all textbook material must be combined with formal training and plenty of
practice, and will be refined, improved, and personalized with experience.
Finally, I have attempted to retain the voice of each author rather than build a unified voice
for the textbook. The reason for this was stated earlier. Each author is truly remarkable and was
chosen for inexhaustible enthusiasm and absolute topical expertise. This expertise and
enthusiasm shines through in their particular voices, which will each become very recognizable
to the reader.
We are tremendously proud of how this book will advance the work of system-based
wilderness medical care, and for its unwavering commitment to the same priority as that work:
The patient.
Seth Collings Hawkins
Morganton, North Carolina, USA
August 2017
Benjamin N. Abo, DO, EMT-P
Assistant Professor of Emergency Medicine
University of Florida College of Medicine
Gainesville, Florida
Assistant Medical Director
Hallandale Beach Fire Rescue
Hallandale Beach, Florida
Medical Team Manager/Medical Director
FLTF-1 US&R / Venom One Special Operations Division
Miami-Dade Fire Rescue
Miami-Dade, Florida
Associate Medical Director—Technical Rescue
Gainesville Fire Rescue
Gainesville, Florida

J. Pearce Beissinger, MS, PA-C, FAPACVS, FAWM, AMGA-SPI

President
Portland Mountain Rescue
Physician Assistant
Portland Adventist Medical Center-Cardiothoracic Surgery
Adjunct Instructor
Oregon Health Sciences University
Co-Owner
Vertical Medicine Resources
Portland, Oregon

Ian E. Blanchard, MSc, EMT-P

Research Paramedic/Adjunct Assistant Professor
Emergency Medical Services
Alberta Health Services
Department of Community Health Sciences
Cumming School of Medicine
University of Calgary
Calgary, Alberta, Canada

Bryan E. Bledsoe, DO, FACEP, FAEMS

Professor
Department of Emergency Medicine
University of Nevada Las Vegas School of Medicine
Las Vegas, Nevada

Richard B. Bounds, MD
Program Director
Emergency Medicine Residency
Associate Professor
Division of Emergency Medicine
Department of Surgery
University of Vermont Medical Center
Burlington, Vermont

Kristen C. Burke, JD
Private Practice
Denver, Colorado

Jonnathan Busko, MD, MPH

Medical Advisor
Maine Region, National Ski Patrol
Medical Director
Hermon Mountain Ski Patrol
Emergency Physician
St. Joseph Hospital
Bangor, Maine

Peter Buzzacott, MPH, PhD

Director of Injury Monitoring and Prevention
Divers Alert Network
Durham, North Carolina

Catherine Campisi, PMHNP-BC

Senior Instructor
College of Nursing
University of Colorado Denver
Denver Colorado

Michael J. Caudell, MD, FACEP, FAWM, DiMM

Professor of Emergency Medicine
Medical Director
Wilderness and Survival Medicine
Medical College of Georgia, Augusta University
Co-Founder
MedWAR (Medical Wilderness Adventure Race)
Augusta, Georgia
President
Appalachian Center for Wilderness Medicine
Morganton, North Carolina
Director
Wilderness Medical Society
Salt Lake City, Utah

James Chimiak, MD
Medical Director
Divers Alert Network
Durham, North Carolina

Ryan Circh, MD, FAWM

Attending Emergency Physician
CarePoint Healthcare
The Medical Center of Aurora
Aurora, Colorado
Keith Conover, MD, FACEP, NSS12893
Clinical Assistant Professor
Department of Emergency Medicine
University of Pittsburgh
Chair
Medical Advisory Committee
Appalachian Search and Rescue Conference
Medical Director
Allegheny Mountain Rescue Group
Pittsburgh, Pennsylvania
Medical Advisor
Eastern Region, National Cave Rescue Commission

Tracy A. Cushing, MD, MPH, FACEP, FAWM

Associate Professor of Emergency Medicine
University of Colorado School of Medicine
Aurora, Colorado

Christopher Davis, MD, FAWM

Wilderness EMS Fellow
Department of Emergency Medicine
Wake Forest University School of Medicine
Winston Salem, North Carolina

Chelsea A. Dymond, BA
Medical Student
University of Queensland–Ochsner Clinical School Program
New Orleans, Louisiana

David Fifer, WEMT, NRP

Lecturer
School of Safety, Security, and Emergency Management
Eastern Kentucky University
Richmond, Kentucky
Coordinator
Red River Gorge Special Treatment, Access, and Rescue (RedSTAR) Unit
Stanton, Kentucky
Director
Appalachian Center for Wilderness Medicine
Morganton, North Carolina

Lee Frizzell, BA, EMT

Executive Director
Stonehearth Open Learning Opportunities (SOLO)
Chair
New Hampshire Northern EMS Region
Conway, New Hampshire

Douglas C. George, MD
Resident Physician
Department of Emergency Medicine
Boston Medical Center
Boston, Massachusetts

Leah Jacoby Groves, MD, DiMM

Emergency Medicine Physician
St. Joseph’s Hospital
Denver, Colorado

Seth C. Hawkins, MD, FACEP, FAEMS, MFAWM

Assistant Professor of Emergency Medicine
Wake Forest University School of Medicine
Winston-Salem, North Carolina
Medical Director
Burke County EMS
Morganton, North Carolina
Medical Director
North Carolina State Parks
Raleigh, North Carolina
Executive Editor
Wilderness Medicine Magazine
Salt Lake City, Utah

Franklin R. Hubbell, DO
Physician
Saco River Medical Group
Medical Director
Stonehearth Open Learning Opportunities (SOLO)
Medical Director
New Hampshire Northern EMS Region
Conway, New Hampshire
Board Member
New Hampshire Medical Control Board
Concord, New Hampshire

Lawrence J. Jones, BA, NREMT, FAWM

Environmental Scientist
Newark, Delaware
Blue Mountain Ski Patrol
Palmerton, Pennsylvania
Director
Appalachian Center for Wilderness Medicine
Morganton, NC

Robert J. Koester, MS
Fellow
Kingston University, London
Chief Executive Officer
dbS Productions LLC
Charlottesville, Virginia

Linda Laskowski-Jones, MS, APRN, ACNS-BC, CEN, NREMT, FAWM, FAAN

Vice President
Emergency and Trauma Services
Christiana Care Health System
Wilmington, Delaware
Director
Appalachian Center for Wilderness Medicine
Morganton, North Carolina
Member
Blue Mountain Ski Patrol
Palmerton, Pennsylvania
Editor-in-Chief
Nursing: the Journal of Clinical Excellence (Wolters Kluwer)
Philadelphia, Pennsylvania

Peter J. LeBlanc, MS, NRP

EMS Academy
University of New Mexico School of Medicine
Albuquerque, New Mexico

Darryl J. Macias, MD, FACEP, FAWM, DiMM

Professor
Department of Emergency Medicine
Program Director
Austere, Wilderness and International EM Programs and Fellowship
Medical Director
International Mountain Medicine Center
University of New Mexico
Albuquerque, New Mexico

Henderson McGinnis, MD, FACEP, FAWM

Associate Professor of Emergency Medicine
Wake Forest University School of Medicine
Medical Director
AirCare Critical Care Transport; Wilkes County EMS
Winston-Salem, North Carolina
Director
Appalachian Center for Wilderness Medicine
Morganton, North Carolina

Laura McGladrey, RN, PMHNP, FNP, MSN, FAWM

Psychiatric Nurse Practitioner
Tennyson Center for Children
Denver, Colorado
Faculty
NOLS
Lander, Wyoming
Adjunct Faculty
University of Colorado College of Nursing
Aurora, Colorado

Howard K. Mell, MD, MPH, CPE, FACEP

CEP-America
Department of Emergency Medicine
Presence St. Joseph Medical Center
Elgin, Illinois

Michael G. Millin, MD, MPH, FACEP, FAEMS

Associate Professor
Department of Emergency Medicine
Johns Hopkins University School of Medicine
Medical Director
Maryland Search and Rescue
Baltimore, Maryland

R. Darrell Nelson, MD, FACEP, FAEMS

Associate Professor
Program Director, EMS and Disaster Fellowship
Department of Emergency Medicine, Wake Forest Baptist Health
Medical Director
Davie County EMS; Stokes County EMS
Winston-Salem, North Carolina

Paul Nicolazzo
Director
Wilderness Medicine Training Center International
Winthrop, Washington

Justin S. Padgett, MS, Paramedic, WEMT

Executive Director
Landmark Learning
Cullowhee, North Carolina

Nancy Pietroski, BSc, PharmD, NREMT, WEMT, FAWM, CTH

GeoSentinel Data Analyst, International Society of Travel Medicine,
Outdoor Emergency Care Course Director, Bear Creek Ski Patrol/Valley Forge Nordic Ski Patrol
Senior Editor, Wilderness Medicine Magazine
Associate Editor, Travel Medicine News
Telford, Pennsylvania

Aaron Reilly, DO, WAIEM, DiMM

International Mountain Medicine Center
Department of Emergency Medicine
University of New Mexico School of Medicine
Albuquerque, New Mexico

Gates Richards Jr, MEd, FAWM

Special Programs Manager
NOLS Wilderness Medicine
Lander, Wyoming

Brian M. Scheele, DO, MS

Toledo, Ohio
Emergency Medicine resident physician, Mercy St. Vincent Medical Center
Toledo, Ohio
Board Member, Pacific Northwest Surgical Outreach
Yakima, Washington

Tod Schimelpfenig, WEMT, FAWM

Curriculum Director
NOLS Wilderness Medicine
Lander, Wyoming

Andrew Schmidt, DO, MPH

Assistant Professor
Department of Emergency Medicine
University of Florida College of Medicine
Jacksonville, Florida
Director
Lifeguards Without Borders
Kuna, Idaho
Justin Sempsrott, MD, FAAEM
Executive Director
Lifeguards Without Borders
Emergency Physician
Kuna, Idaho

J. Matthew Sholl, MD, MPH, FACEP

Associate Professor of Emergency Medicine
Tufts University School of Medicine
Boston, Massachusetts
Department of Emergency Medicine
Maine Medical Center
Portland, Maine

R. Bryan Simon, RN, MSc (Mtn Med), DiMM, FAWM

Co-Owner, Vertical Medicine Resources
Portland, Oregon
Director, Appalachian Mountain Rescue Team (AMRT)
Morganton, North Carolina
Director, New River Alliance of Climbers (NRAC)
Fayetteville, West Virginia

Benjamin Smith, MD
Resident Physician
Department of Emergency Medicine
University of Nevada School of Medicine
Assistant Emergency Medical Advisor
Lake Mead National Recreation Area
Las Vegas, Nevada

William “Will” R. Smith, MD, Paramedic, FAWM

Clinical Assistant Professor of Emergency Medicine
University of Washington School of Medicine
Seattle, Washington
Medical Director
Jackson Hole Fire/EMS; Teton County SAR
CEO/Medical Director
Wilderness and Emergency Medicine Consulting (WEMC), LLC
Jackson, Wyoming
Medical Director
National Park Service
Washington, District of Columbia

Jennifer M. Starling, MD, DTM&H

Adjunct Assistant Professor
Department of Emergency Medicine
University of Colorado School of Medicine
Aurora, Colorado

Shana Tarter, WEMT, EMT-I, FAWM

Assistant Director
NOLS Wilderness Medicine
Lander, Wyoming

Carl Weil, MFAWM, Colorado EMT Instructor Coordinator, NREMT Training Officer
Director
Wilderness Medicine Outfitters
Director
Professional Outdoor Medical Educators; Anaphylaxis Educators
Assistant Director
OnPoint Tactical Medical
Correspondent Assistant
Wilderness Medicine Educators Coalition
Elizabeth, Colorado

Tyler Williamson, PhD

Assistant Professor
Department of Community Health Sciences
Cumming School of Medicine
University of Calgary
Calgary, Canada

Corey Winstead, WEMT

Assistant Chief
Appalachian Mountain Rescue Team
Asheville, North Carolina

David S. Young, MD, MS

Assistant Professor
Department of Emergency Medicine
University of Colorado
Aurora, Colorado

Ken Zafren, MD, FAAEM, FACEP, FAWM

Emergency Programs Medical Director for the State of Alaska
Juneau, Alaska
Associate Medical Director
Himalayan Rescue Association
Kathmandu, Nepal
Clinical Professor
Department of Emergency Medicine
Stanford University Medical Center
Stanford, California
Staff Emergency Physician
Alaska Native Medical Center
Anchorage, Alaska
Dedication
Foreword
Preface
Contributors
WEMS Acronyms, Initialisms, and Independonyms

Introduction to Wilderness EMS

SETH C. HAWKINS

SECTION ONE:
Principles of Wilderness EMS Systems
CHAPTER 1: WEMS Systems
SETH C. HAWKINS

CHAPTER 2: Wilderness EMS Education

COREY WINSTEAD • SETH C. HAWKINS

CHAPTER 3: Wilderness EMS Incident Command

DAVID FIFER

CHAPTER 4: Wilderness EMS Medical Oversight

MICHAEL G. MILLIN

CHAPTER 5: Medicolegal Considerations in Wilderness EMS Care

KRISTEN C. BURKE

CHAPTER 6:The Interface Between Wilderness EMS, Professional Organizations & Guides, and
Other EMS Agencies
J. MATTHEW SHOLL • DOUGLAS C. GEORGE

CHAPTER 7: Wilderness EMS Equipment

CARL WEIL

CHAPTER 8: Wilderness EMS Research

IAN E. BLANCHARD • TYLER WILLIAMSON

CHAPTER 9: Wilderness Event Medicine

LINDA LASKOWSKI-JONES • MICHAEL J. CAUDELL • RICHARD B. BOUNDS • CHELSEA A. DYMOND • SETH C.
HAWKINS • LAWRENCE J. JONES • JENNIFER M. STARLING • DAVID S. YOUNG
CHAPTER 10: Psychological First Aid and Stress Injuries
LAURA MCGLADREY

CHAPTER 11: Wilderness EMS Pharmacology

NANCY PIETROSKI

SECTION TWO:
Management of Wilderness Medical Conditions
CHAPTER 12: Wilderness Survival, Survival Psychology and Lost Person Behavior
DARRYL J. MACIAS • PETER J. LEBLANC • AARON REILLY

CHAPTER 13: Management of Cold Injuries

LINDA LASKOWSKI-JONES • LAWRENCE J. JONES

CHAPTER 14: Management of Heat Illnesses

TOD SCHIMELPFENIG • GATES RICHARDS JR • SHANA TARTER

CHAPTER 15: Management of Altitude Illnesses

KEN ZAFREN

CHAPTER 16: Management of Drowning

JUSTIN SEMPSROTT

CHAPTER 17: Management of Diving Injuries

JAMES CHIMIAK • PETER BUZZACOTT

CHAPTER 18: Management of Lightning Injuries and Severe Storms

R. DARRELL NELSON • HENDERSON MCGINNIS

CHAPTER 19: Management of Animal Bites and Envenomation

BENJAMIN N. ABO

CHAPTER 20: Management of Infectious Diseases

PART 1: Infectious Diseases Associated With Wilderness Environments

FRANKLIN R. HUBBELL • LEE FRIZZELL

PART 2: General Infectious Diseases in the Wilderness Environment

CHRISTOPHER DAVIS • HOWARD K. MELL

CHAPTER 21: General Management of Trauma in the Wilderness

BENJAMIN SMITH • BRYAN E. BLEDSOE • PAUL NICOLAZZO

CHAPTER 22: General Management of Medical Conditions in the Wilderness

LEAH JACOBY GROVES • TRACY A. CUSHING

CHAPTER 23: Management of Behavioral Emergencies in the Wilderness

LAURA MCGLADREY • CATHERINE CAMPISI

SECTION THREE:
Medical Interface With Technical Rescue Operations
CHAPTER 24: Technical Rescue Interface Introduction: Principles of Basic Technical Rescue,
Packaging, and Patient Care Integration
WILLIAM ‘WILL’ R. SMITH

CHAPTER 25: Technical Rescue Interface: High and Low Angle Rescue
R. BRYAN SIMON

CHAPTER 26: Technical Rescue Interface: Swiftwater Rescue

JUSTIN S. PADGETT

CHAPTER 27: Technical Rescue Interface: Open Water Rescue

ANDREW SCHMIDT • BENJAMIN N. ABO • JUSTIN SEMPSROTT

CHAPTER 28: Technical Rescue Interface: Off-Road Vehicle and Helicopter WEMS Response
BRIAN M. SCHEELE

CHAPTER 29: Technical Rescue Interface: Cave Rescue

KEITH CONOVER

CHAPTER 30:Technical Rescue Interface: Search and Rescue in the Non-

Snow/Glacier/Mountaineering Environment
KEITH CONOVER • RYAN CIRCH • ROBERT J. KOESTER

CHAPTER 31:Technical Rescue Interface: Ski Patrols and Mountaineering Rescue in the
Mountainous, Snow, or Glaciated Environment
MICHAEL G. MILLIN • J. PEARCE BEISSINGER • JONNATHAN BUSKO

Index
4WD four-wheel drive
AAPCC American Association of Poison Control Centers
A-EMT Advanced EMT (a specific certification), also known as AEMT
AEMT Advanced EMT (a specific certification), also known as A-EMT
AAC American Alpine Club
AAOS American Academy of Orthopaedic Surgeons
AAR after-action review
ABA American Burn Association
ABC initialism mnemonic representing airway, breathing, circulation
ABCDE initialism mnemonic representing airway, breathing, circulation, disability,
exposure/environment
ABCDEF initialism mnemonic representing airway, breathing, circulation, disability,
exposure/environment, fractures
ABEM American Board of Emergency Medicine
ABMS American Board of Medical Specialties
AC alternating current
ACCET Accrediting Council for Continuing Education and Training
ACE all cotton elastic
ACEP American College of Emergency Physicians
ACGME Accreditation Council for Graduate Medical Education
ACLS Advanced Cardiac Life Support (a specific certification)
ACSM American College of Sports Medicine
ACP advanced care provider (now a discouraged term, with more specific label favored)
ACWM Appalachian Center for Wilderness Medicine
AED automated external defibrillator
AFRCC Air Force Rescue Coordination Center
AGE air gas embolism
AHA American Heart Association
AIDS acquired immunodeficiency syndrome
AK Alaska
AKRCC Alaska Rescue Coordination Center
ALS amyotrophic lateralizing sclerosis
ALS advanced life support
AMRG Allegheny Mountain Rescue Group
AMRT Appalachian Mountain Rescue Team
AMS acute mountain sickness
ANAC Accidents in North American Climbing (formerly ANAM until 2016)
ANAM Accidents in North American Mountaineering (now ANAC as of 2016)
AOE acute otitis externa
APP advanced practice provider (now a discouraged term, with more specific label favored)
APRN advanced practice registered nurse
Arbovirus acronym for arthropod-borne virus
ASA acetylsalicylic acid (aspirin)
ASHICE mnemonic acronym for age, sex, history, injuries, condition, expected time of arrival
ASRC Appalachian Search & Rescue Conference
ASTM American Society of Testing and Materials (became ASTMI in 2001)
ASTMI American Society of Testing and Materials International (formerly ASTM)
ATC air traffic controller (type of belay device)
ATT all-terrain trailer
ATV all-terrain vehicle
AVPU acronym referring to levels of responsiveness alert, verbal, painful, unresponsive
AWA American Whitewater Association
AWFA Advanced Wilderness First Aid (a specific certification)
AWLS Advanced Wilderness Life Support (a specific certification)
BCEMS Burke County EMS
BEEM best evidence in emergency medicine
BLS basic life support
BMA British Medical Association
BMP basic metabolic panel
BOO base of operations
BSA Boy Scouts of America
BSA body surface area (burns)
BSE bovine spongiform encephalopathy
BSI body substance isolation
BUN blood urea nitrogen
BVM Bag valve mask
BZK benzalkonium
CAIS complete androgen insensitivity syndrome
CAP community-acquired pneumonia
CAPCE Commission on Accreditation for Pre-Hospital Continuing Education
CCC Carolina Climbers Coalition
CASIE Computer-Aided Search Exchange
CAT combat application tourniquet
CBC complete blood count
CBRN chemical, biological, radiological, nuclear
cc cubic centimeter
CCME Council for Continuing Medical Education
CDPHE Colorado Department of Public Health and the Environment
CDS (see discussion in Introduction); CDS Outdoor School
CECBEMS istorical name (Continuing Education Coordinating Board for EMS) for organization now
known as CAPCE
CEH continuing education hours
CEN Comité Européen de Normalisation (European Committee for Standardization)
CFR Code of Federal Regulations
CHF congestive heart failure
CISM critical incident stress management
CME continuing medical education
CNM certified nurse midwife (a type of APRN)
CNS clinical nurse specialist (a type of APRN)
CNS central nervous system
CO carbon monoxide
CO2 carbon dioxide
COBS Colorado Outward Bound School
COPD chronic obstructive pulmonary disease
COSFA Combat and Operational Stress First Aid
COSPAS Cosmicheskaya Sistyema Poiska Avariynich Sudov (“Space System for Vessel Searching”)
CoTCCC Committee on Tactical Combat Casualty Care
CPAP continuous positive airway pressure
CPR cardiopulmonary resuscitation
CRAM mnemonic acronym representing communicate, relevant, appreciate, manipulate
CRM crew resource management
CRNA certified registered nurse anesthetist (a type of APRN)
CT computed tomography
CUF Care Under Fire guidelines
CVA costovertebral angle
CVA cerebrovascular attack
CWEMSE Carolina Wilderness EMS Externship
D&I dissemination and implementation
DAN Divers Alert Network
DC direct current
DCI decompression illness
DCS decompression sickness
DEA United States Drug Enforcement Agency
DEET N,N-Diethyl-meta-Toluamide
DiDMM Diploma in Dive and Marine Medicine (a specific certification)
DiMM Diploma in Mountain Medicine (a specific certification)
DMAT Disaster Medical Assistance Team
DMT Diver Medic Technician (a specific certification)
DNA deoxyribonucleic acid
DO doctor of osteopathy (a specific doctorate degree)
DOS disk operating system
DOT United States Department of Transportation
DRA dynamic risk assessment
DRG digital raster graphics
DSM-V Diagnostic and Statistical Manual V (also known as DSM-5)
DSM-5 Diagnostic and Statistical Manual 5 (also known as DSM-V)
DVT deep venous thrombosis
DWR durable water repellent
EAP emergency action plan
EBM evidence-based medicine
ECMO extracorporeal membrane oxygenation
ECG electrocardiogram
ECSI Emergency Care & Safety Institute
EGDT early goal-directed therapy
EOC emergency operations command
EKG electrocardiogram (a discouraged term, with ECG favored)
ELT electronic locator transmitter
EM emergency medicine
EMD emergency medical dispatcher
EMR emergency medical responder (a specific certification)
EMS emergency medical services
EMT Emergency Medical Technician (a specific certification)
EMTALA Emergency Medical Treatment and Labor Act
ED emergency department
EMR electronic medical record
EMRA Emergency Medicine Residency Association
EMT-I Emergency Medical Technician–Intermediate
EMT-W Emergency Medical Technician–Wilderness; historical term now more commonly referred to as
WEMT
ENA Emergency Nurses Association
ENT ear, nose, throat
EP emergency physician
EPIRB emergency position indicating radio beacon
ER emergency room (a discouraged term, with ED more favored)
ERC European Resuscitation Council
ET endotracheal
ETCO2 end-tidal carbon dioxide
ETT endotracheal tube
EUA emergency use authorization
FA First Aid (a specific certification)
FAA Federal Aviation Administration
FAAEM Fellow of the American Academy of Emergency Medicine
FACEP Fellow of the Academy of Emergency Physicians
FACS Fellow of the American College of Surgeons
FAST Focused Assessment with Sonography for Trauma
FAWM Fellow of the Academy of Wilderness Medicine
FBI United States Federal Bureau of Investigations
FDA United States Food & Drug Administration
FDNY New York Fire Department
FEMA Federal Emergency Management Agency
FIND software integrating GIS-type mapping, search theory, and search management
FINER acronym mnemonic referring to feasible, interesting, novel, ethical, relevant
FLIR forward-looking infrared
FLOP acronym for ICS General Staff positions (see Chapter 3)
FOAM free open access meducation
FOAMED free open access meducation–emergency department
FOAMEMS free open access meducation–emergency medical services
fsw feet sea water
FTCA Federal Tort Claims Act
FTL field team leader
FTM field team member
GABA gamma-aminobutyric acid
GCS Glasgow coma scale
GCWR gross combined weight rating
GEMS ground EMS
GERD gastroesophageal reflux disease
GI gastrointestinal
GIS geographical information specialist
GPS global positioning system
GRADE mnemonic acronym referring to Grading of Recommendations Assessment, Development and
Evaluation
GU genitourinary
HAA helicopter air ambulance (also referred to as helicopter-based EMS or HEMS)
HACE high-altitude cerebral edema
HAFE high-altitude flatus expulsion
HAP healthcare-acquired pneumonia

HAPE high-altitude pulmonary edema

HAPE-S high-altitude pulmonary edema
susceptible
HARH high-altitude retinal hemorrhage
HazMat hazardous materials
HBOT hyperbaric oxygen therapy
HD horizontal distance
HEMS helicopter-based EMS (also referred to as helicopter air ambulance or HAA)
HHC Health Help Centre (located in Bhutan)
HIGE hovering in ground effect
HIPAA Health Information Portability and Accountability Act of 1996
HIV human immunodeficiency virus
HMPE high-molecular-weight polyethylene
HMS halbmastwurfsicherung, meaning “half clove hitch belay”; for carabiners, sized to accept this
hitch
HOGE hovering off of ground effect
HRA Himalayan Rescue Association
HRD human remains detection
IC Incident Commander
IC PLuS acronym for ICS Command Staff positions (see Chapter 3)
ICAO-ITU International Civil Aviation–International Telecommunications Union
ICAR International Commission for Alpine Rescue (also known as IKAR-CSA)
IKAR language variant on ICAR
ICP incident command post
ICS incident command system
ICU intensive care unit
IDSA Infectious Disease Society of America
IFR instrument flight rules
IGT4SAR Integrated Geospatial Tools
for SAR
IKAR-CSA International Commission for Alpine Rescue (also known as ICAR)
ILCOR International Liaison Committee on Resuscitation
IM intramuscular
IO intraosseous
IOM Institute of Medicine
IPP initial planning point
IRB Institutional Review Board
ISBAR acronym mnemonic for introduction/identification, situation, background, assessment,
recommendations
ISMM International Society for Mountain Medicine
ISMP Institute for Safe Medication Practices
ISTM International Society for Travel Medicine
ITRS International Technical Rescue Symposium
IV intravenous or intravenous line
IWR in-water resuscitation (drowning care)
IWR in-water recompression (diving)
JAMA Journal of the American Medical Association
JVD jugular venous distension
KT knowledge translation
KTD Kendrick traction device
LASIK laser in situ keratomileusis
LATE mnemonic acronym referring to locate, access, treat, extricate
LED light-emitting diode
LKP last known position
LL Landmark Learning
LLQ left lower quadrant
LNO Liaison Officer
LOG Logistics Section Chief
LUQ left upper quadrant
LZ landing zone
MA Massachusetts
MAC multiagency coordinating
MAP mean arterial pressure
MAT mechanical advantage tourniquet
MD medical doctor (a specific doctorate degree)
MDI metered dose inhaler
MedEx Medical Expeditions
MeSH medical subject headings
MFAWM Master Fellow of the Academy of Wilderness Medicine
MGRS military grid reference system
MHWEMSE Mercy Hospital of Pittsburgh Wilderness EMS Elective
MIEMSS Maryland Institute for EMS Systems
MI myocardial infarction
MIH mobile integrated health care
MIHC mobile integrated health care (preferred to MIH as “health care” is preferred to “healthcare”)
MIST acronym mnemonic for mechanism of injury/illness, injuries, signs/observations, treatment)
MCM medical countermeasure
MDPS Medical Priority Dispatch System
mL milliliter
MN magnetic north
MOA mechanism of action
MOBS Minnesota Outward Bound School (became Voyageur Outward Bound School [VOBS] in 1983)
MPQ Missing Person Questionnaire
MRA Mountain Rescue Association
MRE meals ready-to-eat
MRI magnetic resonance imaging
MRSA methicillin-resistant staphylococcus aureus
MRU mountain rescue unit
NAAK nerve agent antidote kit
NAEMSP National Association of EMS Physicians
NAFTA North American Free Trade Agreement
NASA National Aeronautics and Space Administration
NASAR National Association of Search and Rescue
NASEMSO National Association of State EMS Officials (formerly NASEMSD)
NASEMSD National Association of State EMS Directors (now NASEMSO)
NAS-NRC National Academy of Sciences National Research Council
NATA National Athletic Trainers’ Association
NCAA National Collegiate Athletic Association
NWS National Weather Service
NAWME National Association of Wilderness Medicine Educators
NBDHMT National Board of Diving and Hyperbaric Medical Technology
NC North Carolina
NCHART North Carolina HeloAquatic Rescue Team
NCOBS North Carolina Outward Bound School
NCRC National Cave Rescue Commission
NCTSN National Child Traumatic Stress Network
NDMS National Disaster Medical System
NF National Formulary
NFPA National Fire Protection Agency
NGO nongovernmental organization
NH New Hampshire
NHTSA National Highway Transportation Safety Administration
NIMS National Incident Management System
NJ New Jersey
NOLS independonym (see discussion in Introduction); previously National Outdoor Leadership School
NOAA United States National Oceanic and Atmospheric Administration
NP nurse practitioner (a type of APRN)
NP national park
NPA nasopharyngeal airway
NPS National Park Service
NREMT National Registry of Emergency Medical Technicians
NRP National Search & Rescue Plan
NSA National Ski Association
NSAID nonsteroidal anti-inflammatory drug
NSARC National Search and Rescue Committee
NSS National Speleological Society
NSS-CDS National Speleological Society’s Cave Diving Section
NSP National Ski Patrol
NSS National Speleological Society
NWCG National Wildfire Coordinating Group
NY New York
ODT oral dissolving tablet
OEC Outdoor Emergency Care (formerly WEC)
OEC-T Outdoor Emergency Care Technician (discouraged in favor of “OEC Technician”)
OFC Outdoor First Aid (a specific certification)
OH Ohio
OHCA out-of-hospital cardiac arrest
ONSD optic nerve sheath diameter
OOH out-of-hospital
OPA oropharyngeal airway
ORCA Outdoor Recreation Coalition of America (now Outdoor Industry Association)
OCR Orientation to Cave Rescue (specific certification)
ORS oral rehydration solution (also known as ORT)
ORT oral rehydration therapy (also known as ORS)
OSC Operations Section Chief
OTC over-the-counter
PCP phencyclidine
PDA personal digital assistant
PDF portable document format
PE pulmonary embolism
PEP postexposure prophylaxis
PETSAC Prehospital Emergency Training Standards and Accreditation Committee
PFA psychological first aid
PFA-S psychological first aid–schools
PFC prolonged field care
PFD personal flotation device
PFO patent foramen ovale
PGY post graduate year
PhD doctor of philosophy (a specific degree)
PI principal investigator
PICO mnemonic acronym referring to population, intervention, comparison, outcome
PID pelvic inflammatory disease
PIO Public Information Officer
PLB personal locator beacon
PLS point last seen
PO per ora; by mouth
POA probability of area
POD probability of detection
POS probability of success
POCT point-of-care testing
POCUS point-of-care ultrasound
POIS pulmonary overinflation syndrome
POME Professional Outdoor Medical Educators
POV personally operated vehicle
POW prisoner of war
PPE personal protective equipment
PSA psychological first aid
PSAP public service access point
PSAR preventive search and rescue
PSC Planning Section Chief
PTSD posttraumatic stress disorder
PWC personal water craft
QA quality assurance
QC QuikClot
QI quality improvement
QRS quick release system
QRS complex combination of Q, R, and S waves on an electrocardiogram
QT interval the time between a Q wave and a T wave on an ECG
RAW Rural-Austere-Wilderness podcast
RCT randomized controlled trial
RFID Radio Frequency Identification
RLQ right lower quadrant
RMI Remote Medical International
RN registered nurse
RNA ribonucleic acid
ROPS roll-over protection structure
ROW rest of world
RSI rapid sequence intubation
RT respiratory therapist
RUQ right upper quadrant
SAEM Society for Academic Emergency Medicine
SAM structural aluminum malleable
SAR search and rescue
SAR-GAR search and rescue green–amber–red
SARSAT search and rescue satellite

SBAR acronym mnemonic representing Situation, Background, Assessment, Recommendation

SPAR Small Party Assisted Rescue (specific certification)
SC subcutaneous
SCP spinal cord protection
SEND satellite emergency notification device
SLEP Shelf-Life Extension Program
SMACC Social Media and Critical Care Conference
SMART acronym for Specific, Measurable, Action-oriented, Realistic, Time-bound (see Chapter 3)
SMAT State Medical Assistance Team (disaster medicine)
SME subject matter expert
SMR spinal motion restriction
SMS safety management systems
SNRI serotonin and norepinephrine reuptake inhibitors
SNS Strategic National Stockpile
SOLO Stonehearth Outdoor Learning Opportunities
SPOT satellite personal tracker
SRT Swiftwater Rescue Technician (a specific certification in swiftwater context)
SRT single rope technique (a specific rigging technique in cave and mountain rescue context)
SSRI selective serotonin reuptake inhibitor
SSSF static system safety factor
ST segment segment of electrocardiogram between S wave and T wave
STD sexually transmitted disease
STEP acronym mnemonic representing single-skid, toe-in, hover exit/entry procedure
STI sexually transmitted infection
STOP mnemonic acronym referring to stop, think, observe, plan
TACEVAC Tactical Evacuation Care
TAF task force assignment
TB tincture of benzoin
TB tuberculosis
TCCC Tactical Combat Casualty Care
T-CLOC mnemonic acronym referring to tires, control, lights, oil, chassis
TECC Tactical Emergency Casualty Care
TFC Tactical Field Care
TGA transient global amnesia
TH therapeutic hypothermia
TIA transient ischemic attack
TK4 Tourni-Kwik 4
TLSO thoraco-lumbo-sacral orthotic
TOA tubo-ovarian abscess
TXA tranexamic acid
UA/EM-IRIEM University Association for Emergency Medicine–International Research Institute for Emergency
Medicine
UAV unmanned aerial vehicle (drone)
UC Unified Command
UHF ultrahigh frequency
UIAA Union Internationale des Associations D’Alpinisme
UK United Kingdom
UNM University of New Mexico
UPT urine pregnancy test
URI upper respiratory infection
US United States
USA United States of America
USAR Urban Search and Rescue
USC University of Southern California
USCG United States Coast Guard
USGS United States Geological Survey
USLA United States Lifesaving Association
USMC United States Marine Corps
USP United States Pharmacopeia, also known as United States Pharmacopeial Convention
UTI urinary tract infection
UTM Universal Transverse Mercator
UTV utility task vehicle
UV ultraviolet
VA Virginia
VD vertical distance
VFR visual flight rules
VHR very high frequency
VMR Vertical Medicine Resources
VO2max maximum exercise capacity
VT Vermont
WAFA Wilderness Advanced First Aid (a specific certification)
WALS Wilderness Advanced Life Support (a specific certification)
WAM Wilderness and Austere Medicine (a fellowship at UNM)
WBGT wet bulb globe temperature
WCP Wilderness Command Physician (a specific certification)
WCU Western Carolina University
WEC Winter Emergency Care (historical term, now Outdoor Emergency Care)
WEM wilderness event medicine
WEMR Wilderness Emergency Medical Responder
(a specific certification)
WEMS wilderness emergency medical services
WEMSI Wilderness EMS Institute
WEMSI-I Wilderness EMS Institute-International
WEMSMDC Wilderness EMS Medical Director Course
WEMT Wilderness Emergency Medical Technician
(a specific certification)
WFU Wake Forest University
WFR Wilderness First Responder (a specific certification)
WHO World Health Organization
WHOT White House Office of Telecommunications
WMA Wilderness Medical Associates (became WMA International in 2010, but retaining initialism
WMA)
WM wilderness medicine
WMEC Wilderness Medicine Education Collaborative
WMI Wilderness Medicine Institute (pre-1999) or Wilderness Medicine Institute of NOLS (1999-
2015); rebranded in 2016 to be NOLS Wilderness Medicine
WMO Wilderness Medical Outfitters
WMS Wilderness Medical Society
WMTC Wilderness Medicine Training Center
WPCC Western Piedmont Community College
WPHECC Wilderness Pre-Hospital Emergency Care Curriculum
WSG Wilderness StarGuard
WUMP Wilderness Upgrade for Medical Professionals (a specific certification)
WWII World War II
INTRODUCTION
This book has been written for health care providers serving on formal, system-based teams who
provide their medical care in “wilderness” environments.
The opportunity to care for other human beings outside the normal resources of human
civilization springs from an altruism that is, it appears, native to our species. Indeed, this impulse
could be a foundation of civilization itself. It has been pointed out that the first hominid
attempting to aid another, using only the tools at hand or no tools at all while fending off the
threats of an unforgiving environment, was the first practitioner of wilderness medicine.1 This
would make the discipline of wilderness medicine the oldest of all medical specialties. The
subsequent efforts of our species to improve the sophistication and tools we use for medical care,
along with a host of other social and interactional evolutions, helped give rise to civilization as
we know it. Analyzing this cultural evolution from hominid roots to our present social and
technologic constructions is the purview of anthropology. Many generations of scholars—both in
the evolution of health care as well as other social structures—shaped this as a narrative of
overall progress.
But anthropologists and social theorists are now challenging the degree to which civilization
has improved health. Some suggest the growth of civilization has created as many health
problems as it has solved.2 Somewhat ironically, humans increasingly seek to escape—at least
periodically—the civilization they have built for themselves. People once had to carve
civilizations out of the surrounding wilderness environment, but now must carve wildernesses
out of the surrounding infrastructure of civilization. In the interim, there was a tension, for
example in American settlers of the 18th century, between “a nature that they called wilderness
with another nature called pastoral,” with a goal of “reclaiming large and fruitful tracts from the
waste of creation [wilderness]” into more productive and secure versions of nature.3 Indeed,
contemporary western ideas of nature grew out of the Industrial Revolution, especially by way of
a newly enriched and expanded class of citizens4; in fact, the very idea of wilderness may be a
problematic and reactionary concept invented by post-Industrial Revolution environmentalists
more than a real ecologic phenomenon.5,6 William Forgey, the “father of wilderness medicine” in
the United States,7–12 describes “a time when wilderness was really that and used by those who
lived and traversed through it” in a discussion about the role of medical textbooks used in the
wilderness of the 18th century (cited in Figure 1.1 of Chapter 1). Even more recently, older
adults alive today have commented on the change in landscape and expansion of development,
removing opportunities to experience “wilderness.”13 A more historical definition of wilderness
was “places untamed and not under control of humans,” and as discussed above, was contrasted
with civilization, representing “places of human control.”5,13,14 These themes speak to a pervasive
sense, both academic and affective, that there was a time when wilderness meant something
different than it does today. The paradoxical nature of wilderness in this modern context is
particularly apparent when considering the legal definition of wilderness.15 In the United States,
the National Wilderness Preservation System in 1964 began defining certain areas in the United
States as federally designated “wilderness.” Defining management policies and legal protection
for an area that, by that very definition, are intended to be free of modern human influences is
clearly paradoxical and has been cited in the wilderness medicine literature.13 However, such
definitions and protections do appear to be necessary in our modern era. Acknowledging then
that wilderness now may in fact be constructed, or at least protected, by civilization itself, a more
modern definition of wilderness is an area that an observer would perceive to be predominantly
under the influence (including being allowed by civilization to be predominantly under the
influence) of natural processes and forces.13 The legal definition itself has been cited for its
compelling poeticism, but also criticized as being problematically open to legal interpretation
based on that very poeticism13 (as well as using language of the day that now might be
considered excessively gendered). It reads,
A wilderness, in contrast with those areas where man and his own works dominate the landscape, is hereby recognized as an
area where the earth and its community of life are untrammeled by man, where man himself is a visitor who does not remain.
An area of wilderness is further defined to mean. . . an area of undeveloped Federal land retaining its primeval character and
influence, without permanent improvements or human habitation, which is protected and managed so as to preserve its natural
conditions and which (1) generally appears to have been affected primarily by the forces of nature, with the imprint of man’s
work substantially unnoticeable; (2) has outstanding opportunities for solitude or a primitive and unconfined type of
recreation; (3) has at least five thousand acres of land or is of sufficient size as to make practicable its preservation and use in
an unimpaired condition; and (4) may also contain ecological, geological, or other features of scientific, educational, scenic,
or historical value.16

It is worth noting that all four criteria are based on human perception rather than ecosystemic
reality (“appears to have been affected”) or apparent functional use or value to humans
(“opportunities. . . for recreation,” “practicable use,” “contain. . .features of. . . value”),
reaffirming the influence of civilization and human need over preservation of unaffected areas
simply for their own sake and with true ecosystemic integrity (an example of this limitation on
actual integrity or true absence of human interference would be firefighting operations in
wilderness areas). Clearly, this modern definition of wilderness out of civilization creates an
artificial boundary beyond which a “wilderness” is constructed, with varying degrees of
authenticity to a truly natural, remote, and “untouched” state. Some sources argue that this
federalization of land—especially in the American West—for public use and wilderness
protection has been universally praised, consistently supported by Congress, and is expected to
grow.13,14,17 But a more sensitive analysis points to federalization of land—especially in the
American West—for public use as one of the most contentious of social decisions. This
controversy dates back to the mid-19th century and continues up to the present day in very
immediate and significant ways. Examples of such modern-day controversy include actions by
both the public, such as illegal extremist occupation of a national wildlife refuge in southern
Oregon in 2016 protesting federal land use policies, and the government itself, such as recent
legislative and executive branch efforts to transfer land away from direct federal control, with
President Trump calling federal land acquisitions for parks and other public use from the era of
Teddy Roosevelt to today “a massive federal land grab” which “never should have
happened.”18,19 In the context of WEMS not existing without wilderness, it is heartening to see
that national surveys done in 1994 and 2000 demonstrated that more than 50% of those surveyed
felt 12 of 13 key wilderness values was “very or extremely important,” with “income for tourism
industry” supported to that degree by less than 30% of respondents, and that the trend between
the two surveys was increasing percentage of support for all 13 values.20,21
Interestingly, the further humans venture outside the boundaries of civilization and its
medical resources and into “wilderness,” whether constructed or actual, the more by intent they
risk experiences closer to that of the first hominid trying to help another than a neurosurgeon
performing brain surgery in a university hospital. In other words, the more we seek wilderness,
the more we need to return to our wilderness medicine roots. But in the best of worlds, we can
choose those elements of civilization we bring with us, some of which can even help save our
lives. The most important of these is, again paradoxically, the very characteristic that drove us to
create civilization in the first place: Our minds, with their ability to build and use tools, and their
capacity to problem solve. It is an unfamiliar thought to use now, as we enjoy boundless
dominance over the world around us, that about 70,000 years ago, our species faced near
extinction in a “population bottleneck.” Geneticists and paleoanthropologists estimated that less
than 10,000 members of our species remained—and possibly 2,000 or less—in small pockets in
Africa during a population bottleneck. These figures today would qualify Homo sapiens as either
a threatened or even an endangered species, approaching an extinction threshold.22 The source of
this bottleneck is unknown—the most likely source may be Saharan desert expansion (the largest
supervolcano eruption of the last 2 million years occurred at Mt. Toba around this time and
caused a “volcanic winter” during this time, which and has been speculated to also be an
exacerbating feature; although the explosion is still uncontested, its significance as a population
stressor is now heavily contested).23 It was this era that also coincided with the beginning of
major migrations out of Africa and of the origins of complex language, art, and sophistication in
tool use. These anthropological data suggest that the challenges facing us as individuals in a
hostile environment were replicated on a massive, species-wide scale around 70,000 years ago,
nearly ending our existence. Significantly, a probable solution was an evolution, or even
evolutionary jump, in our hominid brain, in our problem-solving capacity, and in the nascent
features of our capacity to build civilization, such as language and tool use.24,25,*
In Chapter 1 we will define wilderness medicine more formally. But from an introductory
perspective, it is helpful to think of wilderness medicine as medical care and problem-solving
when the surrounding environment has, or has been allowed to have, more power over us
than does the infrastructure (and underlying social structure) of our civilization. I would
note that a cultural anthropology perspective would further argue that civilization infrastructure
is itself secondarily a product of more foundational social structure. While this harkens back to
the older definition of wilderness discussed above (areas distinct from civilization), the concept
of relative power, and of the possibility that this has been permitted by civilizing forces, also
involves the more modern definition of wilderness as itself a product of civilization and human
perception.
This helps to explain why wilderness medicine has such a strong interest in not relying on
civilization and its associated technology to solve problems faced in the wilderness. After all,
many wilderness recreationalists are seeking an escape from civilization and technology, and one
of the attractions of recreating in a wilderness setting—the location for that escape—is self-
sufficiency and reliance on improvised or minimalist tools. In many ways this is an admirable
trait to foster in a society that bemoans the loss of mechanical skills and autonomous thinking in
a population that seems increasingly privileged and entitled. With the development of such
primary skills, we can safely venture deeper and deeper into otherwise dangerous wilderness and
austere areas. That is where the magic happens.
But, as with all magic, there is a price to pay.
First, intentionally putting oneself in dangerous situations without all possible resources by
definition increases risk of injury or illness. While this seems self-evident, it is important to
understand all the resulting consequences. Many of us seek out forbidding environments or
challenge our own abilities in ways that others may see as “crazy.” This includes rock climbing,
swiftwater kayaking, and other sports once thought “extreme” because the price of mistake or
failure can be high. Often in pursuing these sports we deliberately relinquish equipment or routes
that might be helpful in emergencies. This includes carrying the most minimalist medical kit
possible, not bringing any electronic tools due to philosophical convictions about “wilderness”
(see the discussion about post-Industrial Revolution conceptions of wilderness that follows), free
solo climbing not using the ropes and gear common in traditional and sport climbing, choosing
more dangerous wilderness routes or strategies for the thrill of the danger, and similar decisions
based on philosophical convictions or adventure-seeking rather than necessity. This can create
the need, or complicate the ability, for others to assist such individuals in danger. This is not to
argue against such practices in themselves, but to suggest that those impulsions pushing us into
the wilderness in the first place can, when taken further, make it more difficult to care for each
other once we are there. In addition, at least one wilderness medicine school has noted that
environments defined as “remote” from a medical standpoint are shrinking due to technology
and user expectation, even if the actual land area remains unchanged. The 6th edition of NOLS
Wilderness Medicine notes that
communication technology now offers the chance of quick transport from remote areas to urban medical care, and many
wilderness visitors have come to expect such service. In fact, much of what we call wilderness medicine is really a simple
extension of modern emergency medical services (EMS) into the wilderness by cell phone and helicopter instead of into a city
by telephone and ambulance.28

So while there may be continued interest in protecting the magic, there is also interest in
mitigating its cost. Whether that sensitive balance can be tipped in favor of cost mitigation
without loss of magic is heavily debated in wilderness communities, where it is often termed
“acceptable risk.”29(p.xv) In the context of that discussion, it is fascinating to read a wilderness
medicine school define much of what we call wilderness medicine as increasingly a simple
wilderness extension of EMS—the very topic of this book.
A second point, more relevant to this book, is that training in wilderness medicine has
traditionally and historically focused on what to do until help arrives. This is the core of “first
aid” types of medical care (discussed in more detail in the Regulation section of Chapter 1). One
of the most improbable public health stories of 20th-century America is the rapid and successful
development of a sophisticated and relatively unified EMS system organized to ensure that help
would indeed be arriving. As discussed in Chapter 1, many today are not aware that the entire
911 system, and the availability of credentialed and highly trained field medical providers it
dispatches to citizens in need, is less than half a century old, and yet is already taken for granted
as a necessary community resource. We will also demonstrate in Chapter 1 that throughout the
20th century there was unprecedented attention to medical care in wilderness areas (“wilderness
medicine”), intensifying as the century progressed. As EMS and wilderness medicine evolved
and commingled in the later part of that century, a merged subdiscipline evolved.
While the field of wilderness medicine in the 21st century has grown far more expansive, an
early and core principle of wilderness medicine was that it taught skills allowing a condition to
be temporized in the field until “formal health care” or more traditional EMS care could be
applied.30 In some cases, this was via routine health care after leaving the wilderness. However,
for more serious emergencies, training on what to do “until help arrives” presupposes help will
be arriving. More specifically for wilderness medicine, it presumes that wilderness EMS help is
available, accessible, deployable into the wilderness, and functional and effective in that
environment.
The endeavor to satisfy that expectation—which, as noted earlier, harkens back to the very
roots of our shared hominid experience—is the precise topic of every remaining page of this
book.

THE STRUCTURE OF THIS BOOK

This textbook divides into three sections.
Section 1 discusses principles of WEMS systems. This includes an overview of the history
and current state of WEMS systems, including definitions of terms, in Chapter 1; a review of
WEMS educational offerings for further training in this field in Chapter 2; and specific
discussions of how incident command (Chapter 3), medical oversight (Chapter 4), medicolegal
considerations (Chapter 5), equipment needs (Chapter 7), research (Chapter 8), and
pharmacology (Chapter 11) are implemented in a WEMS context. In Chapter 6, we discuss how
WEMS providers interface with professional organizations and guides as well as other health
care professionals. Chapter 9 explores the ways wilderness event medicine overlaps with, or
works within, a WEMS structure. And in one of our most innovative chapters, Chapter 10, we
discuss the ways in which neurobiology and psychopharmacology are driving a new treatment
modality, known as psychological first aid, designed to improve patients’ and providers’
resiliency, self-efficacy, and capacity building in austere environments. The experience of
wilderness itself is often a means to combat social trends toward entitlement and selfishness.
Discussions in this chapter encourage individual self-efficacy at the psychological level, a critical
skill in wilderness rescue operations.
Section 2 discusses the management of specific medical conditions. We begin with a
discussion of survivalism and personal safety in Chapter 12. The ability to operate safely in their
niche wilderness environment is a fundamental need for all WEMS providers. This chapter also
provides important skill sets that can be taught to the public (eg, potential subjects and patients)
before their emergency situation arises, providing the opportunity for preventive search and
rescue (SAR).31 We then discuss cold injuries (Chapter 13), heat illnesses (Chapter 14), lightning
injuries and WEMS management of storms (Chapter 18), management of animal bites and
envenomations (Chapter 19), and management of psychiatric and behavioral emergencies in the
wilderness (Chapter 23). We ascend to altitude to discuss low-pressure altitude physiology and
illnesses in Chapter 15; we submerge into water to discuss drowning in Chapter 16; and then
descend to even greater aquatic depths to discuss high-pressure diving physiology and illnesses
in Chapter 17. In Chapter 20, we divide our discussion of infectious disease management into
two parts: The first addresses infectious diseases associated with wilderness environments, and
the second addressing more commonplace infectious diseases and their management that happen
to occur in the wilderness environment. We discuss the management of general trauma
conditions occurring in a wilderness setting in Chapter 21, and the management of general
medical conditions occurring in a wilderness setting in Chapter 22.
In Section 3, we describe the medical interface WEMS providers must make with technical
rescue operations. Our book is intended primarily for EMS medical providers working in a
wilderness environment. However, this wilderness environment means that WEMS providers
must have technical skills, and often (just as in the front country, with the common combination
of Fire-Rescue-EMS operational teams) WEMS operators must combine technical rescue skills
with medical skills. An introductory chapter frames this issue in Chapter 24, covering principles
of basic rigging, patient packaging, and rope skills requisite for nearly all specialty fields. Then
we move on to specific technical rescue interfaces, including chapters on high and low angle
rescue (Chapter 25); swiftwater rescue (Chapter 26); open water rescue (Chapter 27); the use of
vehicles in rescue operations and medical care (Chapter 28); caving rescue (Chapter 29); general
SAR and mountaineering rescue on terrain without snow or glaciers (Chapter 30); and finally
SAR, mountaineering, and ski rescue in alpine environments where there is snow or glaciated
peaks (Chapter 31).

WORDS MATTER IN WILDERNESS EMS

Why Words Matter
Another central function of this book is both to establish and use appropriate language in
characterizing WEMS operations and theory. We must acknowledge the importance of the
language we use, and the care with which we need to use it. It has been argued elsewhere that, in
medical care in particular, “words matter.”32 Wilderness medicine authorities such as Auerbach
and Lemery have proposed that inherent in wilderness medicine is the need to act as good
stewards of natural resources, and specifically those wilderness areas we use.33,34 This has
become relatively noncontroversial. Similarly, but far more provocatively, McEntyre advances
the theory that we must also consider what it means to be good stewards of language. She argues
that language is life-sustaining and that “caring for language is a moral issue.”35 We would take
the concept of the life-sustaining element of language further and argue that caring for language
is also a clinical issue. Wilderness EMS is a medical field where, in particular, words have many
different meanings, with extensive legal and medical potency and complexity. From a more
pessimistic perspective, Orwell argued that “the decline of a language must ultimately have
political and economic consequences”36—and the consequences for clinical medicine are equally
dire. A theory in linguistic anthropology—most compellingly captured by Whorf’s work in the
early 20th century on linguistic relativity and linguistic determinism—suggests that language
critically influences the way one interacts with and understands one’s world, and may even
mutually construct such interactions, rather than merely reflecting them.37 We create language,
but conversely, the language we use may be operative in framing—or even creating—our reality,
both clinically and globally. In the late 20th century, linguistic anthropologists further developed
a theory of entextualization of language in medicine that explains how nuances of
communication and language can fundamentally affect diagnosis, treatment, patient satisfaction,
and even patient outcome itself.38 For this reason, we have put considerable thought into the
words we use and how we use them in this text.
The idea that “words matter” not only morally, but also clinically, goes even further. As
explained in Chapter 10, new neuropsychiatric findings have suggested that the words we choose
as caregivers have a significant impact on the outcome of our patients, warranting even more
care in our use of language. As posited earlier, of the tools of civilization that we choose to take
into the wilderness, our minds and our problem-solving are the most powerful, and a critical
form of those tools is language. The usefulness of these tools is either heightened or degraded by
our ability to transfer this knowledge into workable form through language. Therefore, the power
of language to assist in problem-solving is almost immeasurable—but misused, the potential
damage can be equally vast. To express this in a WEMS example, otherwise brilliant team
leaders at a command center are nonetheless useless if, when given a radio, they are utterly
incapable of communicating instructions to a team in the field. Words matter, as does care in
their use.
In keeping with that principle of care in the use of language, Table I.1 describes words we
will be using in this book, and encourage among the WEMS community, along with their less
preferable alternates. Word choice is often dismissed as “mere semantics” (although do not
forget the actual definition of semantic is fundamentally related to meaning, not to trivial detail,
despite its popular use), or worse, as “political correctness.” Without getting into that social
debate, we have found, as shown below, that the medical functionality of these words is directly
tied to their correct use. Our agenda is not political but medical and clinical—the ultimate goal in
promoting careful language is to improve patient care as well as the capabilities and knowledge
base of caregivers. Choices in word use are like other evolutions or clinical decisions in
medicine, as will become apparent throughout this book. For example, in Chapter 6, we discuss
issues in the interfacing of WEMS teams and traditional EMS or medical teams, with one of the
significant challenges being shared language conventions. Chapters 21 and 24 discuss the very
real differences implied by changing discussion from “spinal clearance” to “selective spinal
immobilization” to “spinal motion restriction” (SMR) and ultimately to “spinal cord protection,”
(SCP) all describing activities that are similar in operation but very different in meaning. In
Chapter 25, we describe the difficulties in WEMS field operators and emergency medical
dispatchers (EMDs) often experience in understanding route names used by climbers. A similar
problem exists for both paddlers and hikers as well as any recreationalists using route names
unique to their community. In Chapter 25, we also point out that multiple such recreational
communities have different names for the same environmental features, creating a modern Babel
in the wilderness, and severely complicating WEMS operations. Emphasizing a somewhat
different use of language, we point out in Chapter 6 that “exceptional documentation leads to
exceptional continuity of care,” with the reverse being true as well: That continuity of care and
handover failures have been identified as one of the most frequent sources of medical error. As
mentioned earlier, Chapter 10 describes the potentially therapeutic benefits of language itself in
the wilderness.

Table I.1 Precision and Accuracy in WEMS Terminology

Preferred Word/Phrase/Initialism Less Preferred Word/Phrase/Initialism
Advanced Practice RN (APRN) Advanced Care Provider
Advanced Practice Provider
Mid-Level
Drowning Dry drowning
Wet drowning
Secondary drowning
Delayed drowning
ECG EKG
ED ER
Non-fatal drowning Near-drowning
OEC technician OEC-T
Out-of-hospital or OOH Prehospital (unless patient known to be delivered to hospital)
Overwhelmed Traumatized (for emotional trauma)
Physician assistant
Physician’s assistant
PA Advanced care provider
Advanced practice provider
Mid-level
Patient (after care established) Victim
Spinal cord protection Spinal immobilization
Spinal motion restriction
Structured activities, community support therapy Counseling
Treatment
Subject (before care established) Victim
Suspension syndrome Suspension trauma

Word choice demonstrably impacts clinical outcomes and error. For example, we
acknowledge the work by the Institute for Safe Medication Practices and others in identifying
abbreviations that can be misunderstood and lead to medical error. In this book we follow the
conventions established by the ISMP, the US Food & Drug Administration, The Joint
Commission, and the 2004 National Summit on Medical Abbreviations.39–41
In wilderness medical care, words demonstrably do matter. Our goal for words should be the
same as our goal for medical data: that it be precise, accurate, and meaningful.

Subject versus Victim versus Patient

For decades, it has been very common in wilderness medicine and rescue literature to refer to all
those receiving rescue or medical services as “victims.” A slightly more complex convention has
emerged in which these individuals are referred to as “victims” prior to their rescue, and
“patients” afterward. In this text, and in WEMS dialogue in general, we would like to avoid
using the word “victim” at all, replacing it with “patient” throughout, with some rare exceptions
using “subject.” Along with medicine and rescue, medical anthropologists debate each of these
terms as well, seeming them all as essentially dehumanizing and, to some extent, not perfectly
accurate. The best language for this dialogue still eludes these inquiries from many different
disciplines.
First, from a language standpoint, it means the individuals in question have been
“victimized.” This sends the wrong message about how they got into difficulties in the first
place. It cancels their agency in the emergency situation, including possible responsibility for it,
and sets them in opposition to an aggressive and hostile environment. Instead, we want to
promote language which represents the environment as amoral: Either an ally or opponent
depending on the circumstances (for example, there is a section in Chapter 26 entitled “Using the
River”). This is not to imply the use of the word “patient” is simple. Indeed, the EMS community
has wrestled for years with its definition. Take, for example, responders called out to deal with a
full school bus that has run into a restaurant. Which individuals are patients, and which are
bystanders? Furthermore, many wilderness medicine and rescue books discuss technical rescues
of individuals without medical condition, who would thus not be a patient. In this particular
textbook—written for health care providers operating in an EMS context—the use of the word
“patient” is a little simpler. If there is no patient, there is no role for this book. This is not
primarily a technical rescue text. So, if an operation is an assist or extrication—when the
individual declines medical care, and nothing suggests an emergency medical condition is
present, so no care is ultimately rendered—then this book is not operative. That event is a
technical rescue or assist and not patient care. However, we would argue that the default term
used should be patient: Subjects should be assumed to be patients until proven otherwise, rather
than needing to prove themselves as patients.
Second, the dichotomy between “victim” prior to removal from the technical environment
and “patient” after being removed may actually be misleading and potentially harmful itself. If
they are not patients, why would we care how they are packaged during extrication in terms of
SCP (Chapter 21)? Why would we carry out interventions like trying to warm a hypothermic
person still in the water (Chapter 13) or the avalanche field (Chapter 31)? Why would we
perform in-water resuscitation and rescue breathing for an apneic person before they are out of
the water (Chapter 16)? Why would we start intravenous lines in entrapped persons to deliver
fluids and analgesics? Why would we care how an unconscious suspended person is taken off
rope (Chapter 24)? Rescue teams with exclusively technical, and not medical, training can do
horrific things from a patient care standpoint if they buy into the victim-patient dichotomy of
pre-rescue and post-rescue, and do not feel individuals are really “patients” until extricated.
Vehicle rescue in the front country environment is a good example of this falsehood. Even
though someone may be entrapped in a vehicle, a paramedic on scene still establishes care,
evaluates c-spine, starts an IV, delivers pain medications, in coordination with the technical
rescue, not afterward. That is our vision for what should be happening with imbedded WEMS
providers (or teams) during a technical rescue. Theirs is the voice of patient advocacy in the
overall operation, until someone is proven not to be a patient. If there is no patient, there is no
opportunity for patient advocacy. Additionally, it is not clear that a person can ever be
adequately screened for symptoms and capacity to refuse care in the midst of an ongoing
technical rescue. Without such screening, a person should be considered a patient until ruled
otherwise through evaluation.
Third, as explored further in Chapter 10, we contend that posttraumatic stress disorder
(PTSD) risk may be worsened by disengaging rescuers from actively participating in their own
rescue (even just verbally or symbolically), and that PTSD risk may be minimized by promoting
self-efficacy and engaging patients in their own care. This is even more important in a wilderness
environment, where in theory everyone is threatened, although the patient is measurably more so
than the rescuers. The “victim” role takes away agency from individuals in participating in their
own rescue, and reduces self-efficacy and individual capacity building. It suggests they are
simply helpless and rescuers must do all the work. As noted in Chapter 10, the World Health
Organization also discourages the terminology of “victim,” noting that it is a nontherapeutic
term. Even the term “patient” is problematic since it reinforces the paternalistic caregiver-patient
role with some loss of autonomy and self-efficacy—but “victim” conveys the worst message,
especially when one considers some of the variant meanings of the strict definition of the word.*
Finally, in all these operations, a public service access point (PSAP, also known as a 911
center) has presumably been involved. If there is any concern that the person in trouble has a
medical condition (and the problem is not just an entrapment or technical difficulty), in most
systems an EMD has been engaged and EMD protocols have been applied. In that sense, patient
care has been initiated, and thus the object of that care is a patient, even if no provider has yet
touched them.
However, we also acknowledge that in particularly long operations (SAR operations, for
example), it may be days before individuals are reached and their medical condition is known. In
that context, it is traditional to refer to individuals as “subjects” prior to patient contact and as
“patients” once patient contact is made and a need for medical care is established. We are
comfortable with that distinction and feel it would be widely applicable throughout WEMS
operations. Therefore, our convention in this text (and we would advocate for its use throughout
WEMS) will be to refer to individuals receiving care as “patients,” and in those particular
circumstances where there is a clear need to refer to periods of time before their patient status is
known, to refer to them as “subjects.”
In the legal world, courts and academics use the term “victim” to describe a person who
claims to have suffered harm at the hands of another. This use of “victim” fits well within the
Webster’s definition of that term noted earlier. Because liability questions arise after a harmful
course of events has occurred, the use of the term “victim” often accurately describes a person
who has suffered harm due to, for example, a WEMS provider’s negligence (see Chapter 5). This
is the one use where we would endorse “victim” in WEMS dialogue referring to an individual
receiving services.
This distinction provides us with a nuanced and precise set of words we can use in this text
and promote within the WEMS community to describe recipients of our services. A subject is an
individual who is receiving rescue attention prior to establishment of actual contact. Once such
contact is made, a patient is someone receiving medical care from a provider. Once medical care
is delivered, a victim is someone alleging negligence or harm from that care, and that term is
confined to legal dialogue. Or put more facetiously, but still accurately, in the words of Laura
McGladrey, author of Chapters 10 and 23, “patients are not victims unless you hurt them while
caring for them!”
As a side note, it is worth recognizing that linguistic issues involving words such as “victim”
are not new. Setnicka’s landmark Wilderness Search and Rescue (published by the Appalachian
Mountain Club in 1980) has a fascinating Editor’s Note and Preface, well worth reading for
many reasons. Among other things, it reminds us that this same debate about terminology, with
the conviction that “words matter,” was active nearly a half century ago. Setnicka writes:
It seems that we are forever scratching our heads in order to come up with workable, non-sexist words which are simple to
use, such as “rescuepersons” or “layperson.” In general, we have used both male and female pronouns here to achieve a
balance. Throughout this book the word “victim” is used in its broadest sense to describe the focus of a search or rescue
operation: the person who is lost, stranded, sick, or injured. I personally do not feel the word has nasty connotations. . . The
word “rescue” refers to a situation in which others are assisting a “victim” whose location is known. A “search” occurs when
the victim’s location or her physical state is not known. A “recovery” is the location and evacuation of the body of a fatality.42

Interestingly, he uses “subject” and “victim” somewhat interchangeably throughout the

remainder of the book. So even then he was anticipating, or addressing, concerns about the
problematic term “victim,” and the term “subject” was non-controversially and commonly in use
even in the 1970s... and did not require a preceding explanation in an Editor’s Note!

Emergency Department (ED) versus Emergency Room (ER)

The use of “ER” to represent “emergency room” dates from an earlier era when emergencies
would be handled in a single hospital room. This room would be staffed by physicians trained in
other specialties who would be called in from home or from more routine medical care
(discussed in Chapter 1). The advent of emergency medicine as its own physician specialty was
coupled with an expansion of emergency medical resources in hospitals, resulting in entire
emergency departments (EDs) dedicated to emergency care and increasingly staffed by board-
certified emergency physicians. These departments, in the academic sense, now often include
multiple divisions within them addressing subdisciplinary topics (in some centers, including
wilderness medicine). Furthermore, it is worth noting from a “words matter” perspective, that
when the medical literature needs to distinguish between the popular culture, television, and
Hollywood portrayal of emergency medicine, and the actual practice of this medical specialty, it
uses “ER” for the former and “ED” for the latter.43

Spinal Cord Protection versus Spinal Immobilization

There has perhaps been no greater paradigm shift in out-of-hospital trauma care over the last
decades than the move away from spinal immobilization. This issue is extensively discussed in
Chapters 21 and 24. In keeping with contemporary evidence and practice, we do not see a benefit
from traditional spinal immobilization in WEMS patients. For those circumstances where we
suspect spinal cord injury or its risk and wish to implement practices shielding patients from
complications, we use the terminology “spinal cord protection (SCP)”. In our opinion, this is
preferable to spinal motion restriction (SMR). SMR presumes that motion has some relation to
potential or actual further injury during medical care, but this presumption has been effectively
challenged by Hauswald and others and remains unproven.44 Absent any clear indication that
motion affects further injury, we prefer the term SCP for those measures seeking to manage
possible or actual spinal cord injury, as more specific to both the body part involved (spinal cord,
not spinal column, and neurologic, not orthopedic) and the ultimate goal of the intervention
(overall protection rather than specific motion restriction).

Non-Fatal Drowning versus Near-Drowning

In 2002, the World Congress on Drowning redefined drowning to be the process of experiencing
respiratory impairment from submersion/immersion in liquid.45 This definition has been accepted
by prominent organizations involved in drowning care and public health, including the World
Health Organization, the American Red Cross, the Wilderness Medical Society, and the
International Liaison Committee on Resuscitation. It includes three categories of drowning: Non-
fatal drowning with injury, non-fatal drowning without injury, and fatal drowning. For reasons
discussed in greater detail in Chapter 16, the older terminology of “near-drowning”, as well as
“dry drowning,” “wet drowning,” “delayed drowning,” or secondary drowning,” has
significantly impaired our epidemiologic and clinical abilities to study drowning and care for
patients experiencing it. Consistent with this movement, we discourage the use of “near-
drowning” for any WEMS clinical or research purposes. Drowning is fully described in Chapters
16, 26, and 27.46

Suspension Syndrome versus Suspension Trauma

Suspension syndrome is a real condition bearing significant risk for patients or rescuers
experiencing it, as we show in more detail in Chapters 24 and 25. However, numerous myths
abound regarding its etiology and management. The dispelling of those myths represents one of
the major achievements of evidence-based medicine (EBM) and its application in
mountaineering and rescue services in the 21st century.47 A more contemporary understanding of
the physiologic and pathophysiologic parameters of injury demonstrates that the condition is
essentially syndromic rather than traumatic, making suspension syndrome the best term.

Nonphysician Clinician Category

In recent years, there has been a proliferation of credentials that permit providers to operate at a
“clinician” level (capable of operating with prescribing powers and semiautonomously or
autonomously from physician oversight). The most common nonphysician clinicians in health
care are PAs (formerly known as physician assistants, as noted in Chapter 1) and advanced
practice registered nurses (APRNs) such as nurse practitioners.48 Various collective terms have
been used to describe this category of nonphysician clinicians. The term “mid-level” has been
rightly criticized for the potential implication that it quantifies the care delivered by these
providers, or characterizes the quality of that care.49 “Advanced care providers” or “advanced
practice providers” have been proposed as alternatives. However, these terms are problematic as
well. All of them, whether using the nomenclature of “mid” or “advanced,” presume some
relationship relative to an unnamed standard. Terms that categorize a provider as “advanced”
presupposes that the care rendered by these providers is more advanced than others. This might
work in some ways for APRNs, whose practice is defined relative to RNs and is more advanced,
but does not work for PAs, whose practice is defined relative to physicians and is actually less
advanced. Furthermore, if we are defining a category of providers (“clinicians”) as physicians
and these other providers, then using “advanced” terminology for all those providers except
physicians is clearly problematic. Physicians would typically be more advanced in training and
practice than those labeled as “advanced providers” within their provider category, which is
unacceptably paradoxical. In the PA community around the turn of the decade in 2010, there was
a movement to refer to this provider type as “associate providers,” a very appealing term that
seems intellectually and operationally suitable to their role. PAs would thus become “physician
associates.” Some schools, such as Yale University, already termed their program one for
“physician associates.” Handily, such a name change would not require changing the PA
initialism, which would fit either name. Heavy debate followed,50–53 with the whole question
becoming irrelevant in 2017 when the American Academy of PAs disengaged the letters PA
from any underlying definition (see discussion of “Independonym” below). In any case,
whatever the utility of the term associate provider might be for PAs (which itself was heavily
debated), the concept of associate providers does not fit APRNs, some of whom are not clinically
associated with physicians and operate autonomously and independently.54 We have not found an
acceptable overarching term to encompass all provider types who are clinicians but not
physicians. Therefore, when more specific terminology than “clinician” is needed, we simply
refer to clinicians by their specific degree type: PA, APRN, or physician.

EKG versus ECG

As explained in more detail by Emergency Medicine News,55 electrocardiograms (ECGs) were a
19th-century British invention, but the most often cited news report of its invention in England
was written by a Dutch speaker. The Dutch translation was elektrocardiogram, shortened to EKG
in this author’s original references to the technology. However, we are referring to an English
invention using the English language in the 21st century. There is no rational reason to use a “k”
in an initialism when that letter does not appear anywhere in the word it represents. Therefore,
we prefer the term ECG when discussing ECGs.
Prehospital versus Out-of-Hospital
EMS is often referred to as “prehospital” medical care. This dates back to an era where the
presupposition was that all patients cared for by EMS would be transported to a hospital. Now, in
an era where community paramedicine and mobile integrated health care are pioneering new
pathways for EMS care, that presupposition is no longer necessarily true. Such considerations
are especially valid in wilderness EMS, where the complexities of extrication and patient
movement, coupled with increasingly sophisticated treatment by providers, mean that many
WEMS patients are never transported to a hospital. For example, one series from the National
Park Service’s WEMS teams showed that 77% of patients receiving EMS care—and even more
significantly, 84% of patients receiving ALS care—did not require transport.56 Given the degree
to which comprehensive (or at least non-transporting) care may be delivered entirely in the
wilderness without involving a hospital, WEMS practice is much better characterized by the term
“out-of-hospital” care. We use this term, sometimes shortened to OOH, in place of prehospital,
except in those cases where it is known or certain that a patient will be or has been delivered to a
hospital.

OEC-T versus OEC Technician

The abbreviation used to refer to technicians certified in Outdoor Emergency Care is contested.
On their website and in their own publications, including the 5th edition of Outdoor Emergency
Care, the National Ski Patrol use the term “OEC Technician.” Other sources, including multiple
peer-reviewed references in the medical literature by reputable authorities (such as OEC 5th
edition authors, the NSP medical director, actual ski patrols, and resource documents) refer to
this provider type as “OEC-T.”57–60 In keeping with the wishes of the National Ski Patrol itself,
we exclusively refer to this provider type as OEC Technicians, unless we are directly quoting
sources that use other terminology.

Language Conventions Used in this Textbook

We recognize that this textbook is being written for many levels of EMS providers. We have
adopted a number of philosophical and stylistic conventions to address that situation.

Hierarchical Taxonomy
This textbook promotes a horizontal rather than vertical vision of medical hierarchy. In other
words, it is a common feature of the medical world that credentials, degrees, and certificates are
categorized in terms of what provider is “over” another operationally, or which level has more
training. So in medicine (and often wilderness medicine) we refer to “providers at the EMT level
or higher,” with the supposition that height refers to some higher level of training, usually
equated to hours required for certification. In some ways this taxonomy does reflect operational
realities: For instance, a physician is “over” an EMT in the sense that their license is used to
support the paramedic, who has a dependent rather than independent certification. However, in
many ways, this is not a very functional structure for wilderness medicine or WEMS. Physicians
are often put at the top of these medical hierarchies, but in a WEMS operation, it is likely that a
nonphysician skill set may be more critically important for a given rescue or medical need. It
seems evident that in this setting, the relative importance or quality of care delivered depends
upon the nature of the operation. The need dictates the most qualified or most highly trained
provider capable of addressing that need. For example, in a swiftwater situation, the “most
qualified” and “most highly trained” provider may not be a physician with a prescription pad and
an MD degree, but rather a swiftwater rescue technician with proper swiftwater equipment and
an EMT certification. The Outward Bound Wilderness First-Aid Handbook expresses this
concept even more evocatively, stating “in many wilderness scenarios a team of sled dogs would
be more useful than a team of surgeons.”29 A horizontal taxonomy of providers promotes the idea
of overall equivalence, with each provider type being more or less functional depending on
relative context rather than absolute hours of training or position in a front country or hospital-
based medical hierarchy. Nothing speaks more to the fact that, for example, “paramedic” and
“MD” are separate credentials and not sequential or vertically ranked than the fact that multiple
providers identify themselves as “MD, Paramedic” (many are authors of chapters in this book)
and that accredited physician-to-paramedic programs exist and have enrolled students seeking
this dual credential.61,62 As noted in Chapter 6, medical hierarchies based outside of the
wilderness environment can actually complicate and confuse operations rather than enhance
them. For those times when we do use terminology such as “advanced” or vertically derived
terms, we are referring exclusively to hours needed to obtain that degree or certification level.
Otherwise—with the exception of considerations of medical oversight—a hierarchical taxonomy
sets all providers on an equal basis. It then prioritizes their relative roles and leadership based on
the Incident Command System (Chapter 3) and specific operational and medical needs, rather
than traditional medical cultures of hierarchy or arbitrary credentials which may or may not be
meaningful in a given wilderness operation.
Acknowledging that we are writing for many different types of medical providers, we have
constructed our chapters to be easily accessible despite these differences. For example, it is a
challenge to cover a topic in a way that is functional for both a wilderness first responder (WFR)
and a physician. To address this challenge, we have created categories of caregivers, whose
educational basis and scope of practice are likely to be similar. Especially in Section 2 (our
clinical chapters), we end each chapter with an “Implications for Caregiver Levels” section
where we break down discussion and recommendations to each of these caregiver categories. We
have defined these as Basic Life Support, Advanced Life Support, and Clinician categories. This
has proven quite controversial during our discussions as an author group. The precise line
between these categories is contested and uncertain, as is the overall definition of the threshold
between BLS and ALS in EMS overall. As one example among many, many EMS professionals
would categorize EMDs as BLS providers. However, the EMD literature itself categorizes EMDs
as ALS providers.63
In light of this type of controversy, we do not attempt to specify which category a reader
necessarily falls into. Instead, we allow readers to apply this overall categorization and the
contents of the different categories at their own discretion. Their own circumstances and
credentials, the scope of practice laws in their own state, and the operational rules of their own
WEMS team can all influence which category is most appropriate for them. However, based on
national conventions, terminology, and standards in EMS, we can use EMS nomenclature to
define noncontroversial, prototypical caregivers and readers for each section as follows.

First Aid: someone bearing a First Aid certification

BLS: emergency medical responder (EMR), emergency medical technician (EMT)
ALS: paramedic
 Clinician: allopathic (MD) or osteopathic (DO) physician

In EMS care in general, we recognize the critical role played by non-EMS personnel in the
overall chain of survival. Many of the most successful and efficacious interventions in EMS,
such as widespread availability of defibrillators, early initiation of cardiopulmonary
resuscitation, and termination of arterial extremity bleeding, depend on widespread training of
individuals operating at the “first aid” level. The prototype of this level is the First Aider, but it
also includes all other laypeople who may be applying automated external defibrillators (AEDs),
implementing bleeding control, or even just utilizing common sense interventions even if not
formally certified in First Aid. As we note elsewhere and this layperson example demonstrates,
the precise definition of first aid itself is highly contested. However, in this case, we can safely
say that there are a type of individuals without training beyond a first aid level whom we
nonetheless want to train to provide initial care before EMS arrival. . . which in the case of
wilderness scenarios could be hours, making their importance even greater. Indeed, formal
analysis of EMS operations has shown that bystander first aid is critically important in rural
areas, which would by extension be even more significant in remote or wilderness settings.64
With that in mind, we have also created a category of “caregivers” labeled as “First Aid,” outside
the traditional definition of EMS health care providers. Further discussion of the first aid
category of care is in “The Relationship of EMS, WM, and WEMS” section of Chapter 1. In the
clinical chapters of Section 2, as well as in Sections 1 and 3 when relevant, we break down
practice recommendations into recommendations for each caregiver category: First Aid, BLS,
ALS, and Clinician.

Professionalism and Gendered Language

In closing, a note about professionalism and gendered language.
This text uses the term “professional” to refer to responders in the context of their role as
formal caregivers, not in the context of whether they are paid or volunteer (see, for example, this
use in Chapter 26). As noted in Chapter 1, volunteerism has always been a key component of
WEMS; and professionalism, used to define quality rather than occupation, can be equally
present whether providers are paid for their activities or not.
We see no reason to use exclusionary language without reason. Medical anthropologists,
sociologists, and psychologists have clearly shown that gender can be both anatomically and
socially a spectrum, or at least a triad, rather than a dichotomy, and that sex and gender are
socially and culturally as well as biologically constructed.65 From a biologic perspective,
variations in SRY gene expression, presence, or location, hormonal variations such as complete
androgen insensitivity syndrome, putative effects of autism on gender identity, mixed
chromosomal presence, and genetic phenomenon such as enzyme deficiencies in the guevedoc of
the Dominican Republic can all result in intersex traits or identity. From a sociocultural
perspective, an intersex or third gender identity is actually quite common in non-North American
cultures, including in South Asia (Hijra), Nigeria (Yan daudu), Mexico (Muxe), Samoa
(Fa‘afafine), Thailand (Kathoey), and Tonga (Fakaleiti), for example.65 Even in North America,
native cultures have expressions of third genders, such as the Hawai‘ian Mahu and the two-spirit
described in some Native American tribes, as well as the variety of public third gender identities
(transexual, queer, and others) to have emerged more recently in these communities. As this
book is focused on American society and culture, we can use this anthropological evidence to
demonstrate that American social constructions of gender are not exclusive or universal. This is
particularly important to recognize because, in a “words matter” context, sociologic work by
Davis (which won the American Sociological Association’s 2016 Donald Light Award for
Applied Practice of Medical Sociology) suggests that pathologizing intersex identities or
incorrectly assigning or presuming gender via language can have significant deleterious health
and life effects in American society,66 in addition to simply being potentially exclusionary or lazy
in assuming gendered social roles. In addition, multiple publications have shown gender bias and
the damaging effect of gendered language in medicine.67–70 Therefore, whenever possible, we
utilize non-gendered plural pronouns such as “they.” Gendered pronouns are only used when
referring to someone of a specific, known gender. While we recognize the increasingly common
convention of using the plural “they” to refer to a singular, it is not without controversy (one of
our authors colorfully described it as “repugnant”) and is unfamiliar to some readers. We have
only rarely needed to employ it if at all in this text.

Independonyms
A phenomenon has been growing in the WEMS world of adopting freestanding initialisms and
acronyms without underlying meaning.
As a review, an acronym is a word made up of capital initial letters of other words, and that
is read as a word. Common examples would be “NASA” (representing National Aeronautics and
Space Administration), “EMTALA” (representing Emergency Medical Treatment and Labor
Act), and “NAFTA” (representing North American Free Trade Agreement). WEMS examples
would be “NCOBS” for NC Outward Bound School (pronounced “n-cobs”) and “WFR” for
Wilderness First Responder (pronounced “woofer”). An initialism is a word made up of capital
initial letters of other words, and that is not read as a word but is just read as the series of letters.
Examples would be “FBI” (representing Federal Bureau of Investigations) and “POW”
(representing prisoner of war). WEMS examples would be “EMT” (representing Emergency
Medical Technician) and “ICS” (representing Incident Command System). A backronym is an
acronym that starts with the acronym, and then builds a meaning out of that acronym, rather than
vice versa. A backronym example in WEMS would be Frank Hubbell’s book title WILDCARE,
which cleverly represents Working In Less than Desirable Conditions and Remote
Environments.71
Recently, many words in WEMS that started as initialisms or acronyms have “discarded”
their underlying meaning, or are being created without (public) underlying meaning in the first
place. Examples include the school “NOLS,” which formerly represented the National Outdoor
Leadership School, but which is now a freestanding word without underlying abbreviation
meaning72,73; the provider type “PA,” which formerly represented physician assistant or physician
associate but now is a freestanding word without underlying meaning74; and CDS Outdoor
School, which does not have a public definition of the letters CDS according to its medical
director, Dr. Jonnathan Busko. These are neither initialisms nor acronyms, since they explicitly
and intentionally do not represent anything with their constituent. After consulting with multiple
grammarians and copy editors, we concluded that no grammatical term exists to describe these
types of words. In a social media exchange on this topic, Nikiah Nudell of The Paramedic
Foundation found a post on the English Language & Usage Stack Exchange, a question and
answer site for linguists and etymologists that posed a similar question. It asked what the
grammatical term was for acronyms that become words in their own right and no longer typically
reference their acronym origin. Examples of this include laser (formerly LASER), radar
(formerly RADAR), modem (formerly MODEM), and scuba (formerly SCUBA). While
confirming that no adequate grammatical term seems to exist, numerous suggestions were
posted. Of these, the most compelling term without other conflicting meanings was
independonym, suggested by the German contributor Helmar.75 Adapting this meaning slightly,
we will introduce that term in this text (and apparently to the English medical literature). An
independonym consists of initials that no longer reference, or never referenced, an underlying
meaning or definition.

Truthful Language in the Post-Truth Era

Intrinsic to precise and accurate use of language is its truthfulness. And perhaps at no other time
in our history has fundamental truthfulness in our cultural dialogue been under attack. McEntyre
notes that “the generation of students coming through high schools and universities now expect
to be lied to.”33 In 2004, Keyes defined this point in our human history as “The Post-Truth Era”
(noting that Steve Tesich first coined the term in 1992).76 Since then, social media have
penetrated even further into cultural dialogue, culminating in fake news from self-admittedly
spurious sources on social media sites significantly outperforming parallel real news reported by
legitimate media.77 (In this social media context, “performance” is defined as “engagement,”
such as shares and likes.) That reality is even more significant when we recognize that social
media is far and away the most common source for news for “millennials”—the generation
coming of age now in the post-truth era.78 Other terms have been advanced to explain this
phenomenon. Stephen Colbert calls it “truthiness”—“a quality characterizing a ‘truth’ that a
person making an argument or assertion claims to know intuitively, ‘from the gut,’ or because it
‘feels right’ without regard to evidence, logic, intellectual examination, or facts.” Similarly,
politicians have utilized such rhetorical techniques stretching factual reality for centuries, but that
strategy has gained new apparent legitimacy via the use of recent normalizing terms such as
“truthful hyperbole” and “alternate facts.”70,71
Parallels to this exist in the medical world.
Most explicitly, in his text Rigor Mortis, Richard Harris shows how the characteristics of a
post-truth era apply to what he terms “sloppy science,” including a crisis of reproducibility,
questionable economic and ethical drivers of research, and simply poor study design,
implementation, and analysis.81 While his analysis draws from contemporary examples of sloppy
science, it is also important to recognize that medical science has a long history of being hijacked
by social and political agendas, and the fight against this influence is equally long. The
anthropological principle of detachment (balanced by a critical need for self-awareness,
participation, and social engagement),82,83 as well as application of strict biologic science
principles, helps peel away social overlays and agendas in scientific work. A landmark work in
this effort is paleoanthropologist Stephen Jay Gould’s The Mismeasure of Man. While most
directly debunking the precepts of biologic determinism, Gould provides a solid, albeit
controversial, argument against excessively socially biased science of all sorts.84 In addition, fake
news as a specific term has been identified in formal medical literature, in this case attributed to
the appearance of “predatory publishers.”85
More generally, the traditional models of peer review and sourcing of credible medical
information in textbooks and journals have been challenged. In part, this results from
demonstrable flaws in the quality control of that process.86,87 However, it is also related to the
proliferation of social media, and the ostensible benefits of crowd-sourced rather than peer-
reviewed information, as well as the rapidity with which this information can be shared. In the
emergency medical community, this has been formalized in the FOAM (Free Open Access
Meducation) movement, including FOAMED, FOAMEMS, the Social Media and Critical Care
conference, and other social media and digitally sourced clinical data and information. While
FOAM organizers argue that this is merely an educational adjunct and not a primary educational
philosophy or strategy,88 numerous subsequent references suggest it is becoming a primary
educational resource for new practitioners, uniquely positioned to convey cutting-edge
technologies and clinical information. Consider the words of influential emergency medicine
educator Joe Lex: “If you want to know how we practiced medicine 5 years ago, read a textbook;
if you want to know how we practiced medicine 2 years ago, read a journal; if you want to know
how we practice medicine now, go to a (good) conference; if you want to know how we will
practice medicine in the future, listen in the hallways and use FOAM.”89 The point here is
absolutely not to argue that this information is inherently any less truthful than other sources, but
it does bypass traditional medical conventions designed to screen for truthfulness, namely formal
peer review (replaced somewhat by crowd-sourced approval or disapproval) and the publication
threshold for professional publishers (which others have argued plays a meaningful peer review
surrogate role). This crowd-sourcing allows for powerful communication and collaboration
among expert communities. As an example, the investigation and ultimate adoption of the term
independonym described earlier was entirely done on social media, a level of collaboration and
real-time communication that would not have been feasible 20 years ago, as well as another level
of credibility in a search for truthfulness and a form of peer review.
This all has great meaning for WEMS. McEntyre notes that while imprecision is simple,
precision is much more difficult. Also, she correctly points out that while precise language is
often dismissed as “politically correct” and built around satisfying special interests, in fact, “the
practice of precision not only requires attentiveness and effort; it may also require the courage to
afflict the comfortable and, consequently, tolerate their resentment.”35(p44) Two examples from
our book alone illustrate this.
As noted above, we have chosen to use the terminology of spinal cord protection for
measures to prevent further injury to patients with possible spinal cord injuries. This term
challenges the more common terms spinal immobilization (increasingly discredited on both
philosophical and operational grounds) and SMR (the more popular replacement term, but
problematic in its emphasis on motion). Watching our author group debate this topic, it became
immediately clear how important choosing the correct term would be in conveying a precise
meaning to a student or reader. It is very hard to promote the idea that painless, nonphysiological
motion does not seem to correlate with further injury, while describing measures to prevent
further injury as “motion injury.” While the easily fatigued dismiss such controversies as “word
smithing” or “semantics,” those with educational and clinical experience understand the critical
need for language chosen to be precise and truthful. We would also note that the strict definition
of “semantic” is “of or related to meaning in language.”90 Therefore, a word choice that is
semantic means a word choice that fundamentally changes the meaning that is being conveyed—
not a minor issue at all!
As another example, in the history section, we have meticulously built a unique timeline
merging EMS and wilderness medicine historical events with more recent WEMS events. The
history of such a recent field is still being written, and already there is controversy and
allegations of “revisionist history.” Since many of the founders of modern EMS, wilderness
medicine, and WEMS are still in active practice, we have the opportunity—indeed, the
obligation—to reflect a history that is fundamentally truthful. In fact, this is an echo of the
discussion above, regarding the quantity of disinformation available and the willingness of
people to believe all of what they read based on its “truthiness” rather than critically analyzing its
source and face (or actual) validity. It is part and parcel of either the intentional “culture of lies”
in our media and modern historicism described by Paul Weaver,91 the quasi-intentional post-
truthfulness described by Keyes as common in our society,76 or the widespread, unintentional
disinterest in words and their fundamental truthfulness described by McEntyre.35 Regardless of
their origin, such carelessness is the gateway to confusion, misinformation, controversy,
allegations, and disunity. Conversely, care with words and their truthfulness—like care with
medications and their dosing, or research data and its interpretation—is critical for effective
communication, medical teaching and academic inquiry, and actual clinical care in WEMS.

EVIDENCE-BASED MEDICINE
Related to a commitment to precision, accuracy, and truthfulness in language is a commitment to
EBM in clinical practice. This textbook is committed to the principles of EBM and applies them
throughout clinical discussions and care recommendations.
EBM has come to be interpreted as the privileging of scientific evidence over other
considerations in choosing what care to deliver, and how to deliver it. However, EBM, as
described for the first time in 1992 and as it has been subsequently refined, actually proposes a
three-legged system for analyzing clinical efficacy: best research evidence (the most commonly
recognized parameter), patient values and preferences, and clinical expertise.92 It is important to
recognize that best research evidence can include qualitative modes of research as well as
quantitative, such as observation, open-ended interview, and ethnographic study. That
interpretation of EBM is how the term is applied in this textbook, and how we would encourage
readers to utilize it, bearing in mind that clinical expertise may be equally meaningful to research
evidence. This has sometimes been termed “balancing evidence-based practice with practice-
based evidence.”93 Even more importantly, we might add “patient population” to “patient values
and preferences” with “patient population.” The wilderness medicine patient population may be
radically different from the population being studied in a scientific medical publication,
especially if that publication is not in the field of wilderness medicine. This relative deficit of
quality wilderness medicine evidence, and the dangers of indiscriminately applying non-
wilderness studies to a wilderness-based population, has been noted by David Johnson, Jeffrey
Isaac, and others.94 Ultimately, the entire endeavor is all about the specific patient receiving the
specific care. Unless a provider has already performed the specific research answering the
specific question about the specific patient now receiving care, all research is modeling. The
degree to which that model matches the specific patient and the specific environment of care is
the challenge. Clinical expertise plays a role in addressing this challenge, and also can serve as a
surrogate for formal research. However, a growing body of evidence suggests that relying on
clinical experience alone does not result in patients receiving what is contemporaneously
considered the standard of care based on current guidelines.95 And what we categorically reject is
the principle that something should be done simply because it has always been done that way;
because it matches some ephemeral “standard of care” that is not supported by either specific
research evidence or clinical expertise; or—most insidious—because care cannot be done any
other way. We firmly believe in the principle that those who do not believe something can be
done need to get out of the way of those actually accomplishing it. A corollary is the insistence
common in WEMS, especially among those with training levels involving less medical decision-
making or hours of training, that there are “rules” in wilderness medicine and WEMS. While
WEMS care is often driven by protocols (which are themselves simply conveniences to replace
online medical oversight individualized to the patient in question; see Chapter 4 for more on
this), it necessarily requires a level of medical decision-making and autonomy not routinely seen
in other EMS subspecialties. However, the protocolized nature of EMS in general, coupled with
the certainty given to students in certification classes whose teaching style necessarily avoids
ambiguity, often leads WEMS responders to feel that certain interventions “must” be done.
Relevant examples include the application of femur traction splints, the initiation of
cardiopulmonary resuscitation in the wilderness, protection of the cervical spine without
consideration of selective criteria, among other areas of EMS controversy. Medical clinicians are
familiar with “absolute indications” and “relative indications.” An important concept for WEMS
providers to recognize is that, due to the overarching control exerted by the environment, in
wilderness medicine and WEMS almost all interventions are contextual and relative. Beware
fixed rules that do not acknowledge this. Put another way, in the words of the classic joke,
“never accept absolutes.”
In a “words matter” context, we do note that some wilderness medicine authors have
preferred the term “evidence-informed” rather than “evidence-based.” The degree to which this
preference is founded in a search for truthfulness and precision in language is exemplary. For
example, in 2006, Schimelpfenig wrote
This article looks at the research with interest and caution, using the honest phrase “evidence-informed” rather than
“evidence-based.” Answers will be elusive, influenced by the hat we wear when we practice our medicine—search and
rescue, outdoor program leader, park ranger–and by the quality of the research. Science is our guide, but experience and
human bias mould our choices. A memory that has changed over time or an experience that has left us an emotional hook can
lure us down the road to anecdote-based medicine.96

However, as noted above, the original 1990s definition of EBM accounts for the quality of
the research and, even more importantly, the influence of the specific hat worn in the practice
and the influence of experience (as well as the individual patient involved). Also, the most recent
analyses of the evidence available in wilderness medicine (Evidence-Based Review of Wilderness
First Aid Practices published in 2017)98 suggests there is continued comfort in the WEMS and
wilderness medicine community in the more widely used term “evidence-based.” In that sense,
we feel comfortable continuing to use the terminology of “evidence-based” rather than
“evidence-influenced,” while agreeing with the shared conviction that there is a real danger in
the use of anecdote-based medicine not based in or influenced by actual experience or credible
evidence.
In addition, Schimelpfenig here used the interesting term “anecdote-based medicine” as a
dangerous road. This could be seen as excluding qualitative or narrative data as valid. However,
in this medical context, “anecdote-based medicine” means something else. What is noted here as
dangerous, and particularly common in wilderness medicine, is the practice of conveying stories
(with various degrees of exaggeration and misinterpretation) from the original practitioner to
generations of listeners as truth with no known connection to practice. In other words, the
dangerous “road of anecdote-based medicine” is the axioms that develop in medical care from
the alleged experience of one unknown practitioner at an unknown time, which is not backed by
any actual firsthand experience or published evidence. So anecdote is useful in practice (when it
is your own experience), but it gets dangerous in teaching, when you are using someone else’s
anecdote, often transferred through multiple generations and over long periods of time. Clearly,
this is not how the scientific method is supposed to work. It represents the jump from hypothesis
to fact without testing, which then retrospectively has an apparatus of fact built up around it by
anecdote that dissolves with any inquiry. This is also the curse of the multigenerational footnote
in medicine, where a footnote in a contemporary book offering “evidence” for something links
back to an older footnote, which goes to an older one. If you play the rabbit hole game of hunting
them down, the original footnote is a weak hypothesis or suggestion, or does not even relate to
the original contention at all. This issue is entirely separate from formal qualitative data
collection obtained by interview or observation in structured psychological, psychiatric,
sociological, or anthropological inquiry.
Readers who are interested in learning more about the principles of EBM and how it can be
applied to clinical practice should review Users’ Guides to the Medical Literature.98 This
excellent textbook collects a series of peer-reviewed “how to use and appraise” manuscripts
published in the Journal of the American Medical Association into a toolbox useful for learners
of all types of training, explaining how to use research evidence appropriate for their unique
practice settings (including field medicine).99 Also, EMS research in general is discussed in more
detail in Chapter 8, including analyzing evidence, and should be helpful in further exploring
EBM. For those who become even more engaged with this medical perspective, Carpenter and
Ruoff note that EBM in wilderness medicine includes both EBM experts and EBM
practitioners.99 EBM practice is the focus of this textbook, as it is essentially directed toward the
clinical practice of WEMS, and is thus directed toward fostering EBM practitioners (those who
seek to apply research evidence and structured clinical experience at the patient-provider
interface). However, EBM experts are also needed in WEMS, who explore existing EBM
principles, develop WEMS teaching modules or measurement tools based on EBM principles,
and share those with the WEMS practitioner community.99 Numerous advanced training
resources exist to support readers who wish to explore this EBM expert role further.100,101
Examples abound in this text about ways a new emphasis on evidence has changed practices
in rescue sciences and wilderness EMS. These include how we rescue patients in danger of
drowning in submerging vehicles (Chapter 16), how we rescue patients hanging suspended at
risk for suspension syndrome (Chapter 24), and how we package trauma patients in danger of
spinal cord injury (Chapters 21 and 24). Indeed, as discussed in Chapter 1, the principles of
EBM, along with a renewed commitment to collaboration, are what mark the transition from the
consolidation and growth era of the early 1980s to a new era, transitioning in the decade between
2005 and 2014.

SCOPE AND CHARACTERISTICS OF THIS BOOK

Scope
There is an old saying in EMS that “once you’ve seen one EMS system, you’ve seen one EMS
system.” EMS systems, by virtue of the differences in state regulations and variable operational
models and environments, are exceedingly different across the United States. Throw in the
variability of a marginally regulated industry such as wilderness medicine as it applies to
wilderness EMS, and it becomes exceptionally difficult to write a single textbook that accurately
captures wilderness EMS operations and activities across the country. For this reason, we are
confining ourselves in this book to WEMS operations in the United States, with historical and
external references to non-American events and organizations only when it is relevant and
operative to an understanding of American WEMS.

Author Group
Finally, a word about the group of authors writing these chapters.
Geographically, our author group extends from the furthest northeastern reaches of the
country in Maine to the furthest northwestern in Alaska, from the deserts of the American
southwest in New Mexico to the tip of the American southeast in Florida.
Each chapter is written by a subject matter expert, and every attempt is made to balance both
experts holding academic credentials (critical for academic credibility) with experts holding field
operations credentials (critical for EMS credibility). Our author group includes one or more
representatives of most provider and academic groups, such as physicians (including allopathic
MDs, osteopathic DOs, resident physicians, and board-certified EMS physicians); registered
nurses (RNs); APRNs; PAs; paramedics; EMTs (both traditional and wilderness); EMS medical
directors; EMDs; WFRs; counselors and therapists; rescue team chiefs; wilderness medicine
school and outdoor school owners and leaders; professors in medical schools; pharmacologists;
lawyers; Search and Rescue team members; medical directors and advisors of local, national, and
international specialty organizations; state EMS medical directors; professional researchers;
lifeguards (including traditional, surf, and wilderness lifeguards); swiftwater rescue technicians;
and multiple authors of textbooks in their own right.
The history expressed in Figure 1.1 and in its accompanying text in Chapter 1 was largely
crowd-sourced and peer reviewed by an ad hoc email community drawn together for that purpose
of over 60 wilderness medicine, EMS, and WEMS leaders. At every step in this textbook’s
construction we have tried to be as inclusive of various voices and possible, and to be respectful
and truthful (rather than truthy) about historical features of WEMS.

Intended Audience
The intended audience for this textbook are EMS providers and EMS leadership providing
medical care in the wilderness, those providing wilderness medicine care as part of a formal
system-based team, and those involved in such efforts. The definitions of EMS, wilderness
medicine, and wilderness are not necessarily intuitive, and are more formally defined in Chapter
1.

SUMMARY
The intent of this textbook is to define and promote the concept of a practice of medicine that is
derived from, but not identical to, both EMS and wilderness medicine. We hope its commitment
to evidence, truthfulness, clinical experience, and field applicability will help steer the practice of
a new generation of EMS providers working in wilderness environments.

Acknowledgments
I am exceedingly grateful for the review and suggestions provided for this chapter by Paul Sabin
(Professor of History and Environmental Studies, Yale University), Anne Hawkins (Professor
Emeritus of Humanities, Penn State University), Steven Folmar (Professor of Anthropology,
Wake Forest University), and Sherman Hawkins (Professor Emeritus of English, Wesleyan
University). However, any errors or omissions are my own.

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*In a fascinating corollary to this thread in paleoanthropology and genetic research, some geneticists now propose that a similar
evolutionary jump may be about to occur, postulating that a new species—termed Homo evolutis—may emerge in mere
generations.26,27 A hallmark of this theory is the increasing ability of our species to control our own genetic code and key
elements of our environment. If so, this microscopic genetic evolution has fascinating parallelism with the macroscopic evolution
of the relationship between wilderness and civilization. The global movement of civilization carving out a survival niche within
wilderness, to wilderness only being a conceptual valuation within a dominant model of civilization, would be expressed in our
very genes and our characteristics as a species. However, catastrophic elements of that supposed control over nature, including
the threat of nuclear war and climate change with vast and unintended ecosystemic alterations, could reestablish the
predominance of “wilderness” and natural forces over civilization, both genetically and globally.
*Definition of victim per Webster Dictionary:
1. a living being sacrificed to a deity or in the performance of a religious riteone
2. one that is acted on and usually adversely affected by a force or agent <the schools are victims of the social system>:
(1) one that is injured, destroyed, or sacrificed under any of various conditions <a victim of cancer> <a victim of the auto
crash> <a murder victim> (2) one that is subjected to oppression, hardship, or mistreatment <a frequent victim of political
attacks> (3) one that is tricked or duped <a con man’s victim
Wilderness EMS systems have unique characteristics. These chapters explore the system-
based characteristics of wilderness EMS. They offer an analysis of the field as it currently
exists, as well as proposing best practices and future innovations within a scientific and
evidence-based context.
INTRODUCTION
As discussed in our preceding chapter, wilderness EMS (WEMS) is the system-based practice of
wilderness medicine. Therefore, it makes sense for our first chapter describing WEMS to analyze
the ways it operates as a health care system.

DEFINITIONS OF TERMS
“EMS,” “wilderness,” “wilderness medicine,” and “wilderness EMS” are all terms with varying
definitions. Words matter, and establishing strict definitions and using them correctly is essential
to genuine understanding, as discussed in our Introduction chapter.

Definitions of Wilderness and Wilderness Medicine

In our Introduction chapter, we proposed an abstract and conceptual definition of wilderness
medicine: wilderness medicine is medical care and problem-solving in circumstances where
the surrounding environment has more power over our well-being than does the
infrastructure of our civilization. That definition is useful in the context of a more
philosophical and anthropological discussion of wilderness medicine. But more specifically
operational and clinical definitions have been proposed. In the context of WEMS care,
Auerbach’s Wilderness Medicine defines wilderness in this way: wilderness is those areas
where fixed or transient geographic challenges reduce availability of, or alter requirements
for, medical or patient movement resources.1 For us as health care providers, this definition of
wilderness is more useful than more general dictionary-based definitions of “a tract or region
uncultivated and uninhabited by human beings,” or “an area essentially undisturbed by human
activity together with its naturally developed life community,” or “an empty or pathless region,”
or other 21st-century generalized definitions.2 Auerbach’s definition of wilderness is echoed by
the National Association of EMS Physicians (NAEMSP), who further suggest that “wilderness”
be defined locally.3
Other EMS textbooks have also proposed that “wilderness” must be contextual.4 The idea of
a contextual definition in medical care reflects a broader reality about the wilderness. As
discussed further in the Introduction chapter, all post-Industrial Revolution definitions of
wilderness are contextual inventions. They say as much or more about the cultural use of the
word as they do about any independently defined ecological reality. Consequently, with this
word, specific context of use (in this case, a medical context) becomes even more relevant.
Building on its contextual definition of “wilderness,” Auerbach’s Wilderness Medicine goes on
to define “wilderness medicine” in this way: wilderness medicine is medical care delivered in
those areas where fixed or transient geographic challenges reduce availability of, or alter
requirements for, medical or patient movement resources.1
In this text, we will follow the convention established by Auerbach for definitions of
wilderness and wilderness medicine. Such a wilderness medicine definition also mirrors other
similar definitions in the medical literature that emphasize austere environments, resource
limitations, and impairment of timely access to more advanced care.5–7
This definition of wilderness medicine is both more comprehensive and more specific than
definitions that are based exclusively on time, resources, or location.6 Each of these alternate
definitions has critical failures in capturing wilderness medicine practice.3,8 The time definition
(usually more than 1 hour, or sometimes more than 2 hours, from “definitive care,” often citing
the “Golden Hour”) is perhaps most common.9 But this time-based definition fails to define
“definitive care,” as well as excludes care occurring within 1 to 2 hours of definitive care that
still certainly qualifies as wilderness medicine.3 In addition, the significance of a “golden hour”
in out-of-hospital emergency medical care is exceedingly controversial and increasingly felt to
be mythical. Such challenges to the “golden hour” concept make its use as the foundational
definition of wilderness medicine problematic, especially if defined as a literal 60 minute
window.10–20 The resource definition inappropriately excludes many WEMS operations from
wilderness medicine, as WEMS operations frequently have access to resources not available to
typical EMS systems (eg, the high altitude helicopters available in some national parks as
discussed in Chapter 28). A definition based on location ignores the fact that even major urban
centers can include features of wilderness medicine, both in terms of routine practice,21,22 in
geographic areas such as some of the huge American urban parks, or during disasters. This
conviction that wilderness medicine can be anywhere is embodied in the Gusteau Principle: any
location in America can include features of wilderness medicine and require WEMS
management.8,*
In 2012, Frank Hubbell published definitions of various stages of WEMS medical care that
may be useful in further defining subtypes of wilderness medical care. Specifically, he defined
extended care as care lasting from 1 hour to 24 hours. This matches well with an EMS
perspective that an EMS activity lasting more than an hour is an extended medical operation,
although some WEMS operations may be completed in less than an hour. He defined remote
medicine as care in areas where no definitive care is available.23 Indeed, these terms are so
foundational that they became the basis of the cover art for his 2014 textbook WILDCARE.9
That definition of “remote” also matches a growing use of the term remote in the medical
industry to mean an area where more formal medical care must be definitively inserted. This is
similar to the meaning implied, for example, by Remote Medical International (RMI). RMI
provides medical infrastructure for clients and industries working in “remote and challenging”
environments, which they define as areas where traditional medical care is challenged or
diminished by “geographic location, work conditions, environmental extremes, political
instability, or regulatory environments.”24 They provide an integrated medical support model
providing continuity of care throughout the life cycle of a project, of which WEMS or WM
training may only be a part, and which speaks to the need in a “remote” area to replicate an entire
medical infrastructure.

Definition of EMS
Although EMS is taken for granted in contemporary society, it is a very recent innovation in the
history of medicine; indeed, the formal existence of EMS is one of the most significant public
health stories of the 20th century. Though the meaning of “EMS” is often taken for granted,
debate has arisen regarding what is and is not considered EMS or part of an EMS system. A
precise definition is needed to resolve such questions. Amazingly, it was not until 2012 that a
consensus definition was published, when the National Association of State EMS Officials
(NASEMSO) defined EMS as “the integrated system of medical response established and
designed to respond, assess, treat, monitor, observe, and determine the disposition of patients
with injury or illness and those in need of medically safe transportation.”25 That definition has
been widely adopted by EMS organizations, and is of great utility in navigating questions of
“what is EMS” in terms of wilderness medicine. It will be the definition of EMS used throughout
this textbook. Further clarifying that definition, NASEMSO emphasizes the primary health care
focus of EMS, as well as its role as a vital component of emergency preparedness systems. We
agree that EMS as applied in wilderness areas contains critically important elements of public
health and emergency preparedness. NASEMSO also specifically notes the inclusion of multiple
casualty incidents, mass gathering events (Chapter 9), medical oversight (Chapter 4), education
(Chapter 2), and research (Chapter 8) as within the purview of EMS. They go on to clarify that
“anyone participating in any component of this response system is practicing EMS. . . EMS is
the practice of medicine and as such, any of the activities that constitute EMS require oversight
by a physician.”25 They specifically exclude the following from an EMS definition: Good
Samaritan care (as they define such care); basic first aid, cardiopulmonary resuscitation (CPR),
and public access defibrillator use available outside the established EMS system; care, unrelated
to the EMS system, rendered by professionals within an established health care facility; public
health programs and home health care programs unaffiliated with an established EMS system.
These are also important modifiers of an EMS definition for wilderness applications.
However, as noted in the Introduction chapter and later in this chapter, EMS has long
recognized the critical role of first aiders, bystanders, and community support in providing care
prior to the arrival of EMS.26 In many cases, from a public health and patient advocacy
standpoint, EMS serves as the organization that promotes first aid and community health
interventions. In wilderness areas, first aiders and ad hoc caregivers are often the primary care
providers for extended periods—even hours or days—before EMS arrival, unlike many other
EMS systems, and so a WEMS system must pay even more attention to the role and training of
such first aiders. Because of this, our text includes extensive discussion of ways WEMS systems
can promote quality care by such first aiders and Good Samaritans. At the same time, it is
particularly important to acknowledge that, by definition, basic first aid and Good Samaritan care
are not formally part of EMS. Therefore, formal definitions of “basic first aid” and “Good
Samaritan care” become important, and are discussed later in this chapter.
Definition of Wilderness EMS
Building on the definitions of “wilderness” and “wilderness medicine” above, in this text we
define “wilderness EMS” as follows: “wilderness EMS is the systematic and preplanned
delivery of wilderness medicine by formal health care providers.”1 The scope of WEMS
includes, but is not limited to, the topics represented by the various chapters of this book.

RELATIONSHIP BETWEEN EMS, WM, AND WEMS

Understanding the relationship between wilderness medicine and EMS—not just how they are
defined, but how they intersect and operate in real-world activities—is crucial to understanding
the unique role of WEMS in the medical world.
In 1990, Bowman attempted to define these operational categories in a landmark publication
in the Journal of Wilderness Medicine.27 He proposed two separate tracks for caring for the ill
and injured: a “professional medical track” and a “prehospital emergency care track.” While
these definitions reflected a status quo in the middle of the 20th century, they are no longer
useful in defining out-of-hospital care. Even when applying his own definitions, Bowman
described overlaps, and those overlaps now eclipse any benefit from these definitions. As noted
in our introductory chapter, the term “professional” now encompasses volunteers, and out-of-
hospital providers (as well as emergency care providers of all sorts) are now all considered
professionals. In addition, the modern concept of EMS as mobile integrated health care argues
for its inclusion within the overall health care system rather than preceding it. The model of
integrated care makes distinctions between “hospital” and “non-hospital” less meaningful, as
care that was once considered exclusively “hospital” is more and more integrated into out-of-
hospital operations. Put most simply, “prehospital emergency care” is now a common
“professional medical track” delivering treatments that were once exclusively “hospital-based,”
rendering such distinctions largely meaningless. We will discuss this more in Chapter 2 as we
explore educational frameworks and the modern credentialing process for WEMS providers.
However, Bowman was pointing to an important distinction that still exists: ad hoc
wilderness care delivered by recreationalists who do not have a duty to act, versus formal
wilderness care delivered by system-based credentialed providers who do have a formal duty to
act. This credentialing and duty to act, more so than professionalism or where the care is
delivered, is the meaningful distinction in 21st-century medical care in the wilderness.
In Chapter 26 we propose the distinction between a “recreational rescuer” and a
“professional rescuer.” It must be made clear that “professional” in this term does not necessarily
mean “paid,” and that “recreational” refers to the primary activities of the caregiver in the
wilderness and not their relationship to the rescue (no rescue is recreational!). With such caveats,
these terms may be the best current way to understand the distinction between ad hoc care and
formal care, and the caregivers who deliver it.
The transition zone is in those providers who do prepare to deliver care via formal
certifications. Examples would be wilderness guides and experiential education leaders for
organizations such as Outward Bound and NOLS. As discussed further in Chapter 2, a standard
has evolved in this outdoor industry that such professionals should be trained in wilderness
medical care, usually to the Wilderness First Aid (WFA) or, more often, the Wilderness First
Responder (WFR) level. These are undoubtedly formal medical certifications that involve a
scope of practice and a set of standards. In addition, these providers may have established a duty
to act through any implied contractual obligations in the literature they share with clients
describing the requisite medical qualifications of themselves or their staff.
However, within a medicolegal context, while wilderness guides and experiential education
leaders may carry medical certification and may have a limited duty to act, their medical
certifications and duty to act fit most closely within the definition of first aid. As shown
elsewhere—including our Introduction, Education (Chapter 2), and Legal (Chapter 5) chapters
—“first aid” is an extremely contested term whose meaning may be contextual. The International
Liaison Committee on Resuscitation (ILCOR) published a 2015 international consensus
definition of first aid as “the helping behaviors and initial care provided for an acute illness or
injury.”28 ILCOR clarifies that “first aid can be initiated by anyone in any situation,” and that its
goals are “to preserve life, alleviate suffering, prevent further illness or injury, and promote
recovery.” Somewhat less usefully, they define a first aid provider as “someone trained in first
aid who should recognize, assess, and prioritize the need for first aid; provide care by using
appropriate competencies; and recognize limitation, and see seek additional care when needed.”28
This nearly tautological definition of first aid provider could be applied to any health care
provider type, replacing the word “first aid” with that other care type, and begs the question of
how much training is needed to perform tasks that can by definition be done by anyone at any
time. However, the underlying definition of first aid, tied to the concept that it can be initiated by
anyone in any situation, is functional, and is the definition that will be used throughout this
textbook when “first aid” is discussed, with the additional modifier that such care should be
unanticipated, uncontracted, and ad hoc—in other words, applied without a duty to treat. This
distinguishes it from EMS, where the delivery of care is anticipated and planned, and this ad hoc
nature is also sometimes referred to as “Good Samaritan Care.”
Importantly, the ILCOR definition also confirms that first aid is the unregulated practice of
medicine. The concept of first aid as a form of medical care, and should be applied using
universal modern medical care principles, is further confirmed by ILCOR, who state that “first
aid assessments and interventions should be medically sound and based on evidence-based
medicine (EBM) or, in the absence of such evidence, on expert medical consensus.”28
While some WEMS systems do employ WFA as a minimum standard, in general, wilderness
activities that are not operating within the EMS system will certify staff at the levels of WFA or
WFR. In general, skills and scopes of practice within these certifications do not require medical
oversight and are not regulated by state EMS organizations. Most often, EMS systems—
wilderness or otherwise—will certify staff at the levels of emergency medical dispatcher (EMD),
wilderness emergency medical technician (WEMT), wilderness paramedic, or wilderness
clinician. The medical oversight point is also helpful in understanding the distinction between
WEMS and wilderness medicine. While there is not an exclusive distinction here, in general,
activities for which state regulatory bodies require medical oversight are more consistent with
WEMS. Activities considered to be simply first aid and not requiring oversight (although we feel
clinician input is always a benefit) are more consistent with recreational wilderness medicine.
The differences in medical oversight/direction versus medical advising are discussed in more
detail later in this chapter, and medical oversight in general is the entire topic of Chapter 4.
In addition, remember that first aid does interface with EMS and plays an important role
within its operations as care delivered before formal providers arrive. Such citizen-based care has
been crucial to many of the successes of EMS in the 21st century and is well recognized as an
important element of the out-of-hospital chain of survival. Therefore, a recognized interface
between these two types of care (formal “professional” EMS care and informal “recreational”
first aid care) already exists within the standard out-of-hospital care model in the United States.
Finally, there is an element of intent, which gets back to Bowman’s original framework. The
actual care delivered by professional EMS providers or by recreational first aid providers may be
identical. In fact, most experts feel the fundamental principles of basic life support (BLS)
interventions are likely more important to effective wilderness and emergency medical care than
more advanced (ALS) interventions, and this is a pervasive theme of this textbook.29–31 For
example, given a patient in cardiac arrest, high quality CPR is the most important intervention,
which should be the same regardless of the credential of the provider delivering it. If the actual
care is the same, then the final distinction is the intent of the caregiver in delivering that care.
The primary intent of professional EMS personnel dispatched to a medical care operation is
health care. The primary intent of recreational rescuers who find themselves involved in a
medical care operation is not health care, even if it is planned for by developing protocols,
carrying medical kits, and training. Another important use of this concept of “intent” is for
providers with autonomous medical licenses, such as physicians, who find themselves in a health
care role in the wilderness. An example would be physicians delivering medical care on an
expedition. The care such physicians deliver would be the same whether they are expedition
clients or expedition physicians. However, clearly the medicolegal expectations and their role
within the health care continuum are different. Once again, it is the intent that clarifies this. If
they are a team physician, and their primary role and purpose on the expedition is to deliver
medical care, this is a WEMS role. If they are a team member who happens to be a physician,
and their primary role is not to deliver health care to others, then any role they do take on is more
general wilderness medicine. This also explains the role of a clinician who unexpectedly comes
upon an incident. Such a case might be a broken leg on a ski slope. Two people ski up to help—
an orthopedic surgeon skiing for recreation and an on-duty ski patroller. The orthopedic surgeon
would be practicing general wilderness medicine, while the ski patroller would be practicing
WEMS, even if the precise care they both deliver is identical. This example also shows the scope
of practice of general wilderness medical care, depending on the certification/licensure level of
the provider, may actually exceed that of WEMS care.
In summary, there are many ways that WEMS and general wilderness medicine intersect.
However, the most helpful ways to distinguish them are certification type, duty to act, presence
of medical oversight, and intent of care. Characteristics more consistent with WEMS care are
non-first aid certification types (EMD, EMR, EMT, clinician), a demonstrable duty to act which
is a primary intent, and the presence of medical oversight for non-independent certifications.

Medical Advisors and Medical Directors

The Difference Between a Medical Advisor and a Medical Director
The difference between a “medical advisor” and a “medical director” is contested, in many of the
same ways as the distinction between general wilderness medicine and WEMS.1 However, the
distinction outlined in that discussion can also serve to clarify the difference between advisors
and directors. In general, medical advisors serve organizations whose primary purpose is
recreational (meaning it primarily fields “recreational rescuers”) and who plan to provide general
wilderness medicine, while medical directors serve organizations whose primary purpose is
medical and who plan to provide WEMS services.
More specifically, the difference between medical advisors and medical directors is
contextual and functional. To understand this, it is helpful to imagine a single WEMT serving as
a member of both an Outward Bound school and a Mountain Rescue Association team, both of
which also have the same physician as medical advisor (Outward Bound) or medical director
(Mountain Rescue Association team). In each case, the EMT and the physician are both the same
person, with the same certifications and the same training. It is the context and the role they take
that define the difference between their activities, not any objective definitional line or difference
in them, their training, or for the most part their practice. Nothing encapsulates this blurring
better than the historical fact that Outward Bound’s foundational origins—even its name—are
intrinsically connected to marine rescue services.32
However, there are still critical differences.
Traditionally, the term “medical advisor” indicates a consultative role in which a health care
provider advises an organization regarding their medical and risk management activities. The
title implies no specific authority, would appear to have more limited medicolegal risk, and is
most appropriate for those cases where no specific scopes of practice beyond first aid are being
activated by the provider.
In contrast, the term “medical director” indicates a degree of authority beyond that of an
advisor. A medical director is necessary if the services offered by the provider include the
activation of EMS-specific scopes of practice, which is of importance for providers at multiple
levels, including the BLS level. It is our conviction that BLS EMS services benefit from
qualified medical oversight as much as ALS services do. We recognize some other authors and
institutions argue that organizations preparing for first aid-only or BLS-only care may use
medical advisors, and that anything above this level requires medical direction. However, this
argument suffers from a significant flaw: namely, that “first aid” and “BLS” themselves are
contested terms with multiple meanings. It is unclear whether a WFR, for example, is operating
as a first aid level practitioner within their scope of practice and does not require medical
oversight, or is acting as an EMS provider via a state-recognized First Responder certification
which requires medical direction. It is for reasons such as this that the EMS transition to
“Emergency Medical Responder” rather than “First Responder” will likely bring clarity to this
situation. Some states permit BLS providers—generally considered to be providers operating at
the EMT-Basic, first responder, or medical responder level—to provide care without formal
medical oversight, although this action is not supported by NASEMSO.1,33 Again, however, this
regulatory reality begs the question whether BLS care without medical oversight is appropriate.
Our position is that the salient distinction as to whether medical direction (versus oversight) is
needed is whether the system is EMS or not, rather than whether the care delivered is BLS or
ALS.
Based on NASEMSO position statements,34 consensus position papers,35 and medical
standards, all EMS systems, including those operating in the wilderness, should strive to
establish physician-led medical oversight.
Our contention would be that the term medical advisor should be confined to those situations
where health care provider input is purely advisory and is not being used legally or operationally
to activate or support any certification levels or EMS-grade protocols (ie, protocols beyond what
would typically be considered first aid).
The title and role of such advisors highlight two of the most important issues sometimes
missing from these debates: the existence of real out-of-hospital patients and the importance of
increased physician involvement in their care. Whether we call someone a medical advisor or
medical director, or whether we call the system they work within WM or WEMS, may be less
material than recognizing that there is a patient in need and a critical role for a physician to
perform. In that sense, a more important concept than choosing a precisely correct term is
acknowledging the reality that an individual in duress is a legitimate patient, despite
circumstantial location in the wilderness, and deserves care directed by a physician.

The Role of PAs and APRNs in Medical Direction and Medical Advising
One of the most contentious topics in WEMS today is whether nonphysicians can serve as
medical advisors or medical directors. Nonphysician clinicians in WEMS operations include PAs
(formerly known as physician assistants)* and advanced practice registered nurses (APRNs).
Here, careful parsing of the two terms may again be helpful. As we have insisted, words matter,
and terminology for nonphysician clinicians represents a rapidly developing nomenclature amid
a dynamic health care culture.
PAs became active in American health care following the reintroduction of military medics
into civilian practice. Civilian medical systems recognized their advanced training and practice
skills, and in the absence of a clear niche in which they could insert those skills into civilian
practice, a category of “physician assistant” was pioneered at Duke University and soon
implemented elsewhere. It is ironic that, while their historical heritage sprang from austere and
battlefield medical care, the modern PA is more often utilized in clinic- and hospital-based
medicine, and EMS is a more unusual application for this credential.
While most American providers and patients are familiar with the nurse practitioner (NP)
credential, in fact, four separate nursing licenses exist permitting autonomous or advanced
practice for registered nurses (RNs) of which NP is only one,* making advanced practice RN
(APRN) the more comprehensive name for this type of provider.
When considering a medical advisor, clearly a candidate should have a background that
matches the operational needs of the institution. In that sense, precise medical credentialing may
be less important than an individual’s other qualifications to function as a “medical advisor” for
a wilderness-based organization. Nevertheless, we continue to think that clinician-level providers
in general provide the most appropriate and comprehensive medical advisor services. In most
cases nonphysician clinicians work in collaboration with a physician to provide this type of
service, bringing a physician to the equation as well.
On the other hand, “medical director” implies a specific EMS, regulatory, and legal role, the
requirements for which are often dictated by state rules or practice. So, for example, in some
states nonphysician clinicians can serve as medical directors, while in others their role is
confined to assistant medical directors, and in still others they cannot have any medical director
role whatsoever. At this time, it does appear the most consistent practice across the country is to
confine primary medical director roles to physicians. However, the underlying point and purpose
is that the system have physician-level medical oversight, rather than that the individual position
be held by a physician. So, for example, physician assistants must always have physician-level
collaboration.36 Therefore, a PA serving as a program’s medical director will still have physician
collaboration, even if the titular role of director is held by a PA. This becomes more complicated
in the case of APRNs, who are capable of autonomous medical practice, and whose medical
practice is often dictated by a separate regulatory body—a state board of nursing, whereas EMS
is most often regulated by a state medical board. Since nursing has a much smaller footprint in
EMS, largely confined to air medical transport units, the role of autonomous nurse practitioners
is an extremely esoteric issue best addressed by analyzing local and state circumstances and
regulations. The overall principle is this: the ideal and most common arrangement for a WEMS
system is the provision of immediate physician-level medical oversight, but other frameworks
utilizing delegated, collaborative PA oversight or APRN involvement may be necessary and
appropriate in certain systems.

Regulation and Accreditation

The question of medical advisors versus medical directors, as well as the overarching dialogue in
wilderness medicine and WEMS about standardization, is intrinsically connected with the issue
of regulation. Regulation has been an increasingly pressing and contentious issue in wilderness
medicine and WEMS over the past few decades, and it is likely to increase in importance. As
early as 1996, the Wilderness Medicine Newsletter noted, “Standardization, accreditation, risk
management—these are the buzz words of the 90s when it comes to outdoor education and
adventure programming.”37 A classic case study is the issue of ski patrols, which fall into very
different regulatory categories in different states, ranging from nonregulated first aid providers
outside the EMS system in some states to formally regulated providers within the EMS system in
other states.38
The problem of regulation is particularly difficult for WEMS, which represents a merger of
what has historically been one of the least regulated types of medicine (wilderness medicine)
with one of the most regulated types (EMS). A clean distinction from a regulatory perspective
would be to declare that wilderness medicine does not require regulation and WEMS does.
Despite its appealing simplicity, deeper scrutiny blurs the crispness of this dividing line. Some
issues have been discussed earlier, such as the line between first aid and formal medical care, or
the question of whether teams of providers such as lifeguards and ski patrollers are practicing
wilderness medicine or WEMS.
Not only is there a conceptual difficulty in terms of the degree to which WEMS should be
regulated, there is also simply a numerical and cultural evolution in regulation in our society. In
the years from 1970 (the beginning of the WEMS Golden Age of Growth as described below) to
2015, total pages of federal regulations have increased nearly fourfold, from 20,000 to over
80,000.39 While EMS is largely regulated at the state level, EMS educational organizations have
cited similar growth patterns with relevance in out-of-hospital medicine, noting that being aware
of regulations and working to comply with them can be burdensome and occupy significant staff
time and resources.40 Another element of regulation is requisite licensure†. In the 1950s, less than
5% of overall American workers were required to have licensure; by 2008, that percentage was
estimated to be almost 29%.41 Currently all states and the District of Columbia require licensure
of EMTs, which has been cited in the labor literature as one of the occupations with the highest
number of states requiring licensure.42 This makes EMS in general one of the most highly
regulated industries in terms of licensure; extending such regulation to WEMS could be an
expected future evolution for cultural reasons, as well as for legal reasons as an instance of the
practice of medicine, historically a heavily regulated industry itself.
In the sense of the ILCOR definition of first aid cited earlier, many elements of wilderness
medicine are similar to first aid and may be seen in a Good Samaritan context, at least insofar as
they are differentiated from WEMS. One helpful way to think of the regulatory difference
between first aid and EMS would be not definitional but rather functional and contextual. In
other words, the difference cannot depend on either individual people or their defined credential,
but rather the role they are serving and the context in which they are delivering care. Consider
for example that, as discussed further in Chapter 31, in Utah a ski patroller is (by legislated
definition) providing first aid, while in Maryland that same ski patroller is (by legislated
definition) providing EMS care. Or that in North Carolina and the majority of other American
states, an American Red Cross-credentialed First Aider—or a layperson reading the Outward
Bound Wilderness First-Aid Handbook and applying its teachings as unregulated “first aid”—has
a wider scope of practice to treat dislocations than a credentialed paramedic.44–46
This functional distinction between WM and WEMS fits a more expansive definition of
wilderness medicine. The actual practice of WM is extremely broad, including space medicine,
marine medicine, elements of tactical and disaster medicine, and many others beyond the original
conception of care delivered on an outdoor trip or other, more dated definitions discussed earlier.
The expedition physician or the medically credentialed astronaut or the remote jungle clinic
medical APRN are legitimate wilderness medicine practitioners, not EMS practitioners; they are
certainly not practicing first aid in its ad hoc sense, but they also likely do not need to be
particularly regulated beyond the regulations already attached to their respective credential. On
the other hand, those functional attributes of wilderness medical care that fall within the
NASEMSO definition of EMS25—generally speaking, multicredentialed teams, often working
from delegated practice models, preassembled to provide care in a specific jurisdiction using
preset protocols or medical oversight—would deserve regulatory attention.
A flip side to the involuntary nature of regulation is accreditation. According to the Business
Dictionary, accreditation is “certification of competence in a specific subject or areas of
expertise, and of the integrity of an agency, firm, group, or person, awarded by a duly recognized
and respected accrediting organization.”47 Examples of this can already be seen of this in the
credentialing of individuals discussed earlier from a regulatory standpoint. In this educational
and organizational context (and the American Heritage Dictionary affirms that this term is
especially used in the context of educational institutions),48 accreditation is a voluntary process
by which organizations are recognized to meet certain standards; although as accreditation
becomes more powerful, its voluntary nature becomes increasingly theoretical, as market or
regulatory forces compel organizations to comply with accreditation. An important component of
the definition cited here of accreditation is the qualification and authority of the agency granting
accreditation. A critical question to ask is where the accrediting agency itself is recognized and
qualified to serve as a credentialing body for the industry or organization it is ostensibly
accrediting.
Given that standardization is one of the defining problems of the consolidation era of the
1980s to early 2010s described later, accreditation represents a potential solution and possible
direction for WEMS educators and practitioners, and has in fact been cited as a form of “self-
regulation” (discussed later in this section) and an alternative to external, likely governmental,
regulation.49,50 It may play a supportive role for prospective students navigating multiple
educational opportunities in wilderness medical and WEMS training, by setting a baseline
expectation of their experiences and allowing them to compare programs. Historically and
currently, there has been a caveat emptor (“buyer beware”) model often attributed to the industry
of wilderness medicine and WEMS education51–54 and this could help improve that situation. In
addition, accreditation or other forms of regulated standardization can be helpful for
organizational leaders such as rescue teams hiring or accepting personnel; famously, a group of
concerned leaders of outdoor organizations at the 1994 Wilderness Risk Managers Conference
noted that the “tremendous proliferation” of wilderness medicine certifying schools meant that
they “didn’t know whose certifications to accept.”53 And as an example from elsewhere in the
house of medicine, accreditation plays a critical role in the functionality and professional
standing of physician-level fellowships, as noted elsewhere in this chapter and in Chapter 2. It
may come to play a more significant role in non-clinician (BLS and ALS) training and practice
as well, and eventually represent an industry standard that, while ostensibly voluntary, comes to
take on more of a regulatory feel if accreditation becomes critically important to credibility and
industry positioning for education and regulated practice for clinical care. Currently, a primary
EMS accrediting body is the Commission on Accreditation for Pre-Hospital Continuing
Education (CAPCE), formerly the Continuing Education Coordinating Board for Emergency
Medical Services (CECBEMS). One area of growth in regulation and accreditation would be the
recognition of outdoor schools and wilderness medicine schools as accredited institutions of
higher learning. In 2013, Landmark Learning became the first outdoor school to be accredited as
an institution of higher learning by the U.S. Department of Education via the Accrediting
Council for Continuing Education and Training (ACCET) (see Figure 1.1). Such accreditation
will likely continue to expand in the industry, both for educational institutions and clinical
patient care organizations, and will likely form another element to the standardization and
regulation debate and evolution in this field. Some argue that minimum competencies and
accreditation standards only encourage educational organizations to meet the minimum.
However, the capitalist nature of the education at this time suggests that “meeting and
exceeding” standards is often a goal in itself, and it is unlikely that establishing minimum
standards would meaningfully prevent high-performing schools from exceeding them.
The potential benefits of such accreditation and regulation to the consumer must be balanced
against the potential costs to the educational institution or the agency delivering care. For
example, in the federalist model by which most EMS education and practice is regulated in the
United States, the actual details of regulation are deferred to the states. This means that a school
seeking to train individuals in all 50 states and the District of Columbia must navigate up to 51
different sets of regulations and approval processes. This administrative task can, paradoxically,
hamper the preparation and delivery of excellent field medical education. Similarly, from an
agency standpoint, some states divide their EMS regulatory authority into regions or counties.
Such division can create challenges for WEMS teams, like mountain rescue and cave rescue
teams, that by necessity operate in multiple regions/counties, or even multiple states in a region.
Again, significant time can be spent navigating these regulatory and approval processes, which
are often simply artifacts of regulatory and political construct and don’t necessarily represent
differences in environment, terrain, provider skills, or patient needs. As an example, a mountain
rescue team in one county may not be credentialed to provide care in an adjacent county without
formal regulatory approval, despite the fact that a climbing site might straddle two counties and
climbers might freely travel back and forth between them.
Some would argue that the wilderness medicine educational community does not need
external regulation because it successfully “self-regulates.” From a words matter perspective, this
term is interesting. Taken literally, it means that regulation still occurs, just within the internal
industry rather than externally. This by necessity means that some corporation, or conglomerate
of corporations, is establishing a regulatory framework by which it is qualified to regulate others
in that industry. This harkens back a bit to the definition cited earlier of an accrediting agency; an
important element to that definition is that the agency is qualified and credentialed itself to
regulate and accredit. Building a formal regulatory or accrediting infrastructure, even an internal
one, means setting up a formal set of regulations and a formal pathway to accreditation, along
with an explanation of the credentials that justify that organization as a legitimate accrediting
body. Formal internal regulatory structures have potential limitations, including bypass of the
checks, balances, and external validation offered by external regulatory patterns; potential elitism
(one portion of an industry dictates the regulatory standards for an entire industry) or even
antitrust risk; potential conflict of interest for those empowered to regulate in terms of balancing
industry and society-wide needs with individual corporate needs; and evidence that some of the
most significant industry crises of our era may have been precipitated by deregulation and self-
regulation.55–58 Some have explicitly argued that external regulation is preferable for most
industries: for example, a Harvard researcher convening a conference at Harvard Business
School on self-regulations has concluded that third-party verification, accreditation, and
regulation are increasingly important to deliver on the promise of quality standards.59 If the term
is not meant literally, in the sense of setting up a formal regulatory system, and is meant casually,
such as “self-regulation” as a cultural standard, there are limitations to quality parameters of this
as well. An often-cited medical example is the relationship between physicians and
pharmaceutical companies, which was historically “self-regulated” but increasingly criticized for
demonstrable unreconciled conflicts of interest and changes in physician practices based more on
industry interests than patient-centered concerns.60 Perhaps most importantly, without external
regulation, ownership of quality becomes the responsibility of the industry itself; leaders cannot
complain about quality deviations in supposedly marginal or low-performing vendors because
they themselves are actually responsible for maintaining that quality industry-wide.
Regulation is likely to be a defining debate—perhaps the most critical debate—during the
next few decades of growth in wilderness medicine and WEMS.61 Getting it right is critical to
avoid, on the one hand, unnecessary bureaucracy and impedance of creativity and industry
growth and, on the other hand, unregulated medical practice that violates state law and results in
loss of the standardization and safety benefits of regulated medical care, or educational practices
that don’t maintain minimum or comprehensible standards.

HISTORY

A Living Timeline of Wilderness EMS History

Numerous perspectives on the history of both wilderness medicine and WEMS can be found in
the medical literature. However, as Quinn and Rodway point out in Auerbach’s Wilderness
Medicine 7e, “the history of wilderness medicine could be a textbook unto itself”62; that book has
not yet been written, nor has the corresponding textbook on the history of EMS. Figure 1.1 is the
most comprehensive timeline constructed to date in this endeavor. Nowhere are the principles of
precision, accuracy, and truthfulness cited in our Introduction chapter more important than they
are here. Since much of this history is previously unpublished, some of the work is that of a
historian.
Happily, the role of the historian in this project is significantly facilitated by two factors.
First, many of the historical founders of the field are still in active practice and available for
interview and review of data. Second, the digital and social media opportunities for evidence-
building described in the Introduction are phenomenally powerful for this type of work. In
reviewing the data here, much of which relies on memory, shared confirmation, and review of
primary historical materials such as printed curricula and photographs, we ended up forming a
specific group of collaborators to crowd-source and informally peer review the information we
found. This dialogue group consisted of more than sixty leaders in the fields of EMS, wilderness
medicine, and WEMS. It is important to emphasize that this was not a consensus group in the
sense of endorsement. All individuals had the opportunity to review and critique, but no
endorsement phase was included or should be implied. This arrangement resembles other peer
review processes, where reviewers have input but an editor has the final say regarding content.
This method may lack the anonymity and scientific rigor of formal peer review, but its defects
are counterbalanced by the fact that it is far more inclusive of many voices—a balance that is
characteristic of the new era of digital and social information discussed in the Introduction.

FIGURE 1.1. Wilderness EMS Historical Timeline

 For this timeline project, our role as authors of a textbook is to serve as gardeners. More than
one of the contributors questioned if we were getting into the weeds in some of the entries. In
that sense, the garden analogy is helpful. This is not a meticulously pruned and landscaped
garden. It’s a wilderness garden. It is full of intentionally planted species, but has also produced
some surprising volunteers. The degree to which anything turns out to be a weed will only
become apparent when the garden is seen as a whole. In our experience some of the most
beautiful blossoms first emerge as weeds. Our strategy has been to open up a broad opportunity
for planting and growth, see what appears, and then start trimming and weeding. In the process,
we’ve been surprised at some things that have grown and have been retained; we are humble
enough to know we’re just volunteer gardeners, not professional landscape architects, in the
building of this timeline. We expect the timeline will continue to develop and be refined, both
retrospectively and prospectively, as our historical understanding of WEMS evolves. It also
should be noted that, while nearly one hundred people ultimately contributed to the design and
review of the timeline, any errors and misunderstandings within it are my own.

Wilderness EMS History

The Premodern Era: WEMS in Prehistory Through the 19th Century
As we noted in our introductory chapter, wilderness medicine dates back to the first attempts of
one hominid to care for another. Similarly, WEMS could date back to the first time such attempts
were formed into systems, or even just applied in teams. In that sense, the origins of WEMS are
probably prehistorical. However, as Figure 1.1 suggests, numerous publications have suggested
origins of wilderness medical care that could also be considered markers for the initiation or
formalization of WEMS. These include events in ancient history, such as the development of
“recognizable” wilderness medicine by Greek naval surgeons, or much more recent
developments, such as the naval medicine systems established by the British at the onset of the
19th century. One important point emerges in reviewing these historical markers: the important
role marine and naval medicine have played in the growth of wilderness medicine and WEMS.
As we will show, modern wilderness medicine and WEMS took on a much more mountain- and
alpine-oriented emphasis in the United States when they flourished in the golden era of growth in
the mid-20th century. Hence, it can be forgotten that many of the origins of wilderness medical
care come from open water and oceanic wildernesses rather than the mountain wildernesses
many associate it with today. In addition, the American experience exploring what was for
Europeans a New World without the urban medical resources of their day, along with the
incorporation of Native medical practices, lead to a particular generalist medical practice in
North America that could be considered a form of austere medicine. In this context, Bill Forgey,
often considered the “father of wilderness medicine” himself,240,248–253 has written that John
Wesley’s Primitive Physic may represent one of the first American wilderness medicine texts
when it was published in 1740 by this founder of the Methodist and Wesleyan Christian
movements in the United States. Many writers have cited Napoleon’s chief medical advisor,
Baron Jean Dominique Larrey, as the historical originator of an EMS system, with the
ambulance volante system he implemented during the Napoleonic Wars in Europe.64,65 While this
has achieved de facto status as the prevailing EMS origin narrative, surely some systematic
means of caring for and removing soldiers and warriors must have emerged before the
Napoleonic Wars of the turn of the 19th century.

The Early Modern Era: WEMS in the First Half of the 20th Century
The early 20th century saw the introduction of many precursors to what are now familiar WEMS
systems. From a maritime standpoint, the U.S. Coast Guard was formed in 1915 by the merger of
multiple 19th-century marine rescue services.70 From a ski rescue standpoint, the interwar period
saw the founding of multiple ski medicine organizations, culminating in the formation of the
National Ski Patrol in Stowe, Vermont in 1938 as a committee of the National Ski
Association.75–77 And from a mountaineering and mountain rescue standpoint, the oldest
continuously operating mountain rescue team in the United States—the Crag Rats of the Mt.
Hood area in Portland, Oregon—was founded in 1926.71 The Crag Rats and other such teams
would go on to become founding members of the Mountain Rescue Association in 1959.83 From
an EMS standpoint, the first volunteer rescue squad in the United States was founded in the
1920s in Roanoke, Virginia,65 a precursor to the currently most common WEMS provider model,
the modern volunteer rescue squad or fire department.
The World War II (WWII) period did not slow down WEMS advances. Like many military
conflicts, it in fact spurred civilian innovation. Many date the beginning of WEMS systems in
the United States to the formation of the Department of Defense’s 10th Mountain Division in a
unique collaboration of the U.S. Army, the National Ski Patrol, and the American Alpine
Club.1,3,254 More important than the establishment of the 10th Mountain Division was the role
these soldiers played upon return to civilian life and their contributions to ski-based WEMS
operations in American ski areas, especially in the western United States. Also during the WWII
period, Outward Bound was founded in Aberdovey, Wales. This famous organization was
influenced by the wartime pressures upon Great Britain at that time, contributing to its initial
maritime rescue identity and activities255—one example being their role reactivating the
Gordonstoun Cliff Watchers, an auxiliary of His Majesty’s Coastguard watching for ships in
distress and enemy submarine activity.256 Indeed, the name Outward Bound derives from the
nautical term for a boat leaving harbor, further reinforced by Outward Bound’s use of the
nautical flag indicating imminent harbor departure, the “Blue Peter” (a white square inside a blue
square).
Outward Bound schools and philosophies would go on to have a massive impact on the
development of WEMS in the United States, from the establishment of the first American
schools in Colorado (1962), Minnesota (1964), and North Carolina (1966), all the way to the
present day.78 About the same time, in 1965, the National Outdoor Leadership School was
founded.85,86 After retiring the official full name in 2016 and now known simply by the
independonym “NOLS,”86,228,229 this organization, like the Outward Bound schools, has had a
massive impact on the growth of WEMS practices and culture in this country.
The post-WWII era up to the 1960s witnessed the growth and dominance of civic and
recreationalist groups over wilderness medical programs. These include the Sierra Club, the
Mountaineers, local ski patrols, the Boy Scouts, local rescue squads, local marine rescue
services, and local lifeguard agencies and providers, as well as community-based ad hoc or
formal climbing rescue and water rescue teams generally built from groups of recreationalists.
Formal services were also provided by the Coast Guard and rare government-sponsored rescue
services. Organizations combined and formalized, such as the establishment of the National Ski
Patrol in 1953 as a freestanding organization77—rather than a subsidiary of the National Ski
Association as it had existed previously75–77—and the consolidation during this era of multiple
mountain rescue teams into the nationwide Mountain Rescue Association in 1959.83 The Boy
Scouts, founded in 1910, were major drivers of publications and standards in wilderness medical
care during this era.68
However, neither “wilderness medicine” nor “EMS” would have been fully recognizable
terms to anyone prior to the turn of the decade at the end of the 1960s. Most authorities mark the
beginning of both modern EMS and modern wilderness medicine during the late 1960s and early
1970s, and that is where we can thus also mark the birth of modern WEMS.

The Golden Era of Growth: WEMS in the Late 1960s to Early 1980s
Most EMS authorities mark the modern era of EMS as beginning in 1966, a year marked by the
release of the landmark EMS publication Accidental Death & Disability,1 the formation of
mobile “coronary care units” (modern ambulances) in Belfast—an innovation which heavily
influenced North American thinking about ambulance capabilities—and the passage of the
Highway Safety Act of 1966, which established cabinet-level oversight of a new public health
innovation known as “EMS.”65
Modern WEMS and wilderness medicine as we know them today began at the same time. In
this era, specific existing outdoor schools (such as NOLS and Outward Bound described earlier)
and new wilderness medicine schools (described below) played a unique role in the development
of wilderness medicine and WEMS. In perhaps no other medical discipline have nonacademic
private corporations played the leading role in the development of a modern medical specialty.
This situation speaks to WEMS and WM’s unique practice environment and their unique
historical origins in sources generally outside traditional medical educational institutions.
Wilderness Medicine Outfitters, established in 1967 by Carl Weil, was the first wilderness
medicine school.88 It was followed by Stonehearth Outdoor Learning Opportunities (SOLO),
whose founders, Lee Frizzell and Frank Hubbell, taught their first classes in the early 1970s.9
Frizzell and Hubbell established the country’s first fixed wilderness medicine campus in 1976.9
Emergency physician Peter Goth was extremely active in wilderness medicine during this era as
well, working extensively with Outward Bound schools and with NAEMSP, and founded
Wilderness Medical Associates (now known as Wilderness Medical Associates International) in
1984.115,236 During this time NOLS and Outward Bound Schools were also active in wilderness
medical training and practice in their own right (Figure 1.1).85,86,99,98,103,121,122,141 As discussed
further in Chapter 2, these various schools, their leaders, and the other institutions they incubated
produced the vast bulk of WEMS curricula and operational standards in the second half of the
20th century and into the 21st. The impact of these organizations, from their establishment and
development in the 1970s and 1980s on through their role today, on the formalization,
development, and dissemination of wilderness medicine and WEMS as a discrete medical
specialty cannot be overstated. In particular, many of the formal medical certification courses
now traditionally associated with modern wilderness medicine were formalized or invented by
these schools. WFA, as a general term, was being taught by the Boy Scouts and many other
groups before 1967.* WMO developed an advanced version of this coursework and refined it to a
particular curriculum in the late 1960s.† In 1974, SOLO was teaching a Mountain Rescue
Seminar, a precursor to their own unique curricula.‡ NOLS developed a Backcountry Emergency
Care curriculum in 1979, a precursor to the modern, industry-standard WFR curriculum.86,103
Some authorities state the first formal wilderness-oriented emergency medical technician (EMT)
class was taught by the Appalachian Search & Rescue Conference at the University of Virginia
in 1977.111,257 But in fact the first such EMT certification course our working group could identify
was taught by Minnesota Outward Bound School (now Voyageur Outward Bound) years earlier,
in 1974, followed by a similar course taught at North Carolina Outward Bound School’s Table
Rock base camp in 1976.239,167 In 1981, SOLO established the first formal Wilderness EMT
(WEMT) course in the country, along with the concept of initial and recurring WEMT
certification.113,¶ One year later, in 1985, Frank Hubbell of SOLO and Peter Goth of WMA taught
the first formal WFR course at the North Carolina Outward Bound School base camp in the
Florida Everglades.121,122 Since their first introduction in the mid-1980s, WFR and WEMT
certifications have been standard parts of both risk management for outdoor organizations and
response certifications for rescue organizations. These certifications are both described in much
more detail in their current form in Chapter 2.
Other notable programs were introduced during this golden era of wilderness medical
development. Such programs include the first National Park Service (NPS) WEMS class, which
was held in North Carolina in 1972,93,94 as well as the establishment of the NPS ParkMedic
program in Fresno, California in 1978 (Figure 1.1).94,102
Also of critical importance during this era was the formation of the Wilderness Medical
Society in 1983 by Drs. Paul Auerbach, Ed Geehr, and Ken Kizer.85,112 The establishment of this
professional society was a key step in the later growth of wilderness medicine from a largely
“first aid” activity existing outside traditional concepts of medical practice to a legitimate
medical specialty. The Wilderness Medical Society eventually developed its own magazine (first
published in 1984 with Ed Geehr as its first editor),99,** scientific journal (first published in 1990
with Paul Auerbach and Oswald Oelz as coeditors),5,136,†† medical meetings (first held in
Yosemite National Park in 1984),116 and ultimately world conferences on wilderness medicine
(first held in 1991).85
Numerous wilderness medical texts now considered standard resources in wilderness
medicine education were first published during this golden era as well. These include
Wilkerson’s Medicine for Mountaineering in 1967 (now known in its current 6th edition as
Medicine for Mountaineering and Other Wilderness Activities),87 Werner’s Where There Is No
Doctor in 1977 (now available in a 2015 revised and updated version),100 Forgey’s Wilderness
Medicine: Beyond First Aid in 1979 (now in its 7th edition),85 and Auerbach and Geehr’s
Management of Wilderness & Environmental Emergencies in 1983 (now in its 7th edition and
known as Auerbach’s Wilderness Medicine).114 Auerbach’s text is particularly notable for its
encyclopedic treatment of wilderness medicine topics. While the first edition (1983) consisted of
646 pages, its current seventh edition (2017) now includes 2,848 pages in two volumes, and Dr.
Auerbach has become the Redlich Family Professor in the Department of Emergency Medicine
at Stanford University. The experience of this one book and author alone is a marker of the
movement of wilderness medicine from its beginnings outside traditional academia to its current
position of medical authority. Numerous other texts were first published during this era as well,
some of which are listed in Figure 1.1.
On the EMS and emergency medicine side, the era from the late 1960s to the early 1980s
saw the rapid establishment, proliferation, and refinement of EMS operations and the specialty of
emergency medicine.
Emergency medicine was not a recognized medical specialty prior to the 1960s. In fact,
emergency medical care was generally a poorly respected medical practice often delegated to
those trying to build a practice in another specialty, those in some other form of transition or
partial practice, or in many cases, to a nurse, who would call a physician (not obligated to
respond) for any physician-level care needed—all questionable practices for patients who were
often, perversely, the sickest and most emergent.82 This all began to change in the late 1960s as
emergency medicine pioneers worked to forge a specialty out of this niche hospital-based
medical practice. In 1968, the American College of Emergency Physicians (ACEP) was
established, and also quickly developed its own publications, scientific journal, and annual and
specialty medical meetings. In 1970, the first emergency medicine residency was established at
the University of Cincinnati, and the first academic department of emergency medicine was
introduced at the University of Southern California in either 197065 or 1971.82 In 1976, the
American Board of Emergency Medicine was founded to administer an annual board
examination, and in 1979, emergency medicine was formally recognized as a board-certified
medical specialty by the American Board of Medical Specialties (ABMS).65 Despite its strong
positioning in the house of medicine now, many are not aware that emergency medicine has only
been a formal specialty for less than 40 years.
While EMS also did not exist as a standardized national program of any sort prior to the end
of the 1960s, by the early 1970s it was already a well-recognized and assumed component of
American popular culture and medical care. The National Registry of EMTs was founded in
1970 after the American Academy of Orthopedic Surgeons published the first EMT curriculum
in 1969.65 This curriculum and its corresponding certification were quickly identified by the
wilderness medicine community as ideal paradigms for fundamental out-of-hospital medical
knowledge to which wilderness modulations could be added. As noted above, wilderness-
influenced EMT classes began appearing only a few years later in places like Minnesota, North
Carolina, and Virginia, followed by the formal establishment of a WEMT curriculum by SOLO
about a decade later. In 1973, the Emergency Medical Services Act was passed and 911
universal emergency access was established. Many Americans are not aware that 911 services,
now taken for granted, were not universally or even commonly in place prior to the mid-1970s.
Emergency Care in the Streets, the first EMS textbook in the country and built around Nancy
Caroline’s experiences on the streets of Pittsburgh, was published in 1979, and is still available
now in its 9th edition.104 As with Auerbach’s Wilderness Medicine, the appearance and
multiplication of textbooks was a key marker to the growth and sophistication of this new
medical specialty. Numerous EMS textbooks of varying degrees of specialization now exist, this
itself being one. All these types of books owe a significant debt to pioneers such as Nancy
Caroline, Paul Auerbach, Edward Geehr, and Bill Forgey, who carved a path in the wilderness of
the publishing world for descriptions of atypical, field-based medical practices.
The National Association of State EMS Directors (now the National Association of State
EMS Officers) was founded in 1980.65,108 The first full-time EMS medical director was not
appointed until 1981, when that role was created in New York.65 In 1984, the NAEMSP was
founded; like WMS and ACEP, it would go on to create its own scientific journal,
communication publications, and professional meetings.119 In that same year, the National
Disaster Medical System (NDMS), an important parallel system to EMS for disaster response,
was founded by the United States Public Health Service.120 That year the American Society for
Testing and Materials (ASTM) also formed its EMS Committee (F-30) for setting standards for
this new medical specialty.65 In 1985, Warren Bowman wrote Winter Emergency Care (now
Outdoor Emergency Care) for the National Ski Patrol, who also issued the first Winter
Emergency Care certificates (now Outdoor Emergency Care or OEC, discussed in more detail in
Chapter 2).77,*
THE CONSOLIDATION, EXPANSION, AND ACADEMIC ERA: THE LATE 1980S TO 2013
In the period from the late 1980s to around 2013, there was rapid consolidation and expansion of
wilderness medicine, EMS, and WEMS. All three began to gain recognition as legitimate
medical practices. All enjoyed steady growth in their academic and research underpinnings, the
complexity of their educational offerings, and the breadth of their practice opportunities.
During this era of consolidation and expansion, there was extensive reassortment of business
and teaching models. The Wilderness EMS Institute, probably the first school to orient itself
specifically and exclusively toward WEMS operations, was founded by Keith Conover in
Pittsburgh in 1985, following his earlier wilderness medical work with the Appalachian Search
& Rescue Conference.124 In 1987, the National Association of Search & Rescue (NASAR)
aligned with WMA to provide wilderness medicine courses together, an important consolidation
in wilderness medicine history.111 In 1990, the Wilderness Medicine Institute (WMI) in Pitkin,
Colorado was established as a “sister school” to SOLO, to teach SOLO coursework in the
western United States.85,111,122,† Nine years later, NOLS would purchase WMI to form the WMI of
NOLS (now known as NOLS Wilderness Medicine).85,122,† While most of the original golden era
schools retained their founding leadership to this day, WMA underwent multiple ownerships,
from founder Peter Goth to Philip Gormley in 1991, and then to Dr. David Johnson in 1998, with
subsequent rebranding of the company as Wilderness Medicine Associates International in
2010.115,140,208
This era of realignments also included significant expansion, with explosive growth in the
number of outdoor schools teaching wilderness medicine. As early as the 1994 Wilderness Risk
Management Conference, prominent outdoor organization leaders formally noted a “tremendous
proliferation” of wilderness medicine certifying schools, and specifically the difficulty in
choosing between their different educational models and certification credentials.37 Particularly
well-known and respected schools and organizations founded during this era, in addition to
WEMSI in 1985 and WMI in 1990, include Keith Conover’s WEMS elective at Mercy Hospital
in Pittsburgh in 1993,149 Aerie Backcountry Medicine in 1995,153 the Roane State Community
College Wilderness Medicine Program in 1996,158 Landmark Learning in 1996,161 Wilderness
Medicine Training Center (WMTC) in 1997,165 Desert Mountain Medicine in 1998,168 the
Advanced Wilderness Life Support program at the University of Utah in 1998 (followed by the
creation of its host company AdventureMed),171 RMI in 2003,183 CDS Outdoor School in 2004,185
Lifeguards Without Borders in 2005,187 the Appalachian Center for Wilderness Medicine in 2007
(originating a novel regional nonprofit model),197,198 the Academy of Wilderness Medicine in
2007 (a program of the Wilderness Medical Society, which generated its first Fellows in 2007
and first Master Fellows in 2010),196,205,206 the National Center for Outdoor & Adventure
Education in 2009,204 Longleaf Wilderness Medicine (an offshoot of Outward Bound
programming in Alabama) in 2011,209 the Carolina Wilderness EMS Externship in 2011,212 the
Wilderness EMS Medical Director Course in 2011,213 Diploma in Mountain Medicine
certification courses based in Utah (WMS lineage) and New Mexico (University of New Mexico
lineage) in 2012,215,216 the establishment by NAEMSP of a very active Wilderness EMS
Committee in 2012,219 and Vertical Medicine Resources in 2013.221
Academic expansion was also significant during this era. In 1986 and following, building on
the success of pioneering work in establishing emergency medicine residencies more than a
decade before, the first unaccredited EMS fellowships were established at institutions like
Wright State University and the Maryland Institute for EMS Systems.133,* In 2003, the first
unaccredited wilderness medicine fellowship was established at Stanford,3,† and in 2007, the first
unaccredited WEMS fellowship was established at the University of Utah.200,† Novel academic
models matching new paradigms in education appeared. In 2006, WMO taught the first hybrid
distance-learning/in-person wilderness medicine certification course,191 and the first distance-
learning accessible wilderness paramedic baccalaureate program in the country was established
at Western Carolina University in 2007.3,4 In addition, academic credentialing expanded for
wilderness and outdoor schools, with Landmark Learning becoming the first independent
outdoor school to be accredited as a higher learning institution in 2013.238,‡ Academic growth in
this era closed with one of the most significant and landmark series of events of all, beginning
with the decision in 2010 by the ABMS to name EMS a formal medical subspecialty, bringing it
into the ranks of board-certified medical specialties for physicians.223 This opened the door to
accreditation of EMS fellowships, with the first wave of accredited EMS fellowships appearing
in 2012,218 and the first EMS physician board certifications being awarded in 2013.207
As WEMS represents the system-based and regulated practice of wilderness medicine, a
critical element during this era was the growing recognition of wilderness medicine by EMS
regulators and the institution of state and regional protocols to permit wilderness medicine
practice by EMS teams. Much of this work represented pioneering efforts by Peter Goth and
WMA, along with others, in convincing the medical establishment that operationally specific
scopes of practice and EMS protocols were appropriate for formal EMS care in wilderness and
remote areas requiring austere medical care. In 1991 and 1993, Goth published protocols
endorsed by the NAEMSP Rural Committee for WEMS care (Figure 1.1). These represented the
foundational topics that most other subsequent WEMS protocols included, such as adapted
policies for medical care (CPR in 1991) and trauma care (wound management, spinal cord
protection, and dislocation management in 1993).144,150–152 The first protocols to appear in actual
state statute and rules began appearing in the late 1980s and early 1990s. Maine, in collaboration
with NASAR and WMA, implemented WMA-generated protocols around 1990 following work
beginning in 1987, with New Mexico implementing similar WMA-generated protocols around
1990 as well.133 North Carolina followed with similar protocols in 1992, based on Peter Goth’s
work in Linville Gorge with the NC Outward Bound School and the Burke County Special
Operations team.133 It must be pointed out that some American states had such vast areas of
wilderness that de facto wilderness medicine was being practiced by EMS teams at or before this
time, especially on a regional level. Alaska is a good example of such a state. However, it was
also in the late 1980s and early 1990s when this care became formally recognized as well as
separate from frontcountry practice.133 So, for example, Alaska had cold injury guidelines
established in 1988 which were infrequently used by frontcountry providers, which would
therefore qualify as WEMS guidelines. These Alaskan WEMS guidelines were revised and
topically expanded in 1997.133 Another important point the Alaskan experience points out is that,
unlike Maine for example, they have statewide guidelines, but protocols are generated locally
and regionally. This speaks to the difficulty in establishing the first WEMS protocols in the
country, since in the early days of EMS (and up to the present day in some areas) EMS is defined
locally or regionally rather than by state in terms of protocols used. However, it does appear safe
to say that it was in the late 1980s and early 1990s that states such as AK, NM, ME, and NC
began adopting EMS protocols that were specifically for use in backcountry and remote
environments, distinct from frontcountry protocols, marking the beginning of the era of
protocolized WEMS that was defined and approved by state regulators.
Significant efforts at standardization occurred during this period. Holly Weber, the editor of
the Wilderness Medicine Newsletter, described one of the largest such efforts below in 1996. Her
description is emblematic of the shifting alliances and dynamic reassortments of the era, as
leaders attempted to move toward standardization of this novel and largely undefined and
unregulated medical discipline.
. . .Many of the providers of wilderness medical training agreed that a movement toward standardization was imperative and
that its success depended upon the leadership of the larger, more established wilderness medicine schools. At the time there
was perceived to be a great crevasse separating the program efforts among what many dubbed “the Big Three” – SOLO,
WMA, and WMI. Collectively, for the good of the industry, the three agreed to put differences aside, to sit down with neutral
 representation (first thought to be an Outdoor Recreation Coalitions of America [ORCA] representative, later decided to be
a Wilderness Medical Society [WMS] representative), and work to that end.
In February 1995, a working group called the National Association of Wilderness Medicine Educators (NAWME)
gathered with the intention of establishing a not-for-profit prehospital body of educators. NAWME’s primary goals were to
come to an agreement on a minimum standard for the Wilderness First Responder curriculum to work on an accreditation
process for wilderness medicine training agencies, and to look at the bigger issues of quality assurance, instructor
credentials, and recertification issues.
By August 1995, the WMS. . . offered to be leaders in the curriculum project in lieu of NAWME. Their major concern was
that training organizations such as SOLO, WMA, and WMI had such a vested economic interest, that they were unable to
represent the “little voices.” The counter-concern from the NAWME group and a significant number of other “younger”
providers was that the WMS would collect the curricula from these various organizations, synthesize them, and then offer
their own WMS-approved course – the end result of which no organization wanted to be a part. After receiving written
assurance from the WMS president in February 1996. . . that the WMS had no intention of offering training programs or
certification, NAWME was dissolved and the task of standardizing a WFR curriculum was turned over to a subcommittee of
WMS, the Prehospital Emergency Training Standards and Accreditation Committee.37

Subsequently, PETSAC would itself be dissolved. WMS would go on to brand a textbook in

WFA,170 develop training programs (albeit not ones matching certifications in the WEMS
categories of EMS credentials),258 and introduce multiple certification programs (Fellowship in
its Academy of Wilderness Medicine, a Diploma in Mountain Medicine [DiMM] program, and a
Diploma in Dive and Marine Medicine [DiDMM]) (Figure 1.1).259 The major wilderness
medicine schools continued to work on aligning their curricula, with increasing reciprocity of
certifications and standardization of curricula along with collaborative meetings, but without a
formal organizational structure to this effort until the formation of the new Wilderness Medicine
Education Collaborative (WMEC) at the very end of the era (described in more detail later).
Academic and popular publishing also enjoyed explosive growth during this era. In 1987, the
Wilderness Medical Society, under the editorial leadership of Bill Forgey, began publishing
practice guidelines for wilderness emergency care.115 These practice guidelines have evolved to
their current evidence-based and quality-graded form available today through WMS, and are
invaluable for WEMS practitioners and educators in setting standards for wilderness medicine,
matching similar consensus guidelines in existence for other medical specialties. Numerous
textbooks and curricula in both EMS and wilderness medicine were published during this era,
resulting in a dizzying array of resources available to the student and practitioner. Notable
additions to the WEMS medical literature during this era include the landmark swiftwater text
River Rescue in 1985,123 the launch of SOLO’s Wilderness Medicine Newsletter in 1988,260
NAEMSP’s Prehospital Systems and Medical Oversight in 1989,135 and the development in 1990
by the Wilderness Medical Society of a slide show lecture series on wilderness medicine topics
(now existing as two separate product lines, one for community audiences and one for health
care audiences).137 Hubbell and Tilton’s Medicine for the Backcountry was first published in
1990.138 The first set of professional society-based rural/WEMS protocols were introduced by
NAEMSP from 1991 to 1993,144,150–152 and in 1991 WMS published a Wilderness Prehospital
Emergency Care Curriculum.143 In that year as well, both major outdoor experiential education
schools published wilderness medical texts for the first time, with NOLS publishing NOLS
Wilderness First Aid and Outward Bound publishing Outward Bound Wilderness First-Aid
Handbook.86,141 The landmark high angle text High Angle Rescue Techniques was first published
in 1992,148 preceded by Smith and Padgett’s classic On Rope: North American Vertical Rope
Techniques in 1987.132 As noted earlier, the Wilderness Medical Society established its scientific
journal Journal of Wilderness Medicine (now Wilderness & Environmental Medicine) in
1990.5,136 ASTMI published consensus-driven scope of practice and training guidelines for
WEMS responders in 1995.155,156 In 1996, the path-setting EMS Agenda for the Future was
published by the U.S. government’s National Highway Transportation & Safety Authority,162
followed by the EMS Educational Agenda in 2000174 and the publication by the Institute of
Medicine of The Future of Emergency Care in 2006.193 Paul Paris’s Prehospital Medicine: The
Art of On-Line Medical Command was also published by Pittsburgh’s emergency medicine
program in 1996.163 Paul Nicolazzo of the WMTC published Art & Technique of Wilderness
Medicine in 1997,166 with Jim Morrisey of WMA publishing Wilderness Medical Associates
Field Guide in the same year.167 Buck Tilton of WMI published Wilderness First Responder in
1998169 and Paul Auerbach published Field Guide to Wilderness Medicine, a smaller version of
his by then classic textbook, in 1999.172 Christopher Van Tilburg’s brilliant autobiographical
work Mountain Rescue Doctor—required reading in some WEMS programs261—was first
published in 2007,201 and NAEMSP and NASEMSO jointly published Medical Direction for
Operational EMS Programs in 2010.34 Very importantly, this era closed with the first of multiple
following consensus publications from a new entity, the WMEC, representing a conglomerate of
more than a half dozen wilderness medicine schools setting an industry standard. In 2013,
WMEC published its first consensus statement, Minimum Guidelines & Scope of Practice for
WFA, an important installment in the ongoing effort to standardize WEMS definitions.220 And
amazingly, and in perhaps the most clear symbol of a “consolidation” era, EMS itself was only
formally defined at the end of this period, in 2012, by a consensus document from NASEMSO.25
It’s clearly apparent that the academic platform available to support wilderness medical and EMS
operations came into its own during this period, with the introduction of most of the major texts
and didactic tools in use today.
Ultimately, some realignments during this consolidation era “stuck,” such as the WMEC,
which appears poised to make critical contributions to the literature and the field; or the
migration of a satellite wilderness medicine school from SOLO’s headquarters to the west in the
form of WMI, which ultimately became what is now NOLS Wilderness Medicine, one of the
most successful schools in the country; or Peter Goth’s consolidation of work with Outward
Bound schools, NAEMSP, and others into a private company in the form of WMA, also one of
the most successful schools in the country. Other realignments and consolidations did not, such
as the Wilderness Medical Society’s attempts to create the PETSAC consensus committee
among WEMS schools (termed by WMS “prehospital wilderness emergency care” and detailed
in Figure 1.1), or the migration and creation of other satellite schools and WEMS programs, such
as the NAWME or MHWEMSE (Figure 1.1). Similarly, EMS evolved over this time, with
various visions and conceptions developed in the 1970s holding true, and others being
reconceived, redirected, or abandoned altogether in documents such as the 1996 EMS Agenda for
the Future (Figure 1.1). All these realignments, consolidations, and academic evolutions further
shaped WEMS during this dynamic and creative period. It is critical to recognize that the
dynamism of this era, evolving out of the spark plug of the golden era, is what made WEMS as
rich and varied as it is today. However, the flip side to that positive outcome was an absence of
standardization. As noted elsewhere in this textbook, the much-decried flaw of this era was this
standardization gap, which threatened the ability of WEMS to define itself as a legitimate
medical practice and develop credibility with regulators and others tasked with managing the
practice of medicine. Even organizations such as ASTM specifically configured to build
standardization and consensus failed in their attempt to create standards that “stuck” and were
widely cited and utilized, although Bass has pointed out some of the flaws in specific efforts
such as ASTM’s.65 Ultimately, a new era began to appear which moved toward resolution of this
critical flaw of the consolidation era, via a renewed collective commitment to the twin principles
of consensus practice and EBM.
THE CONSENSUS AND EBM ERA: TRANSITIONING DURING 2006–2013 AND EXTENDING TO THE PRESENT
The current era will be put into its own historical context by authors of the future, and we are
close enough to this transition that analysis may be clouded by bias. However, following the
preceding era of consolidation, realignment, and academic proliferation, important next
generational landmarks are emerging. The most important features of them are a renewed
commitment to consensus—different in tone and mission from the realignments of the previous
era in that it presupposed individual alliances and search for common ground rather than outright
consolidation and ownership—and an adoption of the new technologies and filters of EBM.
These themes began in earnest in the second half of the “twenty-aughts”262 (2006 to 2009), and
really took hold and dominated the intellectual and clinical practice of WEMS in the first half of
the “twenty-tens” (2010 to 2015).*
For example, Forgey, the editor of the 5th edition of the WMS practice guidelines (2006),
notes in its foreword that “this edition nudges the guidelines toward evidence-based medicine,
with category stratification of its recommendations.”263 In editions to follow in the twenty-tens,
these guidelines moved from nudge to full embrace, comprehensively utilizing American
College of Thoracic Surgeon guidelines for categorical evidence grading. They also moved to an
online format in 2017, for the first time, a wilderness medicine text directed at a popular
audience consistently and intentionally used evidence grading and consensus documents
throughout the text.227 Also in 2017, the medical literature also saw an explicit evidence-based
filter put into WM and WFA didactics, with the publication of “Evidence-Based Review of
Wilderness First Aid Practices” by Schimelpfenig et al in the journal Wilderness &
Environmental Medicine.233 The first EMS textbook, Nancy Caroline’s Care in the Streets, was
published in 1979 during the golden era of growth, but it has not been until its most recent 8th
edition, published during the current era in 2017, that it has implemented explicit in-text
references for its supporting evidence (to its great improvement). And extremely significantly,
for the first time in its existence over more than three decades, Auerbach’s Wilderness Medicine
included a comprehensive and freestanding “Evidence-Based Wilderness Medicine” chapter in
its 7th edition, first available in 2016.264
Other, more specific clinical examples exist demonstrating a move toward explicit evidence-
based practice in WEMS in ways not previously present. For example, Chapter 24 of our own
text demonstrates how the management of suspension syndrome, unchanged since the 1970s but
based on anecdotal practice, dramatically changed in the early twenty-tens based on new
evidence-based publications in the late twenty-aughts, pointing out an evidence- and
pathophysiologically based protocol would be the opposite of the more anecdotal teaching
prevailing to that date. Other authors have also pointed out the historic landmark this transition
marks for the entry of EBM and more pathophysiologically driven practices into WEMS in the
early twenty-tens.35 Even more significantly, trauma care in WEMS—and EMS in general—
underwent a massive revision with the discrediting of backboards, and the growing move away
from the necessity for rigid cervical collars, which began with the landmark publications of
Hauswald and others in the mid-twenty-aughts and reached fruition with a slew of protocols
published in EMS and WEMS around the early twenty-tens. This transition (whose appearance
in the EMS and WEMS realm was significantly preceded, it should be noted, by selective spinal
cord protection protocols in WM dating far earlier) is discussed in more detail in Chapter 21.
Characteristics of EBM are discussed in more detail in our Introduction and in Chapter 2.
Similarly from a consensus standpoint, the World Congress on Drowning was held in 2002
and developed a new consensus definition of drowning.245 This definition was still in transition
throughout the twenty-aughts and only by the early twenty-tens has it enjoyed widespread
implementation, largely through the efforts of a broad and informal coalition of drowning care
advocates. This change in drowning terminology and its consensus basis is discussed further in
Chapter 16. More formal consensus groups had certainly existed in the prior era, but many were
marked by political collapse (the WMS PETSAC and prehospital wilderness emergency care
initiatives under Bowman) or failure to gain relevance and traction (the ANSI protocols). In
addition, in the context of consolidation, establishing legitimacy and independent identity was so
important for EMS and for WM programs that true collaboration represented a double-edged
sword. This double-edged sword metaphor continues in the WEMS industry’s relationship to
regulation, which discussed elsewhere in this chapter is probably the biggest challenge of this
new era. However, in the early twenty-aughts, a consensus group of wilderness medicine schools
(now known as the WMEC) first formed and began working on industry standards for scope of
practice, publishing an industry consensus scope of practice for WFA in 2013 and one for WFR
in 2016.220,230,* Similarly, in the early twenty-tens, Michael Millin led a Delphi-driven
collaborative project through the then newly formed NAEMSP Wilderness EMS Committee to
develop consensus definitions and scopes for the education and practice of a range of WEMS
credentials.35 This effort was unique in bringing together regulators, industry leaders, end users,
and medical directors for the first time in defining these terms and scopes, with results publishing
in 2018.35 In more general consensus and organizing terms, the concept of regional, collaborative
organizing for wilderness medicine and WEMS appeared in the American southeast in the late
twenty-aughts in the form of the Appalachian Center for Wilderness Medicine.197,198 In a related
project (originally incubated in this collaborative Center), McGinnis and Lareau developed a
very influential and collaboration-founded, student-organized wilderness medicine conference
(now replicated in other parts of the country), moving sites from one school to another each year
of operation.265 Finally, there is perhaps no more compelling indication that a sea change toward
consensus practices occurred in the early twenty-tens than the fact that, after the tumultuous and
creative era that preceded, it was not until 2012 that a consensus definition of EMS appeared.25
A new generation of textbooks (of which this is one) published during this era challenge the
paradigms and expand the definitions established in the consolidation era. Mountain Medicine &
Technical Rescue was published in 2016 by many of the leading authorities in that WEMS
subdiscipline.231 Intended primarily as a DiMM textbook, it should be critically important to
mountain medicine and EMS alpine operations in general, although it has been criticized for
editing lapses and uneven content.266 Further progress is being made in codifying graduate
educational standards, with a wilderness medicine fellowship core content consensus document
published in 2014.224 More outdoor and wilderness medicine schools have joined the ranks of
those providing private outdoor and wilderness medicine school education, each with an
innovative model and market niche. Of note, the first exclusively online outdoor school
providing wilderness medicine training, Base Medical, appeared in 2017 (Figure 1.1). It solves
the typical “hands-on” requirement for wilderness EMS courses by only offering recertification
courses, stating on its website, “Base Medical firmly believes that hands-on training is a crucial
part of wilderness medicine. Therefore, we think it would be unethical to issue initial
certification for WFA or WFR. We only issue recertification.”267 This leaves unanswered the
question of why initial certification without hands-on training is unethical, but recertification in
the same fashion is ethical. As technologies continue to evolve and students need or demand
remote and online opportunities, the ethical and operational parameters of such teaching
modalities would be expected to continue evolving as well. As noted earlier, the golden era
schools themselves are redefining and rebranding: in 2016 the National Outdoor Leadership
School rebranded to NOLS, and converted its WMI to NOLS Wilderness Medicine, a NOLS
division86,228,229,†; and prior to that, WMA rebranded as Wilderness Medical Associates
International (although still retaining the initialism WMA).208,‡ Later in this chapter, we will
discuss the future of WEMS, but truly, with the current meteoric rapidity of almost daily
advances in all elements of WEMS, the future is now.

CARE PROVIDERS
A more complete discussion of various levels of care providers is included in Chapter 2
(Education).

Emergency Medical Dispatchers

Credentialed EMDs (as opposed to telecommunicators not credentialed as health care providers)
are increasingly common in most EMS systems. They have been effectively described as the
“hub” of an effective EMS system, and are sometimes characterized as the “first, first
responders.”268,269 Considering the length of time between a 911 call to a Public Safety Access
Point (PSAP, or 911 call center) and the arrival of first field responders in some wilderness
operations, the important role of EMDs in the delivery wilderness care is apparent. This is even
more true given the rapid proliferation of mobile phone coverage in the wilderness, as well as the
growth of wilderness safety technologies such as sophisticated emergency beacons and text-
capable mapping and navigation tools.1,3
Some countries are embracing novel telecommunications strategies to address austere and
WEMS environments. Bhutan is in the unique situation of developing an EMS system
concurrently with the rest of the health care infrastructure. Much of their emergency medical care
was centralized into a consolidated “Health Help Centre” (HHC) in 2011.270 Outside the capital
city, most of the country’s evolving emergency medical system has characteristics of a WEMS
system (more than 85% of the country is forested and undeveloped, including the highest
unclimbed mountain in the world), but also excellent and nearly universal mobile phone
coverage. The ready availability of cellular phone networks renders the HHC the quickest and
simplest means to access the EMS system, with EMS personnel available to respond on-scene if
necessary. This screening process is ideal for a country with limited resources such as Bhutan,
which has fewer than 100 EMS field personnel. In the future, advances in telecommunications
and telemedicine are likely to have a significant impact on medical care in austere settings in the
future, as well as an ever-evolving role in the delivery of care for WEMS practitioners, as
evidenced by recent developments in telemedicine, robotic-assisted remote care, and remote
radiology and consultation services.

Lifeguards
The relationship between lifeguards and EMS is variable and contested. In some areas and
according to some experts, lifeguarding is considered part of EMS; indeed, in some jurisdictions,
EMS has taken over lifeguarding operations altogether.271,272 In other areas lifeguarding is
considered discrete from EMS. Arguing against the inclusion of lifeguarding in EMS is the fact
that its certification is not typically regulated by state EMS offices and is categorized as a first
aid intervention. But in our opinion, lifeguarding, especially in the wilderness environment,
meets the NASEMSO definition of EMS25 and should be considered a part of EMS, including
medical oversight and the implementation of quality management measures. Regardless of
operational configuration or philosophical definition, there is widespread agreement that non-
lifeguard EMS responders and lifeguards must develop a close, collaborative, and synchronous
relationship and practice. More information about interfaces between various elements of EMS
systems is provided in Chapter 6.
In a wilderness environment, lifeguards and lifeguarding training are particularly critical
given the potential delay of other EMS providers. As discussed in Chapters 16, 26, and 27,
drowning is one of the most time-sensitive wilderness emergencies, and often immediate on-site
rescue and medical care by whoever is present offers the only chance for patient survival. This
argues for widespread lifeguard training among wilderness recreationalists as a first aid
intervention, and also the integration of formally certified lifeguards into systems where aquatic
rescue and drowning medical care is likely to be needed. Landmark Learning, a leading outdoor
school, and Starfish Aquatics Institute, a lifeguard training company respectively, have combined
to develop and implement a unique wilderness lifeguard curriculum known as Wilderness
StarGuard. This curriculum is discussed in more detail in Chapter 2.

Wilderness First Aiders, Wilderness First Responders

WFA and WFRs are both certifications intended for use in a wilderness environment. For the
most part, they operate outside a formal EMS response system. These providers and their
interventions are most often conceived as a first aid service existing prior to EMS arrival or in
cases when more formal EMS care is not necessary. Note that some of these certifications have
advanced formulations such as Wilderness Advanced First Aid (WAFA) and Advanced
Wilderness First Aid (AWFA). These adapted certifications can get quite confusing, as their
content is not regulated, and they can provide educational curricula and imply scopes of practice
significantly exceeding traditional WFA parameters.1 All these certification types are discussed
in more detail in Chapter 2.

Wilderness EMRs, Wilderness EMTs

These providers generally form the largest BLS category of EMS responders in the wilderness.
Each adopts an existing and traditional EMS credential (EMR or EMT) and provides additional
wilderness training. The degree to which this additional wilderness training is recognized outside
the training center, or results in credentialing of operationally specific scopes of practices
differing from the frontcountry, varies across the country. A more complete discussion of the
curricula and scope of practice of these providers is included in Chapter 2.

Ski Patrollers and Outdoor Emergency Care

Ski patrollers represent another category of caregiver whose relationship to EMS is contested.
However, this relationship is increasingly being defined in legislation and practice around the
country.38 According to our definitions in this textbook, ski patrollers are involved in the practice
of WEMS, regardless of their regulatory status in a given jurisdiction. Ski patrollers are most
often certified as OEC Technicians. More discussion of the OEC certification is included in
Chapter 2, and more discussion of the operational activities of ski patrollers is covered in
Chapter 31.

ParkMedics
The ParkMedic credential is a special curriculum and certification managed by the U.S. NPS,
one of the largest WEMS systems in the world. ParkMedics are federal rangers with particular
wilderness qualifications and scopes of practice compared to other rangers and other non-ranger
EMS providers. More details about U.S. NPS operations are included in Chapter 24, and more
details about the ParkMedic curriculum are included in Chapter 2.

Wilderness Paramedics
Just as WEMTs and WEMRs form the bulk of WEMS responders at the BLS level, wilderness
paramedics form the bulk of WEMS responders at the ALS level. Again like WEMTs and
WEMRs, wilderness paramedics utilize existing traditional EMS certification (paramedic) with
additional wilderness training, and again, states and jurisdictions vary in the degree to which
these operations are scrutinized or codified by traditional EMS regulators.

Wilderness PAs, Wilderness APRNs, Wilderness Physicians

Traditionally the role of physicians in EMS care has been medical oversight, with the majority of
oversight being indirect and offline (not in person in the field). However, with the advent of
physician board certification in EMS and a changing philosophy among EMS physicians that
promotes field response, this has begun to change. Physicians are increasingly responding to
wilderness emergencies directly, and this development might be expected for PAs and APRNs as
well. To the extent that in some emergency departments PAs evolve roles as proceduralists, and
that proceduralist role is being explored in other critical medical settings,273 one might expect a
practice to evolve where PAs might provide even more clinician-based field responses than
physicians in the context of wilderness proceduralists. With the narrow exception of the
Wilderness Command Physician course offered by CDS Outdoor School and the Wilderness
EMS Institute,274 which heavily emphasizes medical oversight roles, there is no specific
credential available uniquely identifying these traditional licensees as wilderness-qualified (as
there is, for example, for a WEMT). However, numerous secondary trainings and certifications
are available to physicians, PAs, and APRNs, and are likely to be critical for safe and effective
field response as a clinician. More information about such curricula and credentials is provided
in Chapter 2. A complete discussion about the entirety of the medical oversight role for clinicians
in WEMS is included in Chapter 4.

HIERARCHICAL CATEGORIES OF CARE

In our introductory chapter we explained a rather atypical approach to different types of medical
care. It is worth emphasizing and expanding here, since it is so important to the overall
functioning of a WEMS system.
Typical medical hierarchies presume a vertical sorting, usually based on how long it takes to
obtain a certain license or certificate and the associated scope of practice. This would typically
place physicians at the top of the hierarchy and EMRs or EMDs at the bottom, using relative
language like “more advanced” or “higher” to explain the placement of a given certification or
license on this vertical scale.
As noted in the introduction, this hierarchy, while so prevalent that it stands largely
unquestioned, starts to collapse under logical scrutiny. For example, PAs are sometimes
described as “advanced” providers, despite the fact that the only other credential to which they
are compared—that of a physician—is itself considered more “advanced” than their own. In
other ways, this hierarchy results in nonsensical questions, such as whether a nurse or a
paramedic is more advanced – when clearly the answer is that they have different purposes,
functions, and scopes of practice. Finally, and most importantly, setting a vertical hierarchy
proposing superiority based on scope of practice or duration of education ignores that the
teleology of wilderness medicine, which perhaps more so than almost any other medical
specialty, privileges the importance of operational results rather than the process of obtaining
those results. In part this springs from its unusually deregulated status, and in probably larger
part recognizes a fundamental reality: everyone involved in wilderness care is in a threatening
environment that is potentially dangerous. For this reason, practical considerations aimed at
achieving a goal often take priority. Put more specifically, field operational hierarchies need to
privilege specifically needed skills rather than traditional authority values or arbitrary years of
training or certifications of less relevance. This creates a shifting series of relative role
importance at different points in an operation. So during a swiftwater rescue of a patient with a
foot entrapment, the EMD in phone contact with the patient’s companions is more “advanced”
and in a better position to change outcomes than responding providers who are not yet in direct
contact. Upon arrival, swiftwater rescue technicians (SRTs) may be more “advanced” in the
technical skills they bring to bear on extracting the patient from the water than an orthopedic
surgeon. The orthopedic surgeon may be more “advanced” on the shore in addressing the ankle
fracture the patient sustained; however, during the subsequent extrication, the paramedic may be
more “advanced” in packaging and patient movement techniques needed for safe transport of the
patient. Asking which of these providers overall is more “advanced” is something like asking the
marital status of the number 7; it is a nonsensical question. Each is of paramount importance at
different steps of the operation, and recognizing this is what makes WEMS the delivery of health
care within a system and as a team. This is not to say that command-and-control is not relevant;
in fact, the entirety of Chapter 3 is dedicated to the Incident Command System (ICS), which is
crucial to effective WEMS operations. However, operational leadership structures, which are
functionally driven, are quite different from traditional medical hierarchies, which are most often
culturally driven or sometimes regulatory. Therefore, in the delegated practice most common in
EMS, a physician must collaborate with paramedics and other EMS and rescue providers, and in
an ICS structure, are rarely actually in “command” of an operation. Other authors have noted that
excessively vertical hierarchies of medical authority—accompanied by behavior coined as
“disrespect” in 2012 and later characterized as bullying, and often but not always perpetrated by
physicians in positions of vertical authority—results in impaired communication, patient care
errors and reduced patient safety, disrupted teamwork, collegiality, and morale.275–277 Certainly
every one of those characteristics impaired by a combination of vertical hierarchy and disrespect
are particularly critical to EMS operations. A horizontal hierarchy also recognizes a more
sophisticated legal understanding, as discussed in Chapter 5, that EMS personnel practice
medical care in a collaborative supervisory role with a physician, rather than “under” a
physician’s license.43,278 It also explains better how an individual provider can simultaneously be
both a paramedic and physician.279 The horizontal hierarchy model is also in keeping with more
contemporary terminology and understanding of the relationship between PAs and physicians,
which is increasingly characterized as collaborative within an overall supervisory framework.36
For these reasons we support a horizontal hierarchy rather than a vertical hierarchy in
WEMS operations. In this framework, the individual skill sets of providers and ICS methodology
is privileged in a collaborative and mutually respectful environment, rather than a historical and
possibly outdated medical model of vertical hierarchy, which may privilege authority at the
expense of respect and collaboration.

SURVIVALISM AND PERSONAL SAFETY

WEMS providers typically must personally carry all equipment needed for care, or employ
operationally specific vehicles or animals to do so, in addition to the equipment they need for
their own safety. Because of this, a sophisticated understanding of survivalism and self-care is
critical, as is the need for each individual team member to have self-care ability and functional
capability in the specific environment the WEMS team is tasked with serving (eg, ski
environment for National Ski Patrol or ocean surf for a surf lifeguard team). Fitness also
becomes a much more critical component than it might in other medical practices. One of the
most common mistakes is for qualified medical providers to think they can join a WEMS team
based on medical knowledge alone. The “wilderness” skills are equally important to the “EMS”
skills in all but the most frontcountry of WEMS environments.
Therefore, WEMS providers require personal survival skills for austere environments, search
procedures, advanced wilderness medical knowledge, and geographically specific extrication
techniques, both for the safety of their patients and themselves. A critical element to WEMS-
based survival is an emphasis on team safety and prevention prior to being faced with survival-
level challenges, accomplished by encouraging prior contingency planning and general
wilderness skills education. These often can mitigate or eliminate survival-level threats.
Remember, WEMS teams have an advantage over general wilderness medicine practitioners:
they can preplan their medical care and their operations in a wilderness setting, and often patrol a
single area, the characteristics of which they should come to know intimately.
If faced with a threat to the individual or the team, the most important tool for survival is the
human brain (see this discussion in the Introduction chapter). The most important action to take
when faced with a personal survival situation is not panicking and taking sensible actions
prioritized based on specific life threats.
Priorities for survival (in rough order of relative importance) include access to oxygen,
regulation of body temperature, shelter, access to potable water and nutritious food, protection
from wild animals and natural hazards, and a plan to accomplish either rescue or self-extrication
from the environment.
WEMS teams should consider a variety of communications equipment, not only for
operational communication, but also for emergency communications between team members or
to external resources. These can range from low-technology tools such as whistles (without balls
for those operating in water environments) to high-technology tools such as radios or
mobile/satellite telephones. High-functioning teams carry communication tools at both ends of
this spectrum and train to use either in operationally specific ways.
All team members should be prepared to make an emergency shelter and be prepared for an
overnight bivouac appropriate to their operational environment every time they deploy on a
WEMS mission. Food and water should be sufficient for the WEMS operator at a minimum, but
the operator is being inserted into the environment to care for others, so additional resources may
need to be carried. If certain team members are tasked with carrying extra food or water (or
really any survival equipment), a personal equipment list including survival gear should be
developed that ensures every responder has sufficient gear for their own survival.
In the prevention context, EMS providers are often required to vaccinate themselves against
conditions not required of typical outdoor recreationalists. These include hepatitis A and B
vaccination, inactivated poliovirus vaccination, and tetanus and typhoid immunization. Operators
in some regions may be required to become vaccinated against yellow fever and meningococcus.
Equipment, including equipment necessary for survival and medical self-care, is discussed in
more detail in Chapter 7. It is important to recognize that contents of a medical and survival kit
are one of the most controversial subjects in WEMS. Not only are the contents extremely
dependent on operator training and environment, but there are also wide variances between
prepackaged commercial kits and homemade versions. Subject matter experts make strong
statements on the relative merits of each approach. Buck Tilton, former SOLO instructor and
founder of the WMI (now NOLS Wilderness Medicine), argues that “off-the-shelf versions are
usually better than doing it yourself,” and makes appreciating the value of commercial kits over
homemade ones such as the Commandment Five of his “Five Commandments of First Aid Kits.”
He says “these [commercial] kits are better than the ones most non-MDs could put together at
home, and are well worth the money.”250 On the other hand, the Outward Bound Wilderness
First-Aid Handbook, written by the Wilderness Medical Associations team of Jeff Isaac and
Peter Goth (with the most recent edition written solely by Isaac) notes, “you can do better on
your own.” Isaac writes that “the marketing departments of most outdoor equipment supplies
count on. . . our tendency to try to solve a problem with money. Dozens of kits are offered, most
at prices vastly inflated over the value of their contents.”72 Clearly the right answer is probably
somewhere in between these two extreme positions, and likely influenced again by environment
and provider training. The important point here is that even subject matter experts taking extreme
and definitive positions can disagree on medical kit platforms.
From a safety perspective, WEMS operations can involve Hazardous Materials (HazMat)
elements despite their wilderness settings. Examples would include exposure to dolomite dust in
rockfall disaster responses and sulfur dioxide gases from volcanic fumarole rescues.280,281 Some
authors have emphasized the importance of fielding a multiskilled team with capability to
manage natural hazards of this sort, as well as incorporating compulsory protective measures and
medical monitoring of personnel into safety plans.280
Personal survival considerations are discussed more extensively in Chapter 12.
From a more comprehensive personal survival standpoint, posttraumatic stress disorder
(PTSD) is a real issue for WEMS providers faced with experiences that would strain the
psychological resources of even the most emotionally resilient human being. For prolonged
deployments, it is not unreasonable to gather several times daily to share experiences,
expectations, and concerns in a format that is comfortable and nonconfrontational and that
invites open and honest communication. Having a plan to get together and share stories after
everyone has returned home is also an excellent tool to build WEMS team rapport and trust.
Such interaction itself is preventive for issues in the future and which improves team
performance. Although it should be noted that formal Critical Incident Stress Management
(CISM) methodology has come under criticism in the EMS community and is not felt to be
evidence-based or necessarily appropriate for EMS providers,282 PTSD can still be prevented.
From a commonsensical standpoint, it can treated by deliberate vigilance to recognize team
members who appear to be having difficulty processing difficult experiences, and by regular
opportunities to discuss difficult situations. It should be noted that the literature analyzing the
CISM experience suggests that fixating on difficult experiences through mandatory discussions
may be equally destructive, so the key is keeping the line of communication open and providing
opportunities to debrief and share emotional reactions without necessarily giving these
unnecessary prominence or publicity. One such alternative to CISM is the use of psychological
first aid (PFA), which emphasizes the idea that all members of a team are responsible for being
aware of mental health stressors on their fellow teammates and refer colleagues to appropriate
mental health professionals when indicated.
Psychological survivalism for responders, including a more complete discussion of PTSD
and PFA, are the subject of Chapter 10.

EXAMPLES OF WEMS SYSTEMS

The most typical WEMS systems would be programs primarily geared for environmental
medical care and response in areas typically considered wilderness. These systems would include
mountain rescue teams, ski patrols, state and national park rangers, and other responders to areas
that would be considered typical wildernesses.
However, other examples exist of atypical WEMS systems that nonetheless meet our criteria
for this category of EMS-based health care.
Hyde County, on the Outer Banks coast of the American state of North Carolina, is the
second-least populous county in NC and contains no hospitals or clinician-level health care
providers. All patients must be transported by Hyde County EMS out of the county, by ground or
often by air. Thus EMS personnel are the highest-trained medical providers in the community,
and are often tasked with providing care for many hours. They utilize state-sponsored WEMS
protocols throughout their entire jurisdiction even during their “traditional” operations.
Little Gasparilla Fire-Rescue in Florida offers another example of the intersection between
rural EMS and WEMS. This nonprofit EMS-Rescue-Fire organization recently upgraded its
program to 100% paramedic coverage for Little Gasparilla Island, a barrier island on the Gulf
Coast of Florida that is only 3 miles long and 2,000 ft wide. All EMS response is done
exclusively by ATV—there are no roads on the island, only dirt paths, and no commercial
buildings. If transport is required, patients can only be extracted from the island via nonmedical
ferry boat or air medical ambulance. A single EMS provider is on-duty every day, who is tasked
not only with providing medical care but also with simultaneous Fire-Rescue activities such as
landing medical helicopters when needed. Like other EMS systems, the system here benefits
from a network of first responders and off-duty Fire-Rescue personnel, but of course they must
be on the island at the time of the incident to be of assistance.
The unique Burning Man Event has also been described as an example of the delivery of
EMS care in an austere environment.283 This city of more than 53,000 people is built from
scratch every year for 1 week in the Black Rock Desert of Nevada. Despite its size (it is the
second largest city in Nevada during its operation), it is rural in the sense that transport time is
150 miles to the nearest health care facility and the “urban” infrastructure offered on-site is
completely temporary. In response, EMS personnel have built a sophisticated on-site EMS
system that merges characteristics of WEMS, rural EMS, and event medicine. In 2011, this
system served 2,307 patients in its 1 week of operation. It has been cited as one of the rare
instances where (as in Hyde County NC) EMS offers the highest level of care. In this case, it
actually runs its own hospital receiving facility.284 This example represents an exciting merger
that could also indicate a future for WEMS operations, or for future merged conceptions of rural
and wilderness operations. A somewhat similar situation could be seen in the case of the Everest
ER and other fixed facilities which have more similarity to EMS operations than formal hospital
environments. They are run by EMS or field-oriented personnel with training and clinical
experience as much or more oriented toward out-of-hospital and wilderness medicine than
hospital-based medicine. Another very similar operation would be the EMS care delivered at the
Boy Scout Jamboree held every 4 years, which in similar fashion builds a city of 40,000 nearly
overnight, requiring commensurate EMS services, lasts for 2 weeks, and then disappears nearly
as quickly as it was built. This EMS system employs over 100 medics, a dedicated helicopter,
and a complex ICS system, and is usually put in place in rural or wilderness areas—for example,
the last Jamboree in 2013 was held 60 miles from the nearest trauma center.285 Note that serious
questions have been raised about the future of high quality WEMS operations at Burning Man,
with a recent decision to change Burning Man medical service providers.286

CHALLENGES TO WILDERNESS EMS SYSTEMS287

Numerous challenges exist in the establishment and growth of WEMS systems.

Provider Shortage
A shortage of providers has been well documented for EMS systems in general,288 and for
WEMS systems in particular.1,3,4
The EMS niche specialty of WEMS frequently relies on volunteers.3 This is particularly true
of technical rescue WEMS teams such as cave rescue teams, mountain rescue teams, and ski
patrols, most notably ski patrols in the eastern United States, where volunteer reliance is higher.
In addition, even if mission oversight and leadership becomes largely non-volunteer, it is
unlikely that many WEMS operations will ever be able to avoid significant reliance on
volunteers for mission completion. As an example, during a ground-based carryout, a typical
logistical calculation would be that it takes six well-rested litter carriers to carry a patient a
mile.289 Thus, a carryout of only four miles would require 24 rescuers. Most operations would
take about 4 to 8 hours to complete, simply based on carrying time. This calculation quickly
shows that most organizations launching a carryout would require additional assistance from
individuals beyond their on-duty staff during an operation.
Volunteer personnel might have been a sustainable model in the past, but increasingly it may
not be. Time and financial constraints—two of the most often-cited reasons why personnel leave
rural EMS systems—are also difficulties in staffing volunteer WEMS teams. There was a surge
in volunteerism following the 9/11 terrorist attacks of 2001 in the United States,1 but since that
time there has been a steady trend of flat or declining volunteerism. There was a decline every
year from 2011 to 2015 in volunteerism rates, with an overall drop of 2% (26% of the population
volunteered in 2011 to 24% in 2015).290 Rural volunteer Fire-Rescue personnel, who are often
the source of WEMS providers, have been particularly affected by this drop in volunteerism.291
73% of the nation’s fire departments are all-volunteer, but 70% of rural EMS services struggle to
recruit and retain volunteers, with one-fifth of these expecting the problem to worsen.292 The
growing complexity of the industry, its expanding regulatory requirements, and substantial
increases in training requirements led to increased training and financial costs to volunteers and
seem to be associated with decreased rates of volunteerism.293 An anthropological perspective
helps here as well. Cultural differences from prior generations cited in Generation X and
Generation Y, as well as changes in paternal roles, may drive decreasing volunteerism in rural
EMS and WEMS.292 However, David Fifer (author of Chapter 3) has pointed out that it may be
that volunteerism is not what is dying, but rather what is dying are volunteer organizations that
don’t use modern recruitment and retention techniques. Some exciting examples of more modern
recruitment and retention tools include social media, video, and documentary projects, for
example those employed by the Long Island volunteer documentary team and Teton County
Search and Rescue.294–296
Even WEMS systems formally employing personnel suffer from shortages. This is
particularly severe among state and national rangers. The NPS, one of the largest WEMS
systems in the United States, has has experienced a critical ranger shortage for many years,4,297–299
a problem also seen by rangers in state systems.300 Hiring of new rangers is proving increasingly
difficult, and about 50% of federal rangers specializing in law enforcement (which includes SAR
and emergency medical services) were required to retire from 2010 to 2015 under federally
mandated age guidelines.301 The rangers who remain have often been reassigned away from
wilderness settings, or their funds have been reallocated for monument protection and other non-
wilderness priorities, following the terrorist attacks of 2001. By 2004, millions of dollars in fees
had been diverted to increased security requirements, resulting in a shortfall of $600 million
annually.299 This trend has political and funding elements as well, both described below.
Ranger work capacity is also stretched by the fact that, as their resources are being reduced,
visitor volume is increasing. In 2014, North Carolina (also a formal WEMS system) saw a record
number of visitors to their parks, a 10% increase in volume over 2013.1 This system continued to
set records through 2016, when overall attendance set a new record at 18.8 million annual
visitors, with some parks seeing increases as high as 38% greater attendance over the prior
year.302 Such growth can be seen across the country in state and federal parks. A little over a
decade ago, visitors to NPS parks increased by more than 60 million people while the number of
permanently commissioned rangers dropped by 16%, and the number of seasonal rangers
dropped by 24%.299 It has been estimated that one in five persons requesting SAR assistance in
the U.S. NPS would be a fatality without the response of medically trained NPS personnel.303 If
true, a growing mismatch in visitor to ranger ratio could have significant consequences for NPS
visitors and their medical outcomes.
An EMS physician shortage also exists. As with EMS generally in North America, WEMS
suffers from rare physician field response and an insufficient number of physicians specifically
trained in this subspecialty. This is less so the case in Europe and parts of Asia, where physicians
(often anesthesiologists and surgeons, in contrast to the emergency medicine dominance in the
United States) may be heavily involved in mountain rescue and other wilderness rescue
operations.1,3,304,305 An increased emphasis on physician field response is an important goal for
modern EMS in the United States. Such a priority is especially the case for WEMS, where
autonomous decision-making is a critical skill and protocols can rarely anticipate all situations.
Even without field response, adequate physician oversight is a sine qua non of EMS
operations, and that principle holds true for WEMS as well.1 In some systems this is already
accomplished, as when WEMS teams are built within an already-existing infrastructure that
includes solid physician oversight. Other WEMS programs, such as ski patrols, ocean rescue
programs, and some mountain rescue teams, do not meet this standard. It is well established in
the medical literature that WEMS organizations should have physician oversight for all elements
of their practice, presuming their authority to practice medical care does not stem from another
source besides the EMS-based practice of medicine.34,35,38,306
WEMS systems that staff lifeguards are also facing critical shortages of personnel.307–311 Such
staffing shortfalls have resulted in parks leaving open water sites unguarded, with at least one
documented death in a lake that would otherwise have been staffed with a lifeguard.310 Reasons
cited for this shortage are similar to those for other WEMS systems, including increased training
costs, minimal compensation, and—more specific to lifeguarding—often seasonal-only
employment; the absence of career advancement opportunity also plays a role in many
lifeguarding organizations.307–309 More urban swimming sites can address such a shortage by
limiting hours or changing fee structures, but in the WEMS environment of lakes, rivers,
beaches, and public access/wilderness open water, such an intervention is more difficult.307,311

Insufficient Funding
Insufficient funding has always been a continual challenge for WEMS systems, as it is for EMS
systems in general. Most teams prefer not to charge for their services. Some teams obtain
governmental endorsement and subsequent governmental funding, and of course, some teams are
governmental in the first place, although as noted above this does not ensure adequate funding
either.
It is important to recognize that, in some cases, WEMS systems enjoy more funding and
resource access than other components of either EMS or wilderness medicine operations. One
common misunderstanding about helicopter-based WEMS operations is the perception that it is a
particularly expensive and unfunded service, or a service funded at additional cost to taxpayers.
In fact, most helicopter-based rescues involve state or federal assets, and these operations are
usually rolled into preexisting training budgets at no additional cost.3 However, examples of
nonprofit helicopter-based WEMS and rescue services do exist. In these cases, funding may be
particularly difficult, given the expense of helicopter operations. For example, the Snohomish
County Search & Rescue Helicopter Rescue Team (Washington, USA) has been a long-standing
nonprofit independent helicopter-based rescue team with funding for fuel and maintenance
provided by the federal government. When such funding was discontinued in April 2013, the
team was required to seek other sources for their nonprofit WEMS/rescue operation.312 Other
examples exist of helicopter-based WEMS teams turning to donation-based funding.313
Clearly political considerations such as those described earlier have significant implications
for funding. One example of the interface between politics and funding may help demonstrate
political perceptions about the role of WEMS in our society. In 2017, President Trump made
good on a campaign promise to donate his presidential salary to charity by providing $78,000 to
the NPS as his first beneficiary. This donation, however, was offset by his budget proposal for
the upcoming year for the Department of the Interior (the administrative home of the NPS),
which cut $1.5 billion dollars from the department’s budget (a 12% cut), in the context of an
agency that is already $229 million behind in deferred battlefield maintenance alone.314 The
perspective that the NPS and its WEMS system is a charity deserving of donations rather than a
federal agency worthy of funding is emblematic of the challenge WEMS systems face in funding
and political positioning.
Politics
The role that politicians serve in funding WEMS systems speaks to a larger challenge faced by
WEMS systems: politics in general. WEMS system leaders often note that a significant portion
of their job is navigating various political pressures and stakeholder needs. Successful WEMS
systems must recruit and maintain support from various organizations and individuals who have
a regulatory or political role in their operations. This includes emergency managers, fire chiefs,
professional societies, local, state and federal politicians, patient and recreationalist advocacy
groups, land use advocates, EMS and WM educators, EMS regulators, and many, many others.
One prominent WEMS medical director has said, “to be a good medical director, you have to go
to a lot of pig roasts.”8 One challenge of leading a WEMS system is recognizing that it is
imbedded in a complex political environment that is as equally challenging as the natural
environment a WEMS system is also imbedded in, and equally important to navigate safely and
effectively.

WEMS Societal Validity

WEMS systems must occasionally engage with philosophical and political questions regarding
the fundamental appropriateness of medical operations in wilderness environments. Some
WEMS skeptics suggest that the absence of formal medical care and rescue availability is
intrinsic to the concept of “wilderness,” and may even be critical to its appeal. This philosophy
maintains that individuals venturing into these areas should be self-sufficient and not require or
request rescue or medical care.3
A less extreme but similar position is that services rendered by WEMS services should incur
a fee for those being rescued. In the United States, many rescues and WEMS medical care are
usually either provided on a volunteer, uncompensated basis or by the government and implicitly
paid by society in the form of taxes but not explicitly billed to the patient.4 (This is in contrast to
Europe, where the standard is to charge for services rendered, such that most individuals and
groups there purchase rescue insurance.)316,317 Advocates of billing for rescue suggest that some
culpability for the need for rescue falls on the individual(s) in jeopardy, and that in
acknowledgment of this they should absorb some of the cost. Jonathan Waterman, a former
Denali climbing ranger, writes compellingly in a 1991 Climbing magazine editorial317 (later
reprinted and expanded in his 1998 book In the Shadow of Denali):
Whether rescues occur in the Alaska Range, Yosemite, or in the Tetons, they are risky and expensive. Victims seldom take
responsibility for their rescues, financially or otherwise. In this country, it is assumed that a cry for help will bring immediate
salvation. Of course, the essence of a rescuer’s work is humanitarianism, and it is indeed a noble profession.
But isn’t a rescue a gift? Should a rescued victim take more responsibility and at least return the gift, or pay the bill?... A
good definition of climbing responsibility (after accident avoidance) is to avoid calling for a rescue at all costs, short of
dying. Making others risk their lives unnecessarily is irresponsible and self-indulgent.316

Furthermore, a correlation appears to exist between how risky the public perceives an
activity to be and how likely there are to be demands that the patients or subjects help pay for
rescue operational costs. Some argue that these prospective fees unfairly target activities like
mountaineering that only appear to be riskier, but may not actually be so based on data. For
example, in 2001 only 5% of rescues involved climbers; the remaining 95% did not pay a fee to
defray rescue costs involving their activities,318 despite the fact that, in aggregate and as an
example, Coast Guard rescues in Alaska are substantially more expensive than climbing
rescues.319 On the other hand, Waterman points out that, at least as of the date of his 1991
editorial, the U.S. NPS spent more taxpayer dollars per year—up to $1 million—than any other
land-managing agency for SAR operations (excluding airplane- and ocean-oriented rescues), and
questions whether taxpayers or those rescued should bear this cost.316
Opponents of billing for rescue argue that individuals injured or ill and in jeopardy in a
wilderness environment will delay calls for help from fear of cost. Also, even though state and
national parks have no specifically mandated “duty to rescue,” such authorities do have an
obligation to protect the safety of participants in their regions, which is often extended to rescue
and thus uncompensated medical care.3,316 In some areas that are considered particularly high
risk, a prospective rescue fee may be levied on all visitors. For example, a $150 fee was required
of climbers attempting Mt. Denali (Alaska) in 1995 to defray rescue costs.1
Helicopter operations are often cited as particularly expensive and dangerous. Buck Tilton,
in a review of wilderness medical use of helicopters entitled “Never Cry Helicopter” (a word
play on Waterman’s original editorial), writes, “when you call for a helicopter, do not
underestimate the danger or the expense.”320 Also, to the extent that many wilderness medical
helicopter rescues are accomplished using military assets, especially in the eastern United States,
much of this cost can be rolled into military training and operational budgets already in
existence. While this might blunt the cost, the relative danger of such operations is still a real
consideration. Ken Zafren et al in Auerbach’s Wilderness Medicine note that in many parts of the
world, especially Western and Central Europe, rescue has become nearly synonymous with
helicopter deployment, often including physicians as part of the responding team.304,305 The
ubiquity of technical helicopter rescue, often involving highly trained medical personnel, in that
region suggests that either operational interventions have been made to ensure safety, or that the
cost-benefit to dangerous operations has been felt to still favor frequent helicopter use. However,
in sobering data from the NPS and the Mountain Rescue Association, aviation-related incidents
are not only the leading cause of death for rescuers, but in fact exceed all other causes of death
combined.304 In addition, a recent study of incidents from 1980 to 2013 found the U.S. civilian
helicopter SAR (HSAR) fatality rate to be higher than both the fatality rate for U.S. helicopter
general aviation and for U.S. helicopter EMS (HEMS), suggesting that WEMS operations are
particularly dangerous environments for helicopters.321 (Helicopter WEMS operations are
discussed in more detail in Chapter 28.)
The NPS, the U.S. Coast Guard, the Mountain Rescue Association, the American Alpine
Club, and most SAR authorities do not support levying individual bills for mountain, SAR, or
coastal rescues.322–324 Some exceptions do exist, such as Telluride County, Colorado where
rescues may be billed to individuals who are pursuing “high-risk recreational pursuits.”318 What
may be a somewhat more common practice is for nongovernmental rescue and SAR agencies to
suggest patients make a voluntary donation to the agency,316 which is compatible with both
Waterman’s editorial suggestions for compensation but also avoids subjects not calling in the
first place due to fear of obligatory cost.
It should be noted that, for most EMS systems, billing begins with transport. Therefore, the
philosophy of not billing for rescue only includes those portions of care that are pre-ambulance.
Ambulance transport and in-ambulance care, whether that be an air ambulance (rotor or fixed
wing aircraft) or ground ambulance (traditional frontcountry truck-style ambulance), will
typically incur a fee regardless of whether the patient origination was in the frontcountry or the
wilderness. Typically, wilderness transport platforms such as animals, boats, or ATV/UTVs
(covered further in Chapter 28) are not categorized as ambulances and therefore aren’t included
in such billing calculations.
 In a very interesting legal precedent, in 2013 a volunteer involved in a search and rescue
(SAR) operation in California fell off a 110 ft cliff. The volunteer sued the subject for whom the
SAR operation was being carried out, charging that the subject was responsible for the rescuer’s
injury. The allegation was that the subject “headed out unprepared and unqualified to a remote
and dangerous mountain area with the intent to take hallucinogenic drugs, knowing the
likelihood of becoming disoriented, lost and requiring. . . rescue.” The case was settled out of
court.325 In legal terms this concept of “foreseeability” cites Palsgraf v. Long Island Railroad
Co.,326 a landmark case that established foreseeability as the test for proximate cause. Should this
establish a trend of tort exposure to rescues—that certain actions by an individual in a wilderness
setting might foreseeably lead to need for rescue, thus allowing for individual rescuers to sue
either for injuries incurred during that rescue or for the rescue itself—there could be significant
consequences to rescue finances, recreational insurance, and medicolegal parameters of
wilderness rescue and medical care. However, novel cases such as this one do not appear to be
changing the basic philosophical conviction of most American WEMS organizations that rescue
and wilderness medical care prior to transport should not incur a fee.287

Characteristics of Regulation, Accreditation, and Standardization

Earlier in this chapter, we maintained that “regulation is likely to be a defining debate—perhaps
the most critical debate—during the next few decades of growth in wilderness medicine and
WEMS.” The growth (or restriction of growth) in WEMS regulation, accreditation, and
standardization is a critical challenge facing the next current and upcoming generations of
WEMS leaders. As noted in the History section of this chapter, regulation very much fits into the
arc of the evolution of this field, from its beginnings in the 20th century to the current and future
day. A more complete description of the challenges of regulation, accreditation, and
standardization can be found in the Regulation section of this chapter.

Defining No-Rescue Areas

In the extreme, some regions have been designated as “No-Rescue Areas” even if rescue is
desired and financial impediments are not a concern. Upon entering these areas, in the words of
wilderness medicine ethicists, “people put life and limb at risk while society condones and
presumably enforces a requirement not to assist those in need.”327 Examples of this include Neal
Armstrong and Buzz Aldrin venturing to the moon (surely the epitome of a wilderness
environment where no medical care aside from WEMS would be available), or early
mountaineers venturing above 8,000 m (26,247 ft). But as rescue operations have become
planned and in some cases completed even in these environments, the existence of contemporary
“No-Rescue Areas” is now under challenge.3,328 Whether or not No-Rescue Areas should remain,
the literature continues to cite remote areas where no organized rescue services exist, such as the
Brazilian Amazon east of Manaus.329 There is an obvious and paradoxical tension here for
wilderness advocates. Every No-Rescue Area that moves into a category where protection of
human life is improved represents a success for the continued growth and reach of WEMS. On
the other hand, as we are heirs of adventurers extending back to the dawn of human history, we
may hope there will remain areas in our universe beyond which there is no hope of rescue from
others, and where we venture with the full knowledge that we are truly, if perilously, self-
sufficient.
THE FUTURE OF WILDERNESS EMS SYSTEMS287

Intersection of Rural and Wilderness EMS

An important growth area for WEMS in its capacity as a medical subspecialty involving
resource-deficient or austere medical care is its growing intersection with rural EMS, which was
discussed earlier in this chapter. In addition, the operational environment of some entire
countries would be considered “wilderness” or “austere” in comparison with the medical care
available in developed countries. Exciting work is being done acknowledging the merged nature
of many of these niche specialties delivering remote care. Examples include the corporate model
of companies like RMI330; academic models such as the Wake Forest University-University of
Vermont Rural/Wilderness Emergency Services Conference; educational models such as the
RAW (rural-austere-wilderness) podcast331; and specialty descriptions such as the growing
concept of “rural generalism.”332

Technology
A significant difference between WEMS and wilderness medicine is the technology available to
the WEMS provider. It is most commonly thought that WEMS is technologically austere due to
the frequent reference to “resource deficiency” in defining its operations. However, a WEMS
provider may have more resources than a hospital-based provider. Because of this, as noted in
the definition sections of this chapter and in the Introduction, defining WEMS exclusively as a
medical operation in a resource-deficient environment is problematic. For example, Denali
National Park rangers, clearly operating in a WEMS system, have access to a NPS-owned high
altitude A-Star B3 helicopter. This resource is unavailable to any non-WEMS hospital-based
provider in the United States. Similarly, North Carolina developed an innovative NC
HeloAquatic Rescue Team (NCHART) that merges civilian EMS personnel with military UH-60
Blackhawk helicopters and flight crews.333 They have accomplished many WEMS operations,
including the first nighttime climbing rescue pickoff in NC history, in environments and with
weather availability that no civilian hospital-based emergency physician would be able to access
to secure patient transport.
Many technological innovations and concepts, including portable ultrasound, ultra-small
defibrillators, innovative water treatment systems, and next-generation patient packaging
concepts are introduced elsewhere in this textbook. In truth, rather than being exclusively
resource-deficient, WEMS represents an area of significant technological growth and innovation,
with new products being introduced regularly that have the potential to change WEMS
operations dramatically.
WEMS systems must keep abreast of these innovations and implement them in
circumstances when appropriate, taking into account patient population, environment, and
financial viability. It is likely that the future of WEMS will include high-technology patient care
services being brought directly to patients in the wilderness, rather than awaiting hospital arrival.

EMS as a Physician Subspecialty

The importance of the formal recognition of EMS as a formal medical subspecialty by the
ABMS in 2011 is a critical milestone in the future of WEMS (Figure 1.1). It opened the door to
accredited EMS fellowships and increased the potential for full-time field EMS physicians, as
well as EMS physicians with much more commitment to field medical response and operational
training. Currently, ACGME requires that accredited EMS fellowships include WEMS
components, and the American Board of Emergency Medicine examination of physicians
aspiring to board certification in EMS includes WEMS components as well. In the past,
unaccredited urban-based EMS fellowships might not have any wilderness-based training
whatsoever. The growth, standardization, and accreditation of EMS as a new physician specialty
will expose many more providers to WEMS operations and opportunities, and should increase
the number of physicians providing service in this specialized niche, as well as the depth of their
understanding of both EMS and wilderness operations. Further discussion of educational models
supporting WEMS as a physician subspecialty can be found in Chapter 2.

Evidence-Based Medicine Evolutions and Implementation Science

As described earlier, we are in the midst of a transition to a new era dominated by EBM.
However, EBM was described in the early 1990s, and in the decades that followed a more
sophisticated understanding has developed of the complexities of applying primary research to
patient treatment. This has come to be known as dissemination and implementation (D&I)
science in the United States, and knowledge translation in Canada.264,334,335 D&I, in conjunction
with EBM advances, will continue to evolve as this era does. Already, tools such as best
evidence in emergency medicine (BEEM) rater instrument,336,337 social media crowd-sourced
efforts such as FOAM discussed in our introductory chapter, and novel D&I platforms such as
podcasts, are appearing and proliferating, likely representing a future of EBM WEMS education
and practice.264

SUMMARY
WEMS is, by definition, the system-based delivery of health care. The discussion above outlines
and introduces key elements of these systems, their history, their educational components, and
their unique challenges and features, as well as their projected future. The remainder of this
textbook explores individual elements of this system-based medical care in more detail.

ACKNOWLEDGMENTS
The danger in listing acknowledgments for a chapter like this is the probability that names of
significant contributors will be omitted. That being said, here is a partial list of those who
provided invaluable help in preparing and writing this chapter: Ben Abo, Aram Attarian, Paul
Auerbach, Fred Baty, Pearce Beissinger, Brad Bennett, Jonnathan Busko, Peter Buzzacott,
Christopher Carpenter, Jim Chimiak, Chris Davis, David Fifer, Mike Fischesser, Lee Frizzell,
Loren Greenway, Peter Hackett, Anne Hawkins, Daniel Hawkins, Kelly Collings Hawkins,
Sherman Hawkins, Rich Ingebretsen, David Johnson, Stephanie Lareau, Linda Laskowski-Jones,
Jay Lemery, Daryl Macias, Dave McEvoy, Scott McIntosh, Howard Mell, Michael Millin, Bill
Murray, Paul Nicolazzo, Justin Padgett, Mairi Padgett, George Rodway, Bob Richards, Paul
Sabin, Tim Sachs, Todd Schimelpfenig, Justin Sempsrott, Ralph Shenefelt, Matthew Sholl,
Bryan Simon, Bev Singel, Will Smith, Shana Tarter, Dave Weber, Carl Weil, Deb Whitmore,
and Corey Winstead.

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303. Heggie TW, Amundson ME. Dead men walking: search and rescue in US national parks. Wilderness Environ Med.
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304. Zafren K, McCurley LH, Shimanski CS, et al. Technical Rescue, Self-Rescue, and Evacuation. In: Auerbach PS, ed.
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308. Robertson J. The threat of a nationwide lifeguard shortage looms. Lifeguard Times, Feb 24, 2015. Available at:
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309. Stern M. Lifeguard shortage across the country. Fox 4 News Kansas City, July 10, 2014. Available at:
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310. Tully J. Lifeguard shortage leaves many pools, beaches unprotected. USA Today, June 27, 2012. Available at:
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311. Traylor N. In Light of Lifeguard Shortage, Cities Reconsider Fees. Aquatics International. May 31, 2017. Available at:
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312. Haase A. Rescue crews hope to keep chopper flying. Fox Q13 News, October 6, 2013. Available at:
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313. Mieure E. Donors say “heli yes” to fundraising challenge. Jackson Hole News & Guide, Friday, May 12, 2017. Available
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315. Declerck MP, Atterton LM, Seibert T, Cushing TA. A review of emergency medical services events in US National Parks
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317. Waterman J. Never Cry Wolf: Perspective on Rescues. Climbing. 1991;125:152.
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322. Athearn L. Climbing Rescues in America: Reality Does Not Support “High-Risk, High-Cost” Perception. Golden, CO: The
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323. National Park Service. Analysis of Cost Recovery for High-Altitude Rescues on Mt. McKinley. Alaska: Denali National Park
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324. Roberts R. Climber 9-1-1 Special Feature: common perceptions about climbing and SAR. Northwest Mountaineering
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326. New York Court of Appeals: Palsgraf v. Long Island Railroad Co., 248 N.Y. 339, 162 N.E. 99 (N.Y. 1928).
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*The Gusteau Principle was first advanced by the Wilderness EMS Medical Director Course.8 It is built around the character of
Gusteau in the Disney film Ratatouille, who maintains that “anyone can cook.” Similarly, the principle that borrows the same
name argues that “any place can have wilderness medicine and require WEMS management.”
*As of January 2017, the American Academy of PAs stated “we do not use [the term] ‘physician assistant’ any longer to refer to
the profession as the name does not adequately depict the medical services PAs provide to patients every day.” The uniform use
of the freestanding initialism PA also avoids a disagreement within the industry as to whether the underlying term should be
“physician assistant” or “physician associate,” and avoids the universally discredited underlying term “physician’s assistant.”36
See further discussion of this in the Introduction chapter.
*NP—nurse practitioner
CNS—clinical nurse specialist
CNM—certified nurse midwife
CRNA—certified registered nurse anesthetist
†In this dialogue, as in source materials, the common EMS practice of certification is treated as a form of licensure. Indeed,
leading EMS legal authorities believe that all EMS certification is best considered a form of licensure.43
*See Figure 1.1, footnote iii
†See Figure 1.1, footnote x
‡See Figure 1.1, footnote xi
§See Figure 1.1, footnote xii
¶See Figure 1.1, footnote xii
**See Figure 1.1, footnote xv
††See Figure 1.1, footnote xxii
*See Figure 1.1, footnote xviii
†See Figure 1.1, footnote xxiii
*See Figure 1.1, footnote xix
†See Figure 1.1, footnote xxx
‡See Figure 1.1, footnote xxxvi
*In the context of the “words matter” discussion of our Introduction, there is not yet journalistic consensus on the name for the
decade from 2000 to 2009 or the decade from 2010 to 2019. In this text will use the term “twenty-aughts” for 2000-2009 and
“twenty-tens” for 2010-2019, which seem to be the leading terms so far in use. We acknowledge their awkwardness, as well as
the quirky reality that this awkwardness may itself be an accurate reflection of the character of these decades, as has been
suggested elsewhere.262
*See Figure 1.1, footnote xxxv
†See Figure 1.1, footnote xxiii
‡See Figure 1.1, footnote xxxiii
INTRODUCTION
This chapter orients the reader to the present state of education in the fields of wilderness
medicine (WM) and wilderness emergency medical services (WEMS). Information regarding the
rich history of WEMS in the United States presented in the previous chapter will provide context
for the current paradigm, and a platform for understanding the direction of the field in the
coming years. By reading this chapter, care providers at all levels will gain a greater
understanding of common WM and WEMS educational offerings and certifications, and will be
better equipped to assess the credentials and capabilities of personnel around them in an
increasingly integrated, multilevel system.
Though the purview of this text is specifically WEMS, numerous training and certification
opportunities that fall outside of the current EMS structure are discussed in this chapter. WM
education has largely been established and developed outside of the EMS system in this country,
though the overlap between the two is often significant. Educational opportunities that are
strictly offerings of the WM discipline will be defined as such, and those that stem from, and are
regulated by governmental agencies within the EMS system will be distinguished. While most
individuals practicing WM outside of the EMS system may not be aware of the larger field of
WEMS, WEMS practitioners cannot overlook the significant group of individuals operating in
parallel and often in concert with them who are not part of a currently regulated field. As
discussed in our Introduction chapter, this group operating at a “first aid” level or outside the
EMS system has extremely important contributions to make to WEMS operations, and the
WEMS community has a large stake in ensuring they are well-educated and effective.
Furthermore, as noted in Chapter 6, “having a clear understanding of the scope of practice and
capabilities of all health care providers caring for a patient may act to facilitate communication.”
As such, the full range of educational opportunities available will be discussed.
There is little doubt that the methods by which individuals receive instruction significantly
impacts their comprehension and retention of the material. Formal medical training material is
rife with references to various models of adult learning and comparisons of pedagogical
approaches. Some of these models and approaches have been discussed in reference to WM
education in texts such as Auerbach’s Wilderness Medicine (7th ed.), and in various articles in
Wilderness & Environmental Medicine.1–4 The current trend in WM education revolves around
an attempt to standardize what is included in common courses, not how it is presented. Given
consensus regarding educational methodology in WM, it will not be covered in this chapter.
Ultimately it is the responsibility of the consumer to thoroughly investigate educational
opportunities before committing time and money to their pursuit of wilderness medical
education, as methodology varies between educational organizations. The extent to which
curriculum content resembles accepted standards, instructor qualification appears rigorous,
certification is easily maintained, and training matches desired practice level will be important
factors for the consumer to consider.

PRESENT-DAY WEMS EDUCATION

As outdoor recreation in the United States has grown over the last several decades, so too have
the opportunities for wilderness medical education. These opportunities range in commitment,
cost, and complexity from short half-day modules to training programs involving hundreds of
hands-on and lecture hours. These educational opportunities exist on a spectrum from very basic
to very advanced. Training regimens at the most basic end of the spectrum are outside the field
of WEMS and are geared toward laypersons, who have an interest in outdoor activities but who
may have no other medical knowledge, and are solely interested in expanding their capacity to
provide care for themselves and their companions on isolated wilderness outings. As discussed
later, these are often taught at the first aid level. The middle of the spectrum is more densely
populated with courses geared toward individuals who may spend significant time in the
wilderness, or trip leaders who count the safety of their participants as one of their professional
responsibilities. Also discussed later, this has evolved into a first responder training ground,
which has grown to be distinct from the EMS conception of first responder, despite originally
being attached to this EMS credential by the earliest schools such as Stonehearth Outdoor
Learning Opportunities (SOLO) and precursors to Wilderness Medical Associates International
(WMA). At the other end of the spectrum are courses of study geared toward medical
professionals who may encounter wilderness situations as part of their occupation, or who may
provide medical direction/oversight to field practitioners.
There is no universally recognized or mandated national standard for training WM providers,
no widely utilized accrediting body, and no government agency oversees or regulates any of the
common certifications. As such, specifically WM credentials such as Wilderness First Aid
(WFA) and Wilderness First Responder (WFR) cannot be viewed in the same light as other
certifications such as MD or Paramedic which conform to a widely accepted or government-
mandated set of competencies, and which are universally state-regulated credentials. That said,
over the years, individuals and groups of respected WM experts have worked to build consensus
regarding training content.3–8 Though this effort has not been without setbacks, it has led to
unprecedented communication and cooperation between major education organizations, and
greater information sharing related to best practices and content delivery. Consensus-generated
recommendations when available and applicable are noted in the categories below. Many other
documents have been published which suggest basic guidelines for performing WM, but most
leave out training guidelines. For example, the Wilderness Medical Society (WMS), which has
published nonbinding practice guidelines and curriculum recommendations, has specifically
avoided suggesting training protocols, noting “The WMS neither approves nor disapproves
teaching methods.”1
This lack of standardization is both an opportunity and a liability.
From the standpoint of opportunity and benefit, educators have the freedom to cater and
adapt their courses to the needs of the consumers as they see fit, and to draw on the strengths and
experiences of their instructional staff. There are WM schools that cater to niche markets from
rock climbing, to diving, to motorsports, and choosing an educator who will bring significant
experience related to the environment the buyer will operate in can enhance the applicability of
their training. Also, it can be recognized from the history of EMS (for example, instances in
Figure 1.1) that governmental regulation potentially brings with it increased bureaucracy, slowed
progress, and decisions made on considerations beyond those simply of excellence in patient
care. Many physicians and others who work in hospital-based or more traditional medical care
environments are often frustrated by the regulatory restrictions and obstacles overlaid on their
patient care.
On the other hand, from the standpoint of risk and cost, the buyer (and the buyer’s employer)
must be aware of substandard, outdated, or irrelevant instruction from rogue or inferior
educational providers. The absence of widespread accreditation and regulated content and
practice scopes puts the onus on the consumer to discriminate among various products and
vendors, which can be quite confusing. Some educational organizations have published
recommendations for “ways to choose a quality WM course”9,10 but understandably, those
recommendations generally steer readers toward the characteristics of the schools producing the
recommendations. This is not to say such recommendations are not correct, but the benefit of a
regulated or accredited educational industry is the outsourcing of approval to an outside entity.
All this dialogue is more specifically about WM training, as EMS training does have
accreditation bodies and national standards. This also means that a student must carefully
understand whether the training they are receiving is intended to be used in a regulated
operational environment (such as working for an EMS team that provides wilderness care under
EMS protocols) or an unregulated fashion (such as volunteering on a search with a WFR
credential). The reason this is important is twofold. First, an employer may require certain
certification levels or accreditation standards for an educational vendor as a condition for
employment. Second, in some instances, medical techniques included in WM courses may
exceed those in the WEMS community. For example, a Boy Scout in North Carolina taking a
WFA class approved by the Boy Scouts of America learns dislocation reductions, a skill that is
outside the operational scope of practice (SOP) of a wilderness paramedic in the same state
operating under state SOP rules. This creates a paradoxical situation that starts to strain the
concept of regulated practice of medicine unless the Boy Scout only plans to use that skill
exclusively in recreational environments. However, if a Boy Scout troop wishes to assist in a
rescue as a volunteer, a confusing dynamic develops regarding their educational background and
how that can be applied during actual wilderness medical care.
An important distinction is being made here between WEMS (which, as a legitimate practice
of medicine, must fall under regulatory frameworks from state and federal bodies) and WM
(which may substantially benefit from less regulation). The WM industry has made great
progress toward internal regulation. In parallel, there has been significant growth and
sophistication in the expansion and formalization of the WEMS system. Ultimately, the lines will
need to be made more clear between the unregulated, first aid practice of WM by non-EMS or
pre-EMS personnel on an incident versus the deployed, regulated, professional practice of WM
by WEMS providers. This is discussed in more detail in the Regulation section of Chapter 1
(WEMS Systems).

IMPLICATIONS FOR PRACTICE LEVELS

To truly understand WEMS, the reader must understand the training its practitioners, and those
working outside the EMS field but potentially involved in medical care before EMS arrival, are
receiving. There is no doubt that each of the categories below will be an oversimplification of the
offerings, and will leave some options out. This information is in no way meant to represent an
exhaustive catalogue of the WEMS training opportunities in the United States, but is meant to
orient practitioners at different levels to the potential training those practicing around them have
received. It may also serve as an aid for individuals attempting to choose a practice level and
educational pathway to certification.
Wilderness medical education was conceived, developed, and has been maintained by
wilderness enthusiasts first and foremost. Unlike nearly any other medical specialty, the
education of EMS providers working in the wilderness (and of first aid caregivers providing care
before EMS arrival) has happened largely outside the traditional medical academic
infrastructure, via individual schools and activity-specific recreational organizations. Box 2.1
lists currently active schools for WM with a focus on WEMS.11–13 Note that Box 2.1 is not an
exhaustive list. It is confined to American schools currently in operation and with some type of
WM or survivalism programming that is relevant for WEMS providers. Readers should
investigate any school listed to see if it meets their own purposes; websites are included in the
Box for further reference. In the remainder of this chapter and throughout this book, we use the
following nomenclature when describing programs or organizations that provide WM offerings:

Wilderness medicine school—has its own proprietary curriculum and its own instructors
Outdoor school—uses an external WM school’s curriculum, often has its own instructors (but
not required), multiple WM offerings
Program Host—uses an external WM school’s curriculum, uses external instructors, few WM
offerings, and WM is not its primary institutional mission

In the remainder of the chapter we will break down the most common current offerings in a
dynamic and diverse field.

U.S.-Based Wilderness Medicine and WEMS Training

Box 2.1
Organizations
This list serves as a starting point for readers attempting to locate a provider for their WEMS education. It has been compiled
from independent Internet searches for relevant key words, and from previously existing lists of wilderness medicine training
providers. WEMS training is a dynamic and expanding field and as such some organizations and opportunities for training
may not be represented here. Similarly, organizations included here may no longer be in operation by the time it reaches the
reader. Furthermore, training organizations listed here have not been thoroughly vetted, and the authors make no claims
regarding the content or quality of courses offered by these providers.

Name Website Headquartered In

Adirondack Wilderness Medicine adkwildmed.com NY
AdventureMed awls.org CO
Adventure Medical Training advmedicaltraining.com CA
Aerie School of Backcountry Medicine aeriemedicine.com MT
American Red Cross redcross.org DC
American Safety and Health Institute hsi.com OR
Apex Mountain School apexmountainschool.com CO
Appalachian Center for Wilderness appwildmed.org NC
Medicine
Appalachian Mountain Club outdoors.org MA
Backcountry Medical Guides backcountrymedicalguides.org CA
Base Medical base-medical.com NM
CDS Outdoor School cdsoutdoor.com PA
Center for Wilderness Safety wildsafe.com VA
Central Mountain Arizona Rescue mountainrescue.org AZ
Association
Coconino Community College coconino.edu AZ
Colorado First Aid cofirstaid.org CO
Desert Mountain Medicine desertmountainmedicine.com CO
Enviro-Tech International etisurvival.com CO
First Lead firstlead.com CO
Foster Calm First Aid fostercalm.com CA
Front Range Institute of Safety frisfirstaid.com CO
Hawk Ventures hawkventures.com NC
International Wilderness Leadership iwls.com AK
School
Jackson Hole Outdoor Leadership avalancheandwildmedtraining.com WY
Institute
The Kane Schools thekaneschools.com ME
Kingdom Adventures Mountain Guides kamountainguides.com VT
Landmark Learning landmarklearning.edu NC
Longleaf Wilderness Medicine longleafmedical.com ID
MEDIC SOLO Disaster + Wilderness solowfa.com VA
Medical School
Medical Officer Ltd. medofficer.net CO
Mountain Education and Development mountained.com UT
LLC
Nantahala Outdoor Center noc.com NC
National Center for Outdoor and ncoae.org NC
Adventure Education
NOLS Wilderness Medicine nols.edu WY
Outdoor Emergency Care oectraining.com WA
Peak 7 Adventures peak7.org WA
 Prime Paddlesports primepaddlesports.com NY
Remote 1st Response remote1stresponse.com
Remote Medical International remotemedical.com WA
Remote Rescue remoterescuemed.com AZ
Rescue 3 International rescue3.com CA
Roane State Community College roanestate.edu TN
San Juan School of Wilderness EMS sanjuanems.org WA
Sierra Rescue sierrarescue.com CA
Stonehearth Open Learning soloschools.com NH
Opportunities
Southwest Rescue southwestrescue.com CO
University of Vermont uvm.edu/cnhs/rems VT
Vertical Medicine Resources vertical-medicine.com OR
Wilderness Emergency Care wildernessemergencycare.com CA
Wilderness Emergency Medical akwildmed.webplus.net AK
Education
Wilderness First Aid wfa.net VA
Wilderness First Aid Course wildernessfirstaidcourse.org CA
Wilderness Medical Associates wildmed.com ME
Wilderness Medicine wilderness-medicine.com CA
Wilderness Medicine Outfitters wildernessmedicine.com CO
Wilderness Medicine Training Center wildmedcenter.com WA
Wilderness Medicine of Utah wmutah.org UT
Wilderness Safety Consultants wsc2.com TN

First Aid
As noted above, certifications and courses in this category fall outside the strict WEMS
framework. That said, they account for a high percentage of all the individuals trained in WM,
and many WEMS providers will find themselves taking courses from the following selections as
their introduction to WM, or as continuing education in the field.

Wilderness First Aid (WFA)

WFA courses are an introduction to WM, not a thorough exploration of the topic. Within the
WFA labeled offerings in the United States, there are courses of significantly varying
instructional hours. A consumer wishing to take a WFA course, or an administrator attempting to
choose a level of training or certification needed for their program’s trip leaders, might be
overwhelmed trying to choose from the list of educational companies and offerings returned by a
simple online search. Although there is no nationally accepted standard for a WFA, attempts
have been made over the years to reach consensus with regard to content.2,4,14–16 The most recent
attempt has been led by a group of professional educators and directors known as the Wilderness
Medicine Education Collaborative (WMEC). Information on the writing group and their
recommendations is found in Box 2.2.
The recommendations of this group are nonbinding, and there are numerous WFA courses
offered around the country that are not presented according to the guideline. However, within the
professional education providers, topics covered are fairly consistent. A significant and
controversial deviation from these guidelines is the WFA curriculum promoted by the Boy
Scouts of America (see http://www.scouting.org/filestore/pdf/680-008.pdf for additional details).
This curriculum features most prominently in WFA courses and texts presented by the
Emergency Care & Safety Institute (ECSI) bearing the moniker of the WMS, the American
Academy of Orthopaedic Surgeons, and the Boy Scouts of America as well as the proprietary
Wilderness and Remote First Aid course offered by the American Red Cross.17,18 Among other
topics, these courses are controversial for the ease by which instructors can become certified to
teach this curriculum and the breadth of topics covered in a short time frame by the curriculum,
characteristics which have been described as both strengths and deficits to such courses.19

Box 2.2 WFA Consensus Scope of Practice

Beginning in 2005, public sessions were held at Wilderness Medical Society meetings during which scope of practice (SOP)
for the WFA and WFR levels of training were discussed. A dialogue evolved and eventually a working group (not affiliated
with WMS) formed to develop industry-driven SOPs for wilderness medical certifications. This is an example of the self-
regulation sought in this industry and described in Chapter 1. The following individuals signed on to work on the WFA and
WFR SOPs.

David Johnson—Wilderness Medical Associates

David McEvoy—Aerie Backcountry Medicine
Tod Schimelpfenig—NOLS Wilderness Medicine
Carl Weil—Wilderness Medicine Outfitters
Frank Hubbell—Stonehearth Open Learning Opportunities
Lee Frizzell—Stonehearth Open Learning Opportunities
Andrew Cull—Remote Medical International (WFA SOP only)
Paul Nicolazzo—Wilderness Medicine Training Center
Nadia Kimmel—Desert Mountain Medicine

This group agreed that the following topics should be included in a WFA course provided over no less than 16 hours:
Patient Assessment and BLS, Circulatory System, Respiratory System, Nervous System, Spine Injury, Wounds, Burns,
Musculoskeletal Injuries, Allergic Reactions, Anaphylaxis, Heat Illness, Hypothermia, Lightning, Submersion, and a few
common medical problems. The following are possible elective topics: Dislocations, Spine Injury Management, Local Cold
Injury, Altitude, Poisonings, and Toxins (Snakebite, Arthropods, and Marine Toxins). Their recommendations were
published in Wilderness and Environmental Medicine in 2013.5,14

SOLO has also developed a WFA variant termed Wilderness First Aid Afloat (WFAA). This
unique marine-oriented course deletes certain elements of WFA such as altitude illness felt to be
less relevant for marine applications and significantly expands topics applicable to the water-
based environment.20
The most common training format for WFA is a 16-hour course, delivered over 2 days,
though other models exist. Some companies provide a three-day WFA, some provide the WFA
curriculum in 2 days and include an additional day for cardiopulmonary resuscitation (CPR).
There are hybrid courses of study where 1 day worth of content must be covered by the student
through online modules before arriving for a two-day course, and there are WFA courses
delivered over the entirety of a college semester during shorter class meetings. Even more
confusingly, some organizations offer a “basic” WFA class (at around 8 hours) in addition to a
“standard” WFA class (at the more typical 16 hours), both resulting in certification in
“Wilderness First Aid.” As one can imagine, given the myriad options available for receiving a
certification entitled “Wilderness First Aid,” consistency in outcomes and competencies is
difficult to summarize.
Individuals who enroll in WFA courses do so for myriad reasons. Everyone from the
weekend warrior exploring the topic for the first time, to the Boy Scout headed off to Philmont
for a summer of work, to the seasoned wilderness trip leader using the course to recertify their
WFR for the tenth time, may be enrolled in a WFA course. Indeed, challenging the idea that this
is not a WEMS credential, some SAR teams and wilderness response services utilize WFA or
WFR as a minimum medical standard, especially those that do not purport to specifically deliver
medical care as part of their rescue work (see Chapters 30 and 31 for further discussion of this).
Given the time constraints of providing such a broad curriculum in a short period of time, a
WFA tends to focus heavily on prevention, and recognizing key and obvious signs and
symptoms. Little time is available for anatomy and physiology, and only basic treatment of some
injuries and illnesses can be covered. Though limited in scope, the WFA course is often an
excellent introduction to WM, which opens students’ eyes to the complexities of providing
effective patient care in a wilderness setting.
DURATION AND RECERTIFICATION
WFA certifications are generally valid for 2 years, though some companies certify for three,
while some suggest recertifying every year. Since this certification is the most basic WM
certification on the market, there is no abbreviated version that can be taken to recertify. WFA
graduates generally retake a WFA course to maintain their certification.

Wilderness Advanced First Aid (WAFA)

The WAFA (also referred to as Advanced Wilderness First Aid [AWFA])* course usually
occupies an in-between space in the list of WEMS offerings. Most schools place this credential
level between WFA and WFR, as it may meet the needs of either camp or trip leaders likely to
operate within reach of EMS response, or recreationists seeking more training than a WFA who
do not have the time for a full WFR. Given that there have been no consensus documents
generated for WAFA training, individual companies self-define the intent of their courses and
SOP for graduates. These descriptions vary rather significantly. The Wilderness Medicine
Training Center (WMTC) suggests that their WAFA course is “designed for the recreational
public who wish to learn more about lightning injuries, wilderness toxins, and treating spine
injured patients. . . and for day and weekend trip leaders in college or university outdoor
programs.”21 Contrast this description with the following from WMA: “[WAFA] is
comprehensive medical training designed for remote professionals or wilderness leaders who
venture into remote and challenging environments. . . We prepare students for emergency
situations that involve prolonged patient care, severe environments, and improvised
equipment.”22
Though companies describe their courses differently, some consistencies can be drawn
regarding their offerings. WAFA or AWFA courses are longer than WFA courses, but generally
shorter than WFRs. They are offered in four- and five-day formats, with some companies
offering a hybrid self-directed/on-site format (see Box. 2.7). With more training hours than a
WFA, several additional topics can be explored. Depending on the provider, there may be more
in-depth anatomy and physiology, leadership skills, long-term patient care, greater injury/illness
assessment tools, exploration of evacuation options, or further resources for treatment provided.
More time is available for scenarios as well, providing the WAFA student increased simulated
patient care experience, and deepening their understanding of the material.
DURATION AND RECERTIFICATION
WAFA certifications are generally valid for 2 years, though some providers allow three.
Recertification varies by company. Some allow recertification by WFA course, while some
require a specific recertification course. Several providers also offer bridge programs for students
who would like to progress from WAFA to WFR.23–25

Climbing/Climber First Aid

While WFA, AWFA, and WFR are the most common courses offered within this level of WM
care, one company focused on a subset of the outdoor guide and recreational population. In
response to research that identified a gap in education for overuse injuries in rock climbing
within the most common courses described above,26 Vertical Medicine Resources developed a
unique curriculum with a focus on climbing injuries. Specifically, Climbing First Aid and
Climber First Aid (two different courses with different curricula and length) cover common
injuries and illnesses identified in evidenced-based literature to tailor a course to meet the needs
of the growing climbing community. These courses range from 1 to 2 days, are centered on the
most common traumatic and chronic injuries, and are configured to student’s interest and needs
based upon a pre-course survey.

Basic Life Support

Wilderness Emergency Medical Responder
In this discussion, it is critical to mention the new nationally recognized EMS certification
Emergency Medical Responder (EMR), which is replacing the EMS certification level of First
Responder. For decades, the WFR course and certification shared part of its name with the
nationally recognized certification of First Responder. Indeed, the WFR course as initially
conceived in the late 1970s and early 1980s by industry leaders like Frank Hubbell (SOLO) and
Peter Goth (WMA) was intended to be the wilderness analogue for the new front country EMS
First Responder certification—a certification intended for fire, police, and lay public who would
arrive first at a scene and had very little, if any, equipment (Figure 1.1). First Responder was
standardized and regulated beginning in the mid-1990s by the U.S. Department of Transportation
(DOT), which also regulates the terms Emergency Medical Technician (EMT) and paramedic.27
Though WFR and front country First Responder curricula and certification shared part of their
name, they did not necessarily completely overlap, and over the years grew even more divergent.
This was in general for good reason, as the FR curriculum (like much of EMS in the 1970s) was
originally conceived around motor vehicle accident response, and later expanded to include basic
techniques in urban injury stabilization. In the mid-2000s, the National Highway Transportation
Safety Administration (NHTSA), a division of the DOT, and state providers began developing an
expanded curriculum for the EMR certification, meant to replace First Responder, and add skills
to the SOP. The NHTSA now estimates that EMR training may take approximately 48 to 60
hours to achieve competency, though places no requirements on contact time.28 As the EMR
standard has been rolled out at the state and national level, WEMS providers are taking
advantage of the opportunity to provide their graduates with certifications that can be recognized
in both the backcountry and the front country. Several WEMS schools are now offering
opportunities to add or combine an EMR certification to a WFR. At least one WEMS provider
has branded their WFR course as a WEMR.29 The growing distinction between WFR and
WEMR more clearly than ever delineates a difference between WM and WEMS. WEMR
certification continues the theme of creating hybrid EMS and WM certifications using standards
and terminology familiar to EMS regulators, with additional wilderness modular components,
similar to the original early 1980s concept of WFR. Increasingly this should become a standard
requisite basic certification for WEMS teams, even though WEMR is not in name a certification
recognized by the NHTSA. In Chapters 24, 25, 30, and elsewhere in this book, we also endorse
WEMR (or the equivalent for truly niche specialties such as lifeguarding or ski patrols) as the
minimum acceptable EMS certification for a wilderness rescue team that positions itself as
formal medical care providers in addition to a search or technical rescue team. Alternately, WFR
is now completely divorced from any EMS certification, and is free to grow as a true WM
certification without the need to match regulatory and EMS standards.
The addition of WEMR to the WEMS education offerings is a great service not only to
students, but also to anyone who finds themselves in the care of a trained wilderness medical
provider. The more wilderness and traditional EMS can overlap, work together, and share
training modalities, the better patient care and transfer of care (as discussed in Chapter 6) will be
across the board. On the other hand, there is significant clarity brought to regulatory questions,
certification intent and purpose, and the difference between WEMS and WM at foundational
certification levels by having separate WFR and WEMR certifications.
DURATION AND RECERTIFICATION
National Registry EMR certification has a duration of between 2 and 3 years, depending on the
completion date of the applicant’s course and exam, as well as state by state regulations.
Recertification can be achieved through examination or through continuing education. An
individual may either schedule a computer-based exam through the NREMT, or submit
documentation of 12 or more hours of continuing education (some must be in specific categories)
during the duration of their certification. A National Registry certification is accepted in some
states around the country, though procedures for reciprocity differ. Requirements for individual
state licensure at the EMR level vary.

Wilderness First Responder

WFR certification is the level at which WM training expands significantly upon the idea of “first
aid” and becomes what many consider a “professional” certification. Many wilderness trip-
leading organizations require WFR certification for their trip leaders.30,31 Given the ubiquity of
the model, the weight it carries in the industry, and the number of hours spent teaching this
course type over the last 30+ years, it is no surprise that WFR not only has a very large number
of training providers, but has also seen significant investment in defining its scope.5,7,14 The
growth of the field over the last several decades has allowed a more evidence-based evaluation of
likely wilderness medical injuries and illnesses as incident data are gathered by trip-leading
organizations. Consistency in topic content has been in part driven by a more analytical
perspective on medical situations providers may encounter. Figure 2.1 provides an example of
the kind of data large wilderness trip-leading organizations can contribute to the conversation.
WFR educators are reasonably consistent in their descriptions of what the course entails. For
example, Desert Mountain Medicine describes WFR as “the standard level of training expected
for professional guides, outdoor educators, and search and rescue personnel.”32 Wilderness
Medicine Outfitters states their WFR course is “great for the self-sufficient active back country
person who hikes an hour from town or days in the wilderness. This is the required training for
the professional guide in most all categories.”33 NOLS Wilderness Medicine characterizes their
WFR course as “recommended for anyone who works or recreates in the outdoors or in other
austere environments.”34 A more formal SOP document from the WMEC has grown from this
general agreement regarding what constitutes a WFR.5 Though nonbinding, the SOP document
developed by numerous wilderness medical training providers suggests that a WFR course
provide a minimum of 70 hours of training, and cover a specific list of topics (Box 2.3).
As an increasing number of organizations and professions adopt WFR as the standard
training model for their staff and more educational options, especially online options, have
become available, new providers have entered the market and delivery methods have diversified.
Some WFR courses are run over eight or more straight days, some courses take a day or more
break in the middle to allow students to relax or return home, still others have adopted the
distance learning model (see Box 2.7), allowing students to complete some amount of curriculum
on their own, before completing the remainder of the course on-site (generally no less than 5
days.) WFR is also presented as a semester-long class at various colleges, with curriculum
delivered several hours at a time, including field sessions (Box 2.4).
Perhaps the greatest advantage of the WFR model, and the reason it has been adopted by so
many trip-leading organizations, is the emphasis on and time provided for practical scenarios.
Encompassing 70 hours, most WFR educators can focus on simulated patient scenarios that
integrate each teaching topic. Many also include protracted scenarios in a real or simulated
wilderness environment. These scenarios allow students to explore considerations including:
caring for multiple patients, extended contact time, night operations, environmental concerns,
and teamwork. Combined with lectures and reading assignments, these scenarios round out the
WFR curriculum as a training model that is able to include not only a broad overview of most of
the ills that may befall a wilderness traveler, but also provide detailed training in treatment
options for both common scenarios and rare but potentially deadly situations.
DURATION AND RECERTIFICATION
WFR certifications are generally current for 2 to 3 years from the completion date of the course.
Some providers with a two-year certification duration allow for a third year “grace period”
during which a certification is not valid, but a recertification can be completed. Allowing
graduates longer than 3 years between recertification cycles is uncommon.
Recertification options can be lumped into two general categories: recertification by WFA
and specific WFR recertification courses. Recertification by WFA generally involves completion
of a WFA course, as well as completing additional requirements such as exams, study materials,
and scenarios. WFA courses are designed and delivered for the introductory consumer with no
prior wilderness medical knowledge. As such, the material is far more basic than the scope of a
WFR, and may add little to the knowledge of a WFR. However, WFA courses are offered around
the country with significantly more frequency than WFR recertification courses, and thus many
WFR course graduates use them to recertify. Before enrolling in a WFA course to recertify,
students should contact the provider to discover what resources they will be provided to enhance
the learning opportunities and skills retention during their course.
FIGURE 2.1 A: NOLS Injury Data by Percentage 2002 to 2005. B: NOLS Illness Data by Percentage 2002 to 2005. (Data from
McIntosh S, Leemon D, Visitacion J, Schimelpfenig T, Fosnocht D. Medical Incidents and Evacuations on Wilderness
Expeditions. Wilderness & Environmental Medicine 2007;18;298-304.)

Specific recertification courses are generally 2 to 3 days in length, and are designed to
recertify not only WFR certifications, but also WAFAs, the wilderness portions of WEMTs, and
others. They often involve scenarios and written examinations, as well as updates on evolving
practices in WM. In this sense, a universal “wilderness” module can often be taken that updates
the corresponding traditional certification (FA, EMT, FR, etc.) (Box 2.5).

Wilderness EMT (WEMT)

Though a WFR acquiring an EMR certification is increasingly an option, for many years the
main level of true overlap between WM and EMS has been at the WEMT level (sometimes
termed EMT-W). WEMT training is generally recommended for those who will be, or would
like to be, working at the EMT level in both wilderness and urban environments, or whose
expeditions or organizational responsibilities require a higher level of certification than WFR.
WEMT courses increasingly meet the needs of converging WEMS pathways. While historically
instruction may have focused more on “expedition medicine” where the WEMT is present when
the injury/illness occurs, or shortly thereafter, instruction regarding “rescue” medicine where the
WEMT is dispatched as part of a formal EMS response is increasingly common. As noted
previously, the WEMT credential is actually a hybrid of WM and EMS and is not formally
recognized in most states, though it is well known in the outdoor industry. As noted in Chapter 1,
some rare states do recognize WEMT, albeit sometimes restricted to certain educational schools’
certifications.

Box 2.3 WFR Consensus Scope of Practice

The WMEC, following up on its work to establish a WFA SOP, in 2016 published the following list of topics which should
be included in a minimum 70-hour WFR course5:

Patient Assessment and BLS

Circulatory system (shock, acute coronary syndrome)
Respiratory system
Nervous system (traumatic and nontraumatic causes of abnormal mental status)
Spine injury
Soft tissue injury (wounds, infections, burns)
Musculoskeletal injuries
Heat illness (exhaustion, heat stroke, hyponatremia)
Hypothermia
Local cold injury
Altitude
Lightning
Submersion
Medical problems (flu-like illness, nausea/vomiting/diarrhea, fever, cough, upper respiratory infection, abdominal pain,
allergy, anaphylaxis, genitourinary, dental, diabetes, eyes and ears, poison ivy, etc.; sunburn, motion sickness)
Toxins (poisonings, snake bite, arthropods)
Medical legal considerations
The following electives could be included:
Search and rescue
SCUBA injury
Mental health
 Marine toxins

Box 2.4 Retention

Wilderness medical providers are inherently expected to possess and retain a significant amount of knowledge and skill to
perform their jobs satisfactorily. Given the fact that significant time often passes between the date of their initial training in
wilderness medicine, and the moment at which they may need to put that skill into practice, how much can we expect they
will have retained from their training? Very little research exists on this subject, at least specifically related to WEMS and
wilderness medicine. There is a limited, yet growing, body of knowledge that discusses wilderness medicine knowledge of
outdoor recreationalists, though only three of these studies specifically focus on the retention of topics commonly taught in
curricula discussed in this chapter (WFA and WFR).26,35,36 The studies diverge somewhat in their findings. Schumann et al.
found, not surprisingly, a decrease in material knowledge and skills proficiency with the passage of time after training. The
authors noted that this decline is consistent with previous findings on retention of non-wilderness medical capabilities, such
as retention of BLS and ALS knowledge by health care providers.35 More alarming from that study is the lack of correlation
between participant self-confidence and their skills or knowledge scores. This would suggest that many graduates of
wilderness medicine training courses may be unaware of the deterioration of their own skills, and might inadvertently mis-
portray their ability to provide patient care.
However, a recent 2016 study of wilderness first aid training and retention among American rock climbers found no
correlation between retention of wilderness medical knowledge and whether an individual’s certification in the field was
current or expired.26 This study of 212 rock climbers utilized injury data collected by the American Alpine Club since 1948
to determine the most common injuries and illnesses sustained by rock climbers. Ten questions were devised to test rock
climber knowledge on these common injuries and illnesses with graduates of WFA and WFR programs scoring significantly
higher on all questions than those who had not received training. This study found that scores for trained individuals were
similar without regard to current certification status. Additionally, this study found that rock climbers who rated themselves
higher in their self-assessment of first aid ability also scored significantly higher on the assessment portion of the survey than
those who rated their knowledge as basic. Unlike the Schumann et al. study, this study did not evaluate skill implementation
and was conducted on-site at a number of climbing locations across the United States to prevent the use of outside media
sources to assist in answering questions presented within the survey.
The results of these two studies paint an inconsistent picture of the level to which wilderness medicine training (and the
unstudied field of WEMS training) is retained by students. This puts the onus on the student and organizations relying on the
skills of their employees, to engage in ongoing training and skills evaluation, much like the way in which the field of EMS
requires continuing education. Since practical skills tend to deteriorate more quickly than written knowledge, and printed
medical reference material can be carried in the field, it is reasonable to suggest that ongoing training should focus on
reviewing practical skills and building muscle memory. A written guide to evacuation criteria or medication protocols is of
little use to a provider who performs a poor scene size-up and primary assessment of a patient, or who gathers inadequate
patient history before attempting to make a treatment decision.
Some wilderness medical training companies are already creating and disseminating materials to aid in retention, often
delivered through email or hosted on websites. This is a great value to their graduates and should become more standard
practice across the industry. As the field continues to mature, more formalized retention aides will hopefully become more
available and applied. Several other studies on retention of wilderness medical knowledge and skill have been initiated
within the last few years, and their results should add to the ongoing refinement of curriculum and pedagogy.

Box 2.5 CPR Training for WEMS Providers

Nearly every WEMS course, from a WFA to a Diploma in Mountain Medicine (DiMM), encourages or requires CPR
certification for its graduates. Many courses, including most WFR and WEMT courses, include it as part of the offering.
WFA and WFR courses often include basic layperson CPR training, while EMT and more advanced credentials are generally
required to maintain a health care provider–level CPR certification. For layperson CPR, some providers offer a house-
branded CPR certification, not affiliated with an outside agency. Others teach curricula from organizations like the American
Red Cross (ARC), the Emergency Care & Safety Institute (ECSI), or American Heart Association (AHA). Though
nontraumatic cardiac arrest is relatively rare in the wilderness, CPR is a fundamental skill for rescuers in any context.
Furthermore, CPR for specific wilderness situations such as lightning strike, drowning, and hypothermia may deviate from
standard protocols and should be differentiated for the wilderness provider.

In order to prepare students to work in two sometimes distinct environments, WEMS

education providers have created several different training models for the WEMT course. SOLO
teaches an integrated WEMT course and has done so since they invented this certification type in
1978 (Figure 1.1) They state, “the WEMT [course] is designed for people who work, or plan to
work, as professional medical personnel on fire departments, rescue squads, and ambulance
crews, especially those working far from definitive care. . .”37 Several other providers offer
integrated WEMT courses, which generally combine both wilderness and urban EMS protocols
into lessons. Integrated WEMT courses are often 4 weeks or more in length. For WEMT
programs that do not integrate the material, most follow up the first 3 weeks of traditional EMS
training with a final week of specifically wilderness considerations. Given the base that has been
established in the previous 3 weeks of content, providers can remove most anatomy and
physiology and patient assessment training from what would otherwise be a standard WFR or
WAFA curriculum. During this period, they can focus on prevention, treatment, and evacuation
concerns, as well as injuries and illnesses that are specific to the wilderness.
Though offerings vary, many EMT courses offered by WEMS education providers are
fifteen class days, separated by weekends. Though not the exclusive providers, WEMS schools
are the most common providers of accelerated EMT courses. At the end of these classes,
depending on the state and the provider a graduate may be able to sit for the National Registry
EMT exam, a state EMT exam, and an exam regarding the wilderness content of the course.
Outside of this field, most EMT courses are provided by colleges and take a semester to
complete.
A WEMT course may focus on EMS roles where WEMTs/SAR teams are dispatched, or
expedition medicine where the WEMT is present when the injury/illness occurs, or shortly
thereafter, or combinations. In the first example WEMTs typically have communication with the
“outside” and arrive with transportation/evacuation options in place; in the second the WEMT
may or may not have communication with the “outside” and may need to decide if, how, and
when a patient should be evacuated, or how to care for them if an evacuation is not an option.
During the training for EMT or WEMT, most companies coordinate an opportunity for
students to complete some amount of clinical hours which are usually mandated by the state.
This is most commonly completed through ride-alongs with a local EMS service, or emergency
department observations. For many students, this is the first interaction with truly sick or injured
patients, and is a crucial piece of preparing them to respond to real emergencies in the
wilderness. At the same time, each student’s experience will be uniquely their own. As with all
EMS ride-along and observational training, some will see a plethora of diverse patients, others
may see very few, or even none before they receive their credential.
Where WEMS brushes up against traditional EMS, we must take a moment to understand the
complexities of national regulations regarding the terms EMR and EMT. As referenced
elsewhere, the U.S. DOT sets minimum standards for EMR and EMT training programs.
However, it does not provide EMS training, and there is no national training protocol. Instead, it
leaves final training requirements up to the individual states, allowing them to add (but not
subtract) training topics, modalities, etc. to the basic curriculum framework. As such, some states
have slightly different guidelines for what constitutes an EMR or EMT, much the same as the
differences in certification requirements among wilderness medical education providers. Some
states accept reciprocity from others, but many have their own testing and continuing education
requirements. From the WM side, in 1995 the WMS published a curriculum suggested for
inclusion in “EMT-W” courses (now more commonly known as WEMT).38 (These
recommendations are not frequently referenced in the industry, and in subsequent publications of
the same text, WMS has not updated or referred to these recommendations.) To smooth the
boundaries of this complex patchwork of regulation, a nongovernmental organization, the
National Registry, has stepped in. Though the National Registry has no official jurisdiction, a
certification from the National Registry is accepted in many states. Thus, a student at SOLO
might complete their EMT course and pass their National Registry examination at SOLO’s
campus in New Hampshire. They might then return to their home in Arizona, and their certificate
would be accepted by the Arizona Bureau of EMS and Trauma Systems, the regulatory body that
certifies EMTs in that state, allowing them to work at the EMT level in Arizona with the
credential they earned in a school in New Hampshire. Given this flexibility, and the sometimes
transient nature of wilderness professionals, many WEMS schools have chosen to prepare their
students for National Registry exams, rather than or in addition to the exams of the state in which
the training is provided.
DURATION AND RECERTIFICATION
EMT Portion: NREMT certification is issued for between 2 and 3 years from the completion of
an individual’s course. Recertification is similar to EMR in that it can be achieved through
examination or continuing education. Depending on the recertification pathway one is eligible
for, either 40 or 72 hours of continuing education is required for NREMTs. Some WEMS
schools provide an EMT refresher program which meets standards set forth by the Commission
on Accreditation for Pre-Hospital Continuing Education, and sometimes state standards as well.

Wilderness Portion: The wilderness addition to an EMT certification is generally recertified in

the same manner as a WFR certification and has a duration of 2 to 3 years, depending on
provider. See above for WFR recertification information.
Maintaining both a traditional EMS and a wilderness certification can be a significant
challenge for an outdoor professional. Expiration dates are not consistent and are often offset by
up to a year after completion of a WEMT course. Individuals considering EMT certification
should assess their ability to maintain the credential following initial training before enrolling in
a course (Box 2.6).

Box 2.6 Reciprocity

Portability of certification and reciprocity between providers is a significant hurdle facing the wilderness medicine industry,
not unlike other industries with multiple certifying bodies, or a lack thereof. Since certifications exclusively based in the
wilderness medicine field (WFA, WAFA, WFR) are unregulated, and providers are not credentialed by any governmental
organization, providers must define who can recertify a credential through one of their courses. Some providers can and do
review curricula from other (competing) providers and evaluate whether that competing provider’s certification is one they
will recertify. Others will recertify only a specific list of approved providers, or those offering WFR courses of 70 hours or
more. Still others offer different recertification options based on whether an individual’s certification originated with their
company, or someone else’s. While some individuals are loyal to the provider of their first wilderness medicine course or
come to prefer one provider versus another, many choose (or are compelled) to be opportunists due to limited course
offerings in their geographic location or corresponding with their availability. The consensus WFR and WFA SOPs are a
step in the right direction for consistency among providers, and hopefully will increase portability of certification for
individuals with certifications that adhere to the SOP. In the current environment, consumers should research their providers,
just as they should before any educational endeavor, before committing to a course.

Outdoor Emergency Care (OEC)

The outdoor emergency care (OEC) curriculum was developed in the 1980s to provide a
minimum medical standard for ski patrollers nationwide. Ski patrollers are the most frequent
consumers of this training, originally termed “Winter Emergency Care.” However, with the
change in nomenclature to OEC, it is now marketed to other backcountry recreationalists and
professionals as an all-seasons credential. Many ski patrols require OEC or a higher level of
training such as EMT to work at a ski area. The curriculum is owned and licensed by the
National Ski Patrol (NSP) and is administered by trained providers around the country, resulting
in certification as an OEC Technician. To maintain OEC Technician certification, individuals
must remain members of the NSP. Methods for delivery vary, from hybrid web-based models, to
traditional courses offered with a mix of classroom and field-based activities. The NSP makes no
requirement for teaching methodologies, though they do suggest that at least some portion of the
course should be conducted outside.39 Examination involves both written and practical tests.
Courses are often 80 to 120 hours in length. Formal published analysis of the two programs
concluded that “the OEC-T curriculum includes a skill set and fund of knowledge that exceeds
those of the EMR program, but does not include all the knowledge needed for an EMT
program.” This analysis further noted that “the OEC-T program prepares out-of-hospital
providers to care for patients in the wilderness, with special emphasis on snowsports pathology. .
. the EMT program places a greater emphasis on medical disease and emergency medication
administration.”40 (This analysis used the more atypical initialism “OEC-T.” As discussed in our
Introduction, OEC-T is not consistent with the more standard initialism OEC Technician used by
NSP itself and by this textbook, but is retained here as a direct quote from the study.) Rather
uniquely, the OEC course is one of the, if not the only, certifications in this field that allows for
students to challenge the examination. As usual, methods vary, but some providers offer an
abbreviated course for individuals already possessing some medical or wilderness medical
training, and then administer the examinations. Recent efforts have yielded OEC to EMT bridge
courses in at least one state (NH) with efforts underway in others.41 Further reading regarding ski
patrols and ski medicine can be found in Chapter 31.
The NSP also offers an abbreviated course titled Outdoor First Care (OFC) for “ski area
personnel and other outdoor recreation groups who may encounter medical emergencies before
the ski patrol or other response team arrives.” The course is recommended at 6 to 8 hours in
length, but providers may offer a longer course of study, often involving CPR and automated
external defibrillators (AEDs) use as well. The OFC course, when combined with CPR, appears
to meet the minimum standard for most states regarding medical training for ski area personnel.42
DURATION AND RECERTIFICATION
The OEC credential must be “refreshed” on an annual basis. Refresher courses cover one third of
the OEC course material, and are provided by NSP-approved instructors. There are no other
options for recertification.

Semesters
As wilderness activities have become an industry all on their own, they have spawned an
increasing number of long-term fields of study, designed to prepare individuals for backcountry
employment and/or oversight of a wilderness program. Several organizations now offer
semester-long programs designed to expose students to a broad range of wilderness medical
topics, as well as other rescue or risk management topics. Nearly universally, these semesters
include a WEMT course as their primary offering, and then add other wilderness-focused
options. These additions can include rock rescue, river rescue, avalanche courses, Leave No
Trace, and lifeguard training, among others.
Semester-long programs hosted by WEMS training providers constitute an interesting step
forward in this field. When the first wilderness medical schools were started, wilderness
recreation was less mainstream than present day, and formal training for backcountry activities
was largely confined to the military and a few scattered mountaineering clubs. In the intervening
years, one piece of the industry that has rapidly expanded is the subfield of experiential/outdoor
education. Once the purview of a handful of independent programs, it is now possible to receive
an undergraduate degree, master’s degree, or PhD in the field from colleges and universities
around the country. Many of these college and university programs require graduates to have
completed some level of WEMS training, which some programs provide in-house, while others
require students to enroll in an outside course. The overlap between these two worlds, wilderness
medical education providers expanding offerings to semesters and beyond, and higher education
centers providing WM and WEMS training, will be a field of interest in the coming years (Box
2.7).

Wilderness StarGuard
The Wilderness StarGuard (WSG) is a wilderness lifeguarding curriculum and certification
developed by Landmark Learning and first taught in 2000 for a Florida-based North Carolina
Outward Bound School program (Figure 1.1). The name derives from a partnership between
Landmark Learning and Starfish Aquatics Institute, one of the world’s largest schools providing
lifeguarding certification.43,44 Their lifeguard certifications are termed StarGuard certification, so
this collaborative effort at developing a wilderness lifeguard certification became labeled WSG.
This coursework is primarily designed to meet the needs of wilderness trip leaders and has a
focus on prevention. The WSG program was designed for students who often lifeguard as a skill
set within a larger skill set of trip leading in remote locations, versus students seeking an
occupation or career in the role of lifeguard.47

Box 2.7 Distance/Online Learning in Wilderness Medicine

Distance learning opportunities in the wilderness medicine field have grown significantly since the early 2000s. Responding
to changing student profiles, and growing demand, a number of wilderness medicine schools, just like many traditional
colleges and universities, have created pathways to education and certification that do not require students to come to a
central location. At the WFA and AWFA levels, there are courses which can be completed entirely online with some
combination of mailed materials and online content. As noted in Figure 1.1 in Chapter 1, the first completely online
wilderness medicine school (Base Medical) was founded in 2017. Some programs coordinate some amount of skills
assessment to be completed in person. At the WFR level, providers have compiled online modules which allow students to
shorten the amount of time they spend in a classroom, by completing online coursework ahead of time. Hands-on sessions
are commonly 5 days in length.
Since there are both EMT and AWFA courses available online, and the combination of the two is often considered a
WEMT, it is possible to become a WEMT without having interacted with a sick patient or having stepped foot in the
wilderness.45 While this is unlikely, it is a further argument for employers vetting the credentials and experience of their
potential employees. Within the group of providers who offer distance learning modules, there is little doubt regarding the
efficacy of their programs. Students report positive learning outcomes and often arrive well prepared for the in-person
portions of hybrid programs. However, the caveat is nearly always made that success in a distance program hinges on the
motivation of the learner, and their ability to absorb information from readings, slide-based presentations, video lectures,
etc.18,19,46 Some students, who may not otherwise have time or the ability to travel for an in-person class, will find the
distance option of great value. Others, who learn best through interaction with peers and an instructor, will be well served to
seek out a traditional class. There is no doubt that the industry will continue to grow in this arena just as it has in other
educational modalities.

It is also of utility for organizations providing medical support for water-based outdoor
events. For example, WSG certification was used to support PsicoRoc, the first deep-water
soloing climbing competition on real rock in the United States, at Summersville Lake in West
Virginia in 2016.48 Like many WEMS trainings, this training can stand on its own, or can be
added to traditional lifeguard training as an additional wilderness module and certification. The
primary benefit of the curriculum is translating lifeguarding skills and technologies into a
wilderness environment where water quality, depth, character of underwater bottom surface, and
traditional lifeguarding tools such as rescue buoys or shepherd hooks are not readily available.
More information about lifeguarding, water safety, and training modalities is included in
Chapters 16, 26, and 27.

Diver Medicine Technician

Several organizations provide training in diving related medical emergencies. The most common
curriculum available now is the Diver Medic Technician (DMT) certification approved by the
National Board of Diving and Hyperbaric Medical Technology (NBDHMT).48 Divers Alert
Network (DAN) is developing medical certification courses to merge EMS and dive medicine
training. While a major certification thrust will be at the BLS level, there are also plans to have
certification classes at a first aid and an ALS level. This curriculum is currently under
development and not yet available to consumers at the time of this writing, but course release is
anticipated by 2018.

Advanced Life Support

For the last several decades, nearly all WEMS care provided to patients in the backcountry was
in practice BLS care, even when provided by those trained to a higher standard. However, the
role of advanced levels of care in the wilderness has grown, and training opportunities have
multiplied and become more sophisticated. A major premise of this book is that such growth at
the ALS and clinician level should continue. This, paired with the decreased weight and
increased portability of many ALS level adjuncts, has created a practical environment for
wilderness ALS care. All WEMS field providers and teams, even when operating at a BLS level,
should operate under the medical direction of a physician.50 With these things in mind, training
opportunities for ALS providers have proliferated in recent decades, rounding out the offerings
for providers from the WFA level to physicians.

Wilderness Courses for Professional Providers

Completing a WEMT or WEMR program is only one way to combine a wilderness certification
with traditional EMS or medical training. Several WEMS schools offer wilderness training
modules for traditional medical providers. This sector of the field is complex, given that there is
no agreed upon SOP for such providers, and students come with a wide range of experience.
Generally, courses are geared toward either clinicians and ALS providers (paramedics, nurses,
physician assistants, advanced practice registered nurses, physicians, etc.) or BLS providers
(EMTs, EMRs), though some courses accept the whole range. Some examples in this field are
the NOLS Wilderness Medicine Wilderness Upgrade for Medical Professionals (WUMP), the
WMTC Wilderness Module, Wilderness Medicine Outfitters (WMO) Wilderness Advanced Life
Support (WALS)/Expedition Medic, SOLO Wilderness Trauma Life Support, and the Advanced
Wilderness Life Support (AWLS) course from AdventureMed. Courses range from 2 to 5 days,
and vary significantly in their offerings. Many courses, including those catered to ALS providers,
focus significantly more time on BLS and fundamental skills than on protocols that would be
uniquely the scope of an advanced practitioner or physician. Depending on the length of the
course, and qualifications of the student, some schools will issue a WFR, WFA, WAFA, or
WEMT certificate to course graduates if they have completed both written and practical exams.
These courses are also common sources of continuing education credits for practitioners at all
levels.
DURATION AND RECERTIFICATION
Details vary significantly from course to course. Since some courses do not offer certification,
only a certificate of completion or the like, there is no expiration. For others there is a typical
two- or three-year duration, though some provide four. Courses leading to a common WM
certification will be recertified in accordance with the recertification requirements, referenced
above.

Diploma Programs
The WMS, in partnership with other organizations, offers the Diploma in Dive and Marine
Medicine (DiDMM) and the Diploma in Mountain Medicine (DiMM) for providers with medical
degrees, and other medical certifications on an individual basis.51,52 These programs are rigorous
courses of study, offered in modules, usually over the course of 2 or more years.
Developed and overseen by the International Climbing and Mountaineering Federation,
commonly referred to as the UIAA (Union International des Associations D’alpinisme), the
DiMM is offered by licensed providers around the world. It was first established in 1997 (Figure
1.1). Providers are free to tailor their courses to the specific demands of the mountain
environment in their operational field. Thus, the Nepal DiMM, while sharing core competency
requirements with a DiMM offered in the United States, might focus more on altitude and
expedition medicine, while a U.S.-based course spends more time with rock climbing and alpine
rescue. Requirements are completed through both didactic sections, commonly presented at
conferences, and field exercises held around the country.
The DiDMM program was launched in 2015 by the WMS and is a unique new offering in the
United States. Historically, WM has had a distinctly mountain bent, due in large part to its
origins in mountaineering clubs, and the significant mountainous terrain in the United States.
However, open water is as much a wilderness area as any mountain range and presents
challenges uniquely different to those encountered in the mountains. To meet the needs of
providers working in aquatic environments, the DiDMM provides training in the areas of diving,
dive medicine, sailing, and marine science. Both didactic and field-based modules make up the
DiDMM.
DURATION AND RECERTIFICATION
DiMM programs are required to outline and record participants’ continuing medical education
(CME) in order for graduates to keep their certification.

Fellowship in Academy of Wilderness Medicine

The Academy of Wilderness Medicine (a program of the WMS) offers a unique fellowship
endorsing rigorous educational opportunities for providers with professional medical degrees or
certifications. After completion of a 100-hour core curriculum as well as requirements for
service, teaching, research, and experience, successful candidates are conferred the title of
Fellow of the Academy of Wilderness Medicine (FAWM).53 This is like other academic
fellowship honorifics such as Fellow of the American College of Emergency Physician (FACEP)
or Fellow of the American College of Surgeons (FACS). However, while those fellowship
honorifics are limited to physicians, the FAWM designation is available to any medical degree or
certification holder meeting its standards and requirements, aptly demonstrating the equitability
between different provider types in WM and WEMS and a good example of the principle of
horizontal hierarchy advanced in Chapter 1 of this book. The first Fellowships in the Academy of
Wilderness Medicine were conferred in 2007 (Figure 1.1).54 As of January 2017, over 500
candidates have been conferred Fellowship in this Academy.53
In 2009, the Academy expanded its program to include a Master Fellow (MFAWM)
designation. This designation provides advanced, post-fellow certification in a chosen sub-
discipline within the scope of WM. As of January 2017, seven MFAWMs have been
conferred.12,55,56 Most participants fulfill the requirements of their individualized topical
programming within 2 to 5 years.54

Clinician
In the past, the clinician-level role in WEMS was mainly felt to be that of medical oversight or
medical consultant. However, an exciting evolution in EMS is occurring with a resurgent interest
in field physician response and a true branding of EMS physicians in practice as well as in name.
Concurrent with this was the historic decision in 2010 by the American Board of Medical
Specialties to make EMS a board-certified medical subspecialty, with the first EMS board
certifications issued in 2013.57 This opened the door for physicians and other clinicians to
specialize in out-of-hospital emergency medical care with full academic, political, and clinical
credibility, along with the rigor of a board certification process. Increasingly clinicians are taking
part in all elements of wilderness emergency response, including operator, medical, leadership,
and medical oversight roles. Educational opportunities for clinicians have grown commensurate
with this new operational role.

BLS and ALS Opportunities for Clinicians

All the trainings above are also available for clinicians. Indeed, clinicians in particular often
benefit from trainings with a more BLS and technical focus, as these are skills sets not often
taught or emphasized in their own training programs.

Wilderness Command Physician

The Wilderness Command Physician (WCP) course was first developed in Pennsylvania in 1992
by the Wilderness EMS Institute (WEMSI), and is now taught internationally to physicians
interested in participating on a wilderness EMS team or operation. Specifically, it is designed to
help physicians deal with medical command problems in wilderness systems. It posits that, in an
ideal EMS system, WCPs would be identified, and command requests would be routed only to
those who were trained as WCPs. WCPs would also serve as medical directors for WEMS
agencies, providing standing orders, reviewing cases, providing continuing education, and doing
quality assurance. The curriculum includes extensive topics on how WEMS fits into regular
EMS, how a WCP can contribute to an ongoing WEMS operation or program, and what specific
technical skills and knowledge bases a physician needs to develop to operate safely and
effectively in this environment. While courses are taught internationally by WEMSI-
International and CDS Outdoor School, the course has not been offered in the United States for
more than a half decade, but is still available depending on demand.12

Medical Student and Residency Electives

For medical students and residents with an interest in WM, there are numerous short duration
intensive options for further training. More than twenty programs around the country offer WM
or residency electives, with numerous foci (see Box 2.8).58,59 These experiences are often termed
“electives” because, within the medical training structure, they represent elective time that can be
scheduled by the student or resident physician rather than a required rotation. Programs range
from 2 to 4 weeks, and vary in their application requirements. Curriculum guidelines have been
proposed for medical student elective rotations.61 Although no curriculum guidelines have been
published for resident electives, a core content document has been developed by the American
College of Emergency Physicians Wilderness Medicine Section for use in WM tracks within
emergency medicine (EM) residencies.62

Current Medical Student Electives with a Wilderness Medicine

Box 2.8
Focus11,58,60

Belize Institute for Tropical http://www.outworldrescue.com/we.html

and Wilderness Medicine
Brown University https://www.brown.edu/academics/medical/education/preclinical-electives/biol-6652
Big Sky Medical Clinic http://docsky.us
Central Maine Medical Center http://www.cmmcfmrp.org/wimp-curriculum
Carolina Wilderness EMS www.hawkventures.com/externship
Externship
Cornell Medical College cornellwm.org
Icahn School of Medicine https://sap.mssm.edu/elective/courses/descript2.cfm?cnum=399
Johns Hopkins University http://www.hopkinsmedicine.org/emergencymedicine/residency/wilderness_medicine.html
Maine Medical Center/ Tufts http://www.wildernessmedicineelective.com
University
Marshall University http://jcesom.marshall.edu/residents-fellows/programs/family-medicine/wilderness-
medicine
Medcor at Yellowstone https://www.medcor.com/onsite/SpecialOperations_YellowstonePark.asp
NOLS Wilderness Medicine https://www.nols.edu/en/courses/courses/wilderness-medicine-expedition-WME/
Saint Louis University http://www.slu.edu/medicine/surgery/division-of-emergency-medicine/emergency-
medicine-student-resources/medical-student-rotations
St. John’s Medical Center http://www.tetonhospital.org
UCSF-Fresno http://www.fresno.ucsf.edu/undergrad/wilderness_medicine.html
University of Arizona http://emergencymed.arizona.edu/students/elective/emd-850b-wilderness-medicine-
advanced-wilderness-life-support
University of California San https://healthsciences.ucsd.edu/som/emergency-
Diego med/education/clerkships/Pages/med%20students.aspx
University of Colorado http://www.coloradowm.org
University of Michigan https://medicine.umich.edu/dept/emergency-medicine/education/other-
programs/wilderness-medicine
 University of Montana http://www.cfc.umt.edu/wi/education/aerie.php
University of Nevada Las http://www.lasvegasemr.com/wilderness-medicine.html
Vegas
University of New Mexico http://www.unmmountainmed.com
University of South Carolina http://emergencyresident.com/info_wilderness_medicine.php
University of Utah http://awlsmedstudents.org/studentelective.html
University of Virginia https://med.virginia.edu/emergency-medicine/education/medical-student-
education/wilderness-medicine-immersion/
Wilderness Medical https://www.wildmed.com/wilderness-medical-courses/medical-professionals/wilderness-
Associates medical-elective/
Wilderness Medical Society http://wms.org/conferences/elective/

While all these elective programs meet some programmatic goal or subdiscipline of WM, not
many specifically focus on wilderness EMS. The Carolina Wilderness EMS Externship would be
an example of this rare group of WEMS-specific electives.63 It is notable within the medical
education world for its emphasis on hands-on experiential education, as well as its unique
collaborative approach linking a county EMS system, a WEMS team, a community college
system, a community hospital, and a major research university.64 Another such program was the
Mercy Hospital of Pittsburgh Wilderness EMS Elective (MHWEMSE) run by Dr. Keith Conover
at Mercy Hospital of Pittsburgh, exclusively for second and third year EM residents. This
program began in 1993 but was discontinued in 1996 (Figure 1.1).
Also, while most programs are based at universities, another interesting innovation has been
the introduction of medical school and residency rotations run by independent nonprofit
organizations. The WMS (historically with the support of Roane State Community College’s
Wilderness Emergency Medicine program) offers a medical student/resident WM rotation that
would be an example of this type of rotation.65 In 2017, the WMS also introduced an “Advanced
Resident Elective” for resident physicians with prior WM experience.65
The implementation of an elective program at the University of Pennsylvania has been
analyzed in the medical literature, with the interesting result that 40% of students surveyed felt it
was the best experience to date of their medical school career.66 This phenomenon has been
replicated by WM electives with a more WEMS-specific focus.67 Indeed, it has been noted that
WM is one of the top three most highly ranked electives within EM residency programs, and
44% of EM residency programs in one survey actually require WM training of some sort as part
of their curriculum.68,69
A theme of WM has been the innovation of techniques and principles, like selective spinal
cord protection, that are then later adopted into traditional medical operations. This extends also
to traditional medical education. Medical schools may find that the innovations in WM electives
and their appeal to students could provide fertile opportunity for improvements even in
traditional medical education.11,70,71 New medical school electives appear nearly every year, but
Box 2.8 describes some of the currently active medical school electives available through
universities and other organizations.

Wilderness Medical Expeditions

Geared toward physicians and advanced providers, some wilderness medical expeditions
(WEMS) schools and organizations such as the WMS offer wilderness expeditions during which
medical topics are taught. The goal is often a mix of work and play, with a premier expedition
run by professional staff that will count toward continuing education hours (CEHs) or for CME
credit. Providers can choose expeditions from Antarctica to Everest, and Croatia to the Grand
Canyon. Depending on the program, education credits can be specifically focused in areas like
dive or high altitude medicine, or more general to EM.

Wilderness Medicine Fellowships and EMS Fellowships

Clinician-level training in WEMS is available in postgraduate fellowships. It is important to
recognize that this type of post-residency physician fellowship is different from the fellowship
offered by the Academy of Wilderness Medicine, which is nonresidential, open to all provider
levels, and is described elsewhere. Post-residency fellowships occur after graduation from
medical school (or analogue for PAs and APRNs) and residency training. Generally they are
pursued by clinicians who plan to pursue that specialty as a specific career, and usually last
between 1 and 2 years. Fellowships with a focus on WEMS may be categorized as EMS
fellowships (with a wilderness focus) or WM fellowships (with an EMS focus). Both types are
discussed in more detail below.
Nearly all fellowships in WM, and all EMS fellowships, are placed within Departments of
Emergency Medicine in their respective academic facility. The first unaccredited WM fellowship
was established at Stanford University in 2003 (Figure 1.1). Currently there is no accreditation
system for WM fellowships. The first unaccredited EMS fellowship appears to have been
established at Wright State in 1986 (Figure 1.1). However, as discussed in Figure 1.1, this was so
early in EMS development and so long before EMS fellowship accreditation that the definition
of an “EMS fellowship” is somewhat contested, and it is possible that earlier experiences, such
as a MIEMSS fellowship earlier in the 1980s, might meet the definition of an “EMS fellowship.”
This situation was clarified in 2012, when ACGME developed accreditation standards for EMS
fellowships. The first wave of ACGME-accredited EMS fellowships was approved in 2012 to
2014 (Figure 1.1.) Since those foundational programs, multiple fellowships in both EMS and
WM have arisen. Specific descriptions of programs below will also help explain why the
growing standardization of WMS and WM fellowships has made the possibility of a specific
WEMS fellowship less likely, and none currently exists. It is worth pointing out that EM is the
most fertile source of WM academic programs, and that EM residencies come in both three-year
and four-year configurations. Many four-year programs use the fourth year in a mode somewhat
like a fellowship. At Johns Hopkins University’s four-year EM residency, there is a track within
the fourth year run by Dr. Michael Millin that specifically focuses on wilderness EMS. While it
is not accredited as a fellowship of any sort, it does give specialized training in wilderness EMS
that exceeds that of a simple one-month residency elective rotation.72 As noted earlier, a core
curriculum has been proposed for such WM tracks within EM residencies.62
WILDERNESS MEDICINE FELLOWSHIPS WITH EMS FOCUS
Although currently there is no accreditation for WM fellowships, a widely accepted core content
for WM fellowship training (specifically for EM specialists) has been published.73
While all WM fellowships promote training and academic work on medical care in remote
environments, certain WM fellowships have a particular focus on WEMS in the sense that they
explicitly and primarily intend to train fellows in system-based response to and medical
oversight of wilderness emergencies. Some WM fellowships with this type of WEMS focus are
described below. In particular, the Utah program is notable in explaining how, because of the
organization and confirmation of distinct year-long curricula for both EMS74,75 and WMS,76 no
one program can probably claim to cover both accredited EMS content and consensus-driven
WM content in a single year. No program has yet developed a comprehensive two-year
fellowship experience meeting both EMS and WM credentialing standards as they currently
exist. The closest model appears to be the type developed by the University of New Mexico,
where separate EMS and WM fellowships exist which could be taken sequentially if desired for
a 2-year WEMS experience. Currently, Wake Forest University is implementing such a 2-year
sequential program for a WEMS Fellow. If successful, the first Fellow from that program would
graduate in 2019.

University of California, San Francisco-Fresno (UCSF-Fresno): The home academic

facility for the National Park Service Parkmedic Program, also providing medical oversight
for that program.54
University of Utah: This academic center, long known for its WM programs and as the
founding institution of the Advanced Wilderness Life Support program, is located within 45
minutes of seven major ski resorts, with two additional resorts within a 90-minute drive.
Faculty and fellows are intrinsically involved in on-mountain care and ski patrols at many
of these resorts, and their air ambulance AirMed provides on-mountain support and air
evacuation for ski accidents. Fellows also participate on SAR teams and other mountain
medicine programs. The medical director of Teton SAR is adjunct faculty in this program
and fellows train with and teach for Teton SAR, as well as opportunities to work with
Denali SAR via the medical director of Denali National Park, also adjunct faculty in this
program. The Fellowship here also has an innovative “Wilderness and Expedition Medical
Specialist” program providing medical direction and on-call emergency services to
wilderness organizations.77 Notably, the fellowship here started as a combined EMS-
Wilderness Medicine fellowship more than a decade ago. In subsequent years, EMS
fellowships became accredited by the American Board of Medical Specialties (detailed in
Figure 1.1 and above) and WM fellowship directors created a standardized curriculum for
WM 71). That degree of content has meant that both EMS and WM fellowships are
effectively 1 year experiences. This led to a discontinuation of formal claims of
specialization in both EMS and WM, although operationally fellows still experience a
training program deeply steeped in both disciplines.
University of New Mexico Wilderness and Austere Medicine Fellowship (WAM). UNM
has long had a commitment to the system-based application of WM in an EMS context.
Fellows here have opportunities to serve both as an operational and/or a medical team
member of Albuquerque Mountain Rescue; to provide Grand Canyon National Park
medical direction; to provide educational training in Yosemite and Joshua Tree NP; to serve
as medical providers and medical oversight for the Badwater 135 Ultramarathon in Death
Valley National Park and the Bataan Memorial Death March in White Sands New Mexico;
work at the Taos Ski Clinic; and serve on the New Mexico Disaster Medical Assistance
Team.78

Box 2.9 offers a listing of current fellowship opportunities in WM.11,79

In addition, the Emergency Medicine Residency Association (EMRA) and the Society for
Academic Emergency Medicine (SAEM) maintain updated current lists of WM fellowships.59,80
EMS FELLOWSHIPS WITH A WILDERNESS MEDICINE FOCUS
Accredited EMS fellowships are required to include WM content, although this has been
estimated to be 5% or less of the overall content. However, some EMS fellowships have a
specific and more expansive WM focus, thus effectively providing the opportunity for WEMS
training. Some EMS fellowships with a WM focus are described below.

Wake Forest University EMS & Disaster Fellowship: EMS Fellows here are formally
engaged in the Carolina Wilderness EMS Seminar, Summit, and Externship; serve as
responding field personnel for Linville Gorge Wilderness Area and various North Carolina
State Parks; lecture at the annual Southeastern Student Wilderness Medicine Conference
and the University of Vermont-Wake Forest University collaborative rural/wilderness
emergency services conference; have the opportunity to work with the Appalachian Center
for Wilderness Medicine on WEMS initiatives; and staff multiple disaster response
modalities, including a Mobile Disaster Hospital, a SMAT-II team, and the opportunity to
serve on the federal NC Disaster Medical Assistance Team based in the same county.81
Wake Forest University is currently building an accredited/consensus-compliant two-year
fellowship and enrolled its first Fellow for that track in 2017. If successful, this program
would graduate the first WEMS Fellow from an accredited/consensus-compliant program in
2019.

Box 2.9 Current Wilderness Medicine Fellowships

Augusta University http://www.augusta.edu/mcg/em/ed/fellowships/wildreness/fellows.php

Baystate Health https://www.baystatehealth.org/education-research/education/fellowships/wilderness-medicine
Carilion Clinic http://carilionwildmed.weebly.com/about.html
Eastern Virginia http://www.evms.edu/education/centers_institutes_departments/emergency_medicine/fellowships/
Medical School
George Washington http://smhs.gwu.edu/emed/education-training/fellowships/environmental
School of Medicine
and Health Sciences
Madigan Army http://www.mamc.amedd.army.mil/education/graduate-medical-education/fellowships/austere-
Medical Center and-wilderness-medicine.aspx
Massachusetts General http://www.massgeneral.org/education/fellowship.aspx?id=94
Hospital
Stanford University http://emed.stanford.edu/specialized-programs/wilderness-medicine/fellowship.html
University of https://healthsciences.ucsd.edu/som/emergency-med/education/fellowships/wilderness-
California at San Diego medicine/Pages/default.aspx
School of Medicine
University of http://www.fresno.ucsf.edu/em/wilderness/
California San
Francisco-Fresno
University of Colorado http://www.coloradowm.org/programs/fellowship/
University of New http://www.unmmountainmed.com
Mexico School of
Medicine
University of Utah http://medicine.utah.edu/surgery/emergency_medicine/fellowships/wilderness-medicine/
 Upstate Medical http://upstate.edu/emergency/education/fellowships/wilderness.php
University
Wilderness Medical http://wms.org/fawm/
Society
Yale University http://medicine.yale.edu/emergencymed/fellowships/copy_of_index.aspx

University of New Mexico EMS Fellowship, Rural and Tribal EMS Track: As noted
above, UNM has separate WM and EMS fellowships, and although separate, each
inevitably flavors the other given shared faculty and operational environment. In particular,
of the three EMS fellowship slots available each year at UNM, one focuses primarily on
Rural and Tribal EMS. The UNM description of this experience clearly highlights its
rural/wilderness focus:“[This Fellow works] closely with our new Center for Rural and
Tribal Out-of-Hospital Medicine. Rural EMS Fellows will have the opportunity to work
closely with rural and frontier counties of New Mexico, tribal EMS agencies, and remote
National Park Service agencies, including Grand Canyon and Carlsbad Caverns National
Park. The unique challenges of rural and austere EMS will be explored, including the
development of extended care 911 protocols, community paramedicine strategies in remote
locations, and approaches to austere and wilderness medical care.”82

The National Association of EMS Physicians maintains a complete list of EMS

Fellowships.83
Additionally, while not precisely fellowships, a few family practice residencies maintain
tracks within their residencies that graduate residents with special training and qualification in
WM. These include the Montana Family Medicine Program, the Family Medicine Residency of
Idaho, and Saint Vincent Wilderness Medicine Track.84–86

Wilderness EMS Medical Director Course

The Wilderness EMS Medical Director Course (WEMSMDC) was established in 2011 (Figure
1.1).87 It recognizes that many physicians have extensive EMS training, but little wilderness
medical experience, and similarly, that many physicians have deep wilderness or wilderness
medical training, but little exposure to the EMS operational environment or EMS oversight. It
was developed to support physicians and other health care providers tasked with providing
medical oversight to EMS systems operating in a variety of wilderness environments. In many
ways it addressed the same needs as the WCP curriculum established by WEMSI almost 2
decades earlier. Similarities include recognition of a particular need for clinician-level medical
oversight in WEMS operations, and the need for a training that is specific to clinicians (rather
than all providers) and to the EMS wilderness environment (rather than general WM).
Differences include use of a formal Delphi process in developing the WEMSMDC curriculum
and class format (WEMSMDC is more classroom-based, while WCP is more field-based and run
in concert with WEMT training). The WEMSMDC remains the only WEMS curriculum with
dual professional society endorsement from the WMS and the National Association of EMS
Physicians, and was named one of the Top 10 EMS Innovations of 2011 by the Journal of
EMS.88 However, until now there has been no professional society-recognized training for
physicians to provide this type of EMS oversight. Following its first class, the WEMSMDC was
incorporated as a nonprofit organization in December 2012 and continues to be offered
throughout the United States.
WEMS INSTRUCTOR TRAINING
A discussion of training opportunities would not be complete without information on what the
qualifications might be for a trainer. Similar dynamics regarding credentialing and regulation are
at play in the arena of instructor training as in the greater fields of WM and EMS. EMS
education is strictly regulated on a state by state level, while organizations such as the National
Association of EMS Educators (NAEMSE) provide widely recognized instructor training courses
which are structured around meeting instructor training requirements in numerous states.
Conversely, the WM field sees no national credentialing, and training for instructors comes
exclusively through the educational organization for which they are teaching. Both models have
their own strengths and liabilities, and belie the origins of both industries. Heavier regulation,
with its genesis in government bureaucracy, allows for standardized training and more universal
understanding of achieved certification. Lack of standardization and strict requirements, driven
by individual schools responding to consumer demand, provides the opportunity for more nimble
innovation in methodologies and adaptation to the learning requirements of diverse participants.
The WM education industry has found some consistency in content through the WFR and
WFA SOPs referenced above. However, the authors of those documents leave instructor training
up to individual schools. Among at least the larger or older training centers, a few themes in
instructor qualification can be parsed out. Many companies prefer or require that instructor
candidates have completed a course from their company. This ensures that applicants are familiar
with the particular curriculum and pedagogy of their intended employer. Most, but not all,
require that instructors possess a higher level of certification than the level they intend to teach.
Some classes directed at the clinician level, such as AdventureMed’s AWLS class, require that a
physician be a lead instructor for each class. Patient care experience is preferred or required, and
some providers help candidates make arrangements for EMS experience during their training
period. Instructor candidates who meet the prerequisites often attend instructor training courses
hosted by the provider. They focus on deepening the knowledge base of the candidate, assessing
their readiness to instruct, and teaching educational methodology. Candidates who successfully
complete instructor training programs are often assigned to co-teach courses with a seasoned
provider for continued refinement and assessment, and for curriculum consistency, as they move
toward independence. The amount of training and duration of “apprenticeship” varies
significantly both within and between providers.
The field of wilderness medical training has, for the most part, operated with a high degree
of integrity for decades, and most providers take great pride in their training procedures and seek
highly qualified individuals for their employment. However, because training for instructors
varies by company, this is one area where consumers should thoroughly vet their provider.
Students attempting to choose a provider for their training, or administrators who require a
training certificate for their trip leaders, should inform themselves as to the relative merits of
various companies. Some companies place a higher value on wilderness expedition experience
for their instructors, while others place a higher value on clinical patient care experience. Some
have a high bar for both, and expect a strong background in teaching as well. Instructor training
courses range from a couple of days (or less) to a couple of weeks. At least one provider offers
the ability to become a WFA instructor only through an online course that can be completed in as
little as 90 minutes.89 As with any learning environment, a good instructor can make all the
difference, especially in retention and comprehension. Since most companies have a fairly high
pass rate for students seeking certification, a consumer or administrator should ask themselves
whether they want to come away with just a certification, or a certification and a strong ability to
perform skills in a challenging environment.
For the most part, independent WM schools teach from a proprietary curriculum developed
in-house. However, there are also organizations which will license their curriculum for use by
other companies and individuals. Sometimes a little digging is required to unearth what
curriculum any given provider might be teaching from. It is worthwhile to do this bit of
homework before enrolling in a course.

SUMMARY
Educational opportunities for the WEMS provider are plentiful and expanding year over year.
The last several decades have seen a dramatic increase in the availability and sophistication of
training courses for practitioners at every level, and the creation of previously unrecognized
practice levels. Two worlds, WM and traditional EMS, previously somewhat siloed, are
increasingly overlapping in an integrated field with practice guidelines at many levels. Education
in these two fields has been developed on two significantly different paths, and as the two merge,
exciting possibilities are created for training well-rounded medical professionals capable of
practicing in diverse environments. How this education is pursued by the individual, and
presented by the educator, continues to become more standardized in its traditional form, even as
nontraditional offerings are developing and diversifying at increasing speed.

Acknowledgments
The authors would like to thank the following individuals for their contributions to the content
and revisions of this chapter: Bryan Simon, Lee Frizzell, Carl Weil, Nadia Kimmel, Tod
Schimelpfenig, David Johnson, Shana Tarter, Jim Chimiak, and Paul Nicolazzo. Additionally,
many of the aforementioned have been instrumental in the conception and development of
wilderness medicine education, for which we are personally grateful.

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*The terms AWFA and WAFA are used interchangeably throughout this chapter though offerings from different companies may
vary significantly.
INTRODUCTION
Although it is not a clinical discipline, incident command is a crucial component of any
wilderness emergency medical services (WEMS) response. The classic definition of incident
command revolves around the activities of ordering, directing, and controlling resources (be they
logistic or human), but the essence of incident command is actually simpler: Incident command
is really about optimizing the potential for your incident to have a good outcome by applying
basic principles of organization and management.
This is important because wilderness responses are inherently chaotic. They generally
involve many different responders from many different disciplines who are attempting to work
together against numerous challenges, potentially including terrain, weather, fatigue, time,
limited communications, limited resources, and safety hazards. When used well and applied
properly, incident command brings order to this chaos and helps all the pieces of a response fit
together.
Much in the same way that certain specific techniques of medicine have been formalized into
standardized patient care protocols such as cardiopulmonary resuscitation, Advanced Cardiac
Life Support, and others, specific techniques of incident command have been formalized and
standardized into the Incident Command System (ICS). First developed in the western United
States in the 1970s, ICS is a standardized but flexible methodology for managing incidents of
any kind and size. In that sense, it is like a protocol for “treating” the “symptoms” of an
emergency response operation. In the United States, it is a core component of the National
Incident Management System (NIMS), and its use is mandatory among federal agencies,
including the land management agencies responsible for emergency responses in the vast tracts
of federal wilderness throughout the country. State and local responders too are generally
obligated to use ICS, even if they are not under the direct control of the federal government,
because doing so is often a condition for receiving federal funding.
Even if your agency is not obligated to use ICS, choosing not to use it is unwise. Refined
since its creation through input from many different disciplines, and through application in
countless incidents, ICS is a time-tested set of best practices that is used on a daily basis by
public and private organizations throughout the country. Savvy responders know that when used
properly, ICS makes the most of the resources assigned to an incident and improves the
execution of the mission.
Modern ICS is an “all-hazards” methodology that can be applied to any kind of response, but
its history is closely tied to wilderness incidents in particular. ICS was first created under a
different name by the U.S. Forest Service in California as a way to manage their response to the
large wildland fires that often strike that state. Having seen its effectiveness, the national wildfire
community soon adopted it for use wherever wildfires occurred. Its popularity grew throughout
the rest of the emergency response community. The U.S. Coast Guard began applying ICS to
environmental accidents and collisions at sea, incidents that have many of the same
characteristics as wilderness EMS incidents.1 The U.S. National Park Service mandated the use
of ICS for all incidents in 1988.2 In the wake of the September 11, 2001 terror attacks, George
W. Bush’s Homeland Security Presidential Directive-5 resulted in ICS becoming an official
component of NIMS in 2004.3
Even if it were not encouraged to be used by national policies, ICS has several features that
make it the ideal system for managing wilderness EMS incidents (Figure 3.1):

Standardization and Common Terminology: ICS works the same way no matter which
jurisdiction you are in and no matter what the specific mission is. It has its own universal
nomenclature to bridge the differences between agency- and jurisdiction-specific jargon,
ensuring that all the responders on an incident are using common terminology.

FIGURE 3.1. Benefits of using ICS. ICS, Incident Command System.

Scalability and Flexibility: ICS can be applied to the smallest incidents or the biggest
incidents; it is simply a matter of how many of its features an incident manager wishes to
use. Its principles can be employed if you are functioning as an individual Good Samaritan
responder, as a member of a moderately sized response to a backcountry rescue, or as the
senior commander on a massive, complex search and rescue operation. As an Incident
 Commander, you can “right-size” the response structure by selecting the components of ICS
that make sense for that incident. You can even modify some of the traditional components
of ICS as long as you are staying consistent with the logic of the system.
Unity of Command: As a member of an organized response using ICS, each responder
reports to only one individual. They know whom to receive information from, and whom to
bring information to. In the challenging environments of wilderness EMS responses, this
helps prevent conflicting information, maintains personnel accountability, and enhances
safety.
Span of Control: When used properly, ICS assists you in delegating effectively and can help
you avoid becoming overwhelmed by limiting the number of subordinates that each
supervisor oversees. The limited “span of control” that each supervisor has also helps to
improve safety by ensuring that they effectively monitor the small number of people acting
under them.
Facilities: ICS recommends the establishment of temporary facilities that can be easily
found by all responders, such as an Incident Command Post, equipment staging areas, and
helicopter landing zones. It might seem counterintuitive to set up these kinds of facilities in
the austere and fluid environment of backcountry responses, but doing so can dramatically
improve the effectiveness of a wilderness EMS response by making sure everyone knows
where to get needed resources and by minimizing the clutter of vehicles and personnel
along narrow fire roads, for example.
Management By Objectives: ICS uses this term to help manage the mission by breaking it
down into specific action steps. Ideally, these steps are determined through subject matter
expertise. Management By Objectives is about deciding what your immediate goals are;
deciding what steps must be taken to achieve those goals; and then measuring your progress
by how well you are achieving those goals and adjusting your actions if you are not meeting
them.

Over the course of roughly 40 years, ICS has been refined to help make incidents successful.
Today, the National Park Service is considered to be a model of how an agency can apply ICS to
wilderness incidents of every size and scope.2 Likewise, the U.S. Forest Service, Coast Guard,
and many large Search and Rescue (SAR) teams have earned reputations for incident
management excellence and the use of ICS. They have done so by making ICS a part of their
everyday culture. These organizations apply ICS to small, routine incidents, and the comfort
level they develop by doing so helps them be successful in managing rare, complex incidents
when they occur. Making ICS a part of your agency’s day-to-day operations will help you master
incident management, too.
As you read this chapter, keep in mind that wilderness medicine is not confined to the
mountains and the woods. Any situation in which resources are limited and the time to definitive
care is lengthy could be considered an austere or “wilderness” situation. Although the examples
in this chapter do occur in traditional wilderness settings, you can apply them as well to an urban
disaster zone, for example, or perhaps a hospital running on generator power that needs to be
evacuated.

UNDERSTANDING FIELD INCIDENT MANAGEMENT

With the broad strokes and background of ICS having been laid out, let’s explore the system
further and discuss its implementation in the field. As described earlier, ICS has six core features
that are helpful in managing wilderness EMS incidents. There are additional core features that
are more relevant to other kinds of incidents, but those are best left to the purview of other texts.
To manage a wilderness EMS incident well, you must understand these basic characteristics.

Standardization and Common Terminology

It is important to understand that ICS is designed to smooth over the differences in operating
procedures and jargon used by various agencies and responders through use of its own standards,
terminology, and titles.
When responding to a wilderness EMS incident, it is best to use these terms and titles, rather
than those unique to your agency. Wilderness responses almost always involve multiple
agencies, and confusion abounds when personnel cling to their own vernacular. For example, the
senior ranking officer on duty with Agency A, a rescue squad, might be referred to by that team
as their Duty Officer. The senior ranking officer on duty with Agency B, the state land
management agency with jurisdiction over the area in which the incident is occurring, might be
referred to as the District Ranger. To bridge those differences and maximize clarity, ICS uses the
title Incident Commander for the senior ranking official overseeing an incident. The rationale for
this approach is that each agency’s personnel are used to referring to their leaders by the titles
used in their own systems, and intuitively understand all of the responsibilities and authority that
those titles convey in their jurisdictions. But when those agencies come together on a wilderness
EMS mission, those titles may not be clear to individuals who do not normally deal with them.
The standardized terminology of ICS largely consists of two categories: Position Titles and
Facility names.

Position Titles
For the most part, ICS position titles are intuitive. For example, the ICS titles of Safety Officer,
Branch Director, and Unit Leader (as just a few examples) all clearly communicate what those
individuals’ responsibilities and scope of authority are, much like Incident Commander.
To highlight this further, let’s explore some of the standard ICS position titles that might be
used on a wilderness EMS response:

Incident Commander (IC): As discussed earlier, this position is the senior official
overseeing the incident response in the field. These officials are responsible for appointing
all the other positions in the ICS organization, or fulfilling those areas of responsibility if
they do not. They are also responsible for establishing the mission’s objectives and
approving all of the broad activities that occur during an incident. They are accountable for
the mission’s overall success or failure.

When an incident involves multiple agencies or jurisdictions that share primary

responsibility for the response, it is often wise to use a Unified Command model. In Unified
Command, there are multiple ICs, each representing the primary agencies or jurisdiction, who
work together as one command team. Often, they will select one individual to serve as the “first
among equals” and represent the Unified Command team to the rest of the ICS organization. If a
Unified Command model is used, the rest of the ICS structure is still organized as it normally
would be under a single IC.
 Command Staff: Positions that directly assist the IC in accomplishing organization-wide
goals.
Public Information Officer: The position responsible for providing incident information
to the media and general public.
Liaison Officer: The position responsible for coordinating the involvement of
organizations that might wish to help with an incident, but are not part of the official
response to the incident. For example, the Liaison Officer might work with local faith-
based relief organizations that wish to supply refreshments to the responders.
Safety Officer: The position responsible for ensuring the overall safety of the incident
responders, including ensuring that they are equipped with proper personal protective
equipment and physically capable of performing their assignments.

An acronym for remembering the Command Staff positions is IC PLuS, for the IC “plus”
the first letters of the three traditional positions that assist them (Figure 3.2).

General Staff: The primary supervisors of each of the standard ICS organizational sections,
referred to as Chiefs.
Finance/Administration Section Chief: The position responsible for tracking the costs
related to an incident, as well as handling general administrative tasks such as personnel
timekeeping.

FIGURE 3.2. The “IC PLuS” Command Staff Positions.

Logistics Section Chief: The position responsible for coordinating all of the support
functions that keep an incident going smoothly: communications, supplies, utilities,
facilities, transportation, nourishment and medical care for responders, and the
acquisition of additional equipment.
Operations Section Chief: The position responsible for coordinating the tactical response
to the incident. The Operations Section does the “boots on the ground” fieldwork of
search, rescue, patient care, and patient evacuation.
Planning Section Chief: The position responsible for coordinating the nonlogistic and
nonadministrative aspects of an incident, including personnel accountability, anticipation
of future incident needs, GIS services, and distribution of important information to
incident personnel.

An acronym for remembering these General Staff positions is FLOP, for the first letter of
each section’s name (Figure 3.3). As of 2017, the Federal Emergency Management Agency
(FEMA) has suggested the addition of an Intelligence & Investigations Section and
corresponding Chief to the standard General Staff positions. If formalized, the author proposes
the acronym FLOPI to recall this.
As we will discuss later in the chapter, not all of these Command and General Staff positions
are needed on every wilderness EMS incident, especially when the incident is of a short duration.
In fact, the IC is the only specific position that must be filled on every incident. However, the IC
PLuS and FLOP positions are the core ICS positions that you should think about establishing on
any mission that is not simple in scope. And recall that the IC is responsible for carrying out the
responsibilities of any positions and tasks they do not establish and delegate.

Incident Facilities
ICS also makes use of standard terminology when referring to incident facilities. Although it
may at first seem illogical to establish fixed facilities on a wilderness EMS response, doing so
will make running a successful mission much easier by providing points from which, and around
which, operations can be conducted. In the context of wilderness EMS, a “fixed facility” is
simply a known location with some minimal utilities to allow work to be done.

FIGURE 3.3. The “FLOP” General Staff Positions. Because the Operations Section is often the first to be created as an ICS
tree expands, it is usually listed first when reading actual ICS trees from left to right. However, the positions in this tree are listed
in accordance with the FLOP mnemonic. ICS, Incident Command System.

Standard ICS facilities that might be established on a wilderness EMS incident include:
Incident Command Post: The location from which the IC and his or her staff direct the
incident response. This can be a tent, a vehicle, or even just a table. However, not every
incident requires an Incident Command Post to be established. On very small incidents, it is
often appropriate for the IC and other staff to enter the woods along with rescuers and
supervise activities directly.
Staging Area: The location to which responders are directed to report, to organize their
equipment, and await mission orders.
Helispot: The location at which helicopters are designated to land. This is the ICS term for a
landing zone, as well as the general EMS terminology for an improvised helicopter landing
site (with “helipad” being an established site).

Scalability and Flexibility

To manage wilderness EMS incidents well, it is important to understand that ICS is scalable and
flexible, and further still to know how to scale it. Its scalability means that if an incident is small,
the ICS organization can be small as well; but if an incident is large or complex, the ICS
organization can be expanded to reflect that. In other words, not all the features of ICS are
needed on every call. Many wilderness EMS incidents can be easily managed through ICS
simply by designating an IC, which is the only ICS position that is always required. In fact, 95%
of all incidents consist only of an IC and individual responders (referred to as Single Resources
in ICS terminology) working under them.3
ICS is modular, and the ICS organization for a given incident is built using a “building
block” approach. Starting out, the organizational tree for an incident will need only one block:
that of the IC. As an incident grows in complexity, or if its complexity is understood from the
beginning, the IC will add additional blocks by establishing the positions described earlier. There
are a few different indications for when the ICS organizational tree should be expanded, and
more positions created.

Span of Control
One of the key features of ICS is the principle of “Span of Control.” This principle states that the
ideal number of individual responders that a single person can supervise is somewhere between
three and seven. Below three, it is inefficient to have a supervisor dedicated to them. Above
seven, a supervisor cannot effectively supervise them. With this in mind, maintaining Span of
Control is one of the primary reasons to build more blocks onto your ICS organization. A large
number of responders will require several supervisors, and an organizational tree will be needed.

Incident Complexity
Most wilderness EMS incidents are complex by their very nature, but only moderately so: They
involve a fairly straightforward response to a report of an ill or injured person in a given
wilderness location, albeit with many challenges. But some incidents are indeed complex in the
truest sense of the word: They involve an unusual number of challenges or exceptional
circumstances. If your incident involves factors such as a wide area search for an ill or injured
subject, multiple patients, unusually rugged terrain, or unusual aspects such as a plane crash or
concurrent natural disaster, consider expanding your ICS organizational tree to ensure that all of
your bases are covered.

Incident Duration
Most wilderness EMS incidents are of a relatively short duration, spanning only one Operational
Period. Operational Periods, in ICS terminology, are units of time against which the incident’s
progress is measured. Normally, operational periods last 12 hours, but they can be shorter or
longer at the discretion of the IC. With the standard 12-hour Operational Period in mind,
consider expanding your ICS organizational tree if it appears that the incident will last an entire
period or span more than one. Fresh personnel and increased amounts of supplies will almost
certainly be needed, and more ICS positions will be necessary to manage those resources and the
turnover in personnel between periods.
When choosing to expand the ICS organization, you have several options, and they can be
used alone or in combination. The determination of which options to use, and in what ways, is
often a matter of the IC’s philosophy and comfort level with different approaches to incident
management.

Appoint Command Staff and Establish Sections: One of the easiest ways to scale an ICS
organization up to meet the demands of a more complex incident is to appoint the
Command Staff described earlier and to create Sections, led by the Chiefs that comprise the
General Staff. The Command Staff takes pressure off the IC so that he or she can maintain
overall situational awareness and ensure an effective response. The General Staff do the
same by taking point on the specific areas they lead.
 Not every Command Staff position needs to be filled, nor does every Section/General Staff
position need to be. For example, there may be no need to appoint a Liaison Officer if no outside
entities are seeking to assist in the response. Moreover, very commonly, the creation of
Finance/Administration and Planning Sections is not necessary on incidents of limited scope and
duration. It is almost always helpful, given enough personnel with the proper qualifications, to
appoint a Public Information Officer, a Safety Officer, and Operations and Logistics Sections led
by Chiefs.

Create Divisions, Groups, and Units: Within the Operations Section, Divisions or Groups
can be established to further organize the incident response. Divisions are geographic areas,
such as Divisions A and B to denote activities occurring on each side of a river. Groups are
functional areas of relatively small size, such as a Treatment Group consisting of several
patient care providers, or several rope technicians organized into a Rescue Group. Within
the Logistics Section, Units coordinate specific areas of support activity. For example, it
may become necessary to create a Communications Unit to handle radio systems and traffic,
or a Staging Area Unit to manage the area where vehicles and other equipment report for
assignments.
Create Branches: Within the Operations and Logistics Sections, Branches can be created to
organize major areas of activity that have numerous personnel operating within them. For
example, it may become necessary to create a Medical Branch within the Operations
Section to coordinate the patient care aspects of a response to a wilderness plane crash that
has produced numerous patients.
Create Strike Teams or Task Forces: Strike Teams are small teams of individual rescuers
organized around a common skill set, such as a Rope Rescue Strike Team tasked with
rigging a particular hazard. A Task Force is a small team of individual rescuers with varying
skill sets but a common mission, such as a Medical Task Force consisting of an Emergency
Medical Technician (EMT), paramedic, and physician tasked with providing patient care.

If all of these organizational levels are created, they flow in descending order from the IC
down to the small group level. The IC supervises the Section Chiefs, who in turn supervise the
Branch Directors, who in turn oversee the Division/Group Supervisors, who in turn oversee the
Strike Teams and Task Forces. The Strike Team and Task Force Leaders supervise the individual
rescuers assigned to them.
Generally, it is wise to scale your ICS organization by building your Sections from the top
down and your Strike Teams, Task Forces, and Groups from the bottom up. Use Branches
between those two levels if further organization is needed, and keep the ideal supervisory Span
of Control of three to seven subordinates in mind. In other words, begin to scale your ICS
organization up by creating some basic Sections and then building small units.
Let’s try a small example. You are the IC organizing a response to a report of a subject who
has fallen while rappelling over a cliff, approximately 45 minutes by foot from the nearest
trailhead. Twenty rescuers from several agencies with various skill sets and scopes of practice
have responded, and are assembled at the trailhead awaiting orders. You decide to establish an
Operations Section, led by a Chief, and group the rescuers as follows (Figure 3.4):

A three-person Hasty Team to reach the subject as quickly as possible and begin care.
A seven-person Litter Team to follow them with the equipment necessary to package, treat,
and remove the patient.
 Two separate 5-person Rope Teams, totaling 10 individuals, to rig any steep or high angle
problems.

With your Operations Section Chief coordinating these resources, you are free, as the IC, to
concentrate on the other broad aspects of the mission: accounting for personnel, dealing with the
media, coordinating the patient’s eventual transportation to definitive care, and documenting
activities. Because you had limited personnel and did not create additional positions to which
these functions would be delegated, you handle them yourself.
If the incident was or became more complex, for instance, if multiple patients had been
involved and more rescuers responded, you might have chosen to further organize those small
units into Groups within the Operations Section. For example, you might have created a Medical
Group to oversee Treatment Units and a Transportation Unit, along with a Rescue Group to
oversee multiple rope rescue teams. Or you might have chosen to create Branches, such as an Air
Operations Branch to focus on the coordination of helicopters involved in the rescue.

FIGURE 3.4. The concept of Span of Control states that the ideal number of individuals that one person should supervise is 3 to
7.

Rarely, however, will such a large degree of organization be called for on a wilderness EMS
incident. Moreover, it is perfectly acceptable to create just the specific kinds of organizational
components that are needed while skipping over others. It might be beneficial to create a Rope
Rescue Task Force, for example, without ever creating Divisions, Groups, Branches, or even an
Operations Section in the first place. The scalable nature of ICS means that you truly make your
organizational tree as big or as small as you wish in order to accomplish the mission.
Consider this example, from an account of an ocean rescue of approximately 60 individuals
conducted by the Lifeguards of the San Diego, California Fire/Rescue Department:
Within ten minutes of the group entering the water, several of the swimmers raised their hands to signal they needed
assistance [. . .] Twelve swimmers were immediately rescued and brought back to La Jolla Cove, including a 16-year-old
female who became unconscious while with the lifeguards [. . .] All lifeguards in the water began to direct and bring the
remaining 52 swimmers to the south end of the beach. Eleven of those swimmers were directly rescued by lifeguards using
rescue boards, personal water craft (PWC) or rescue boats. The remaining swimmers were escorted to the shore by lifeguards
in several groups. At this point in the rescue, the incident commander took steps to organize the incident through an
expanding incident command system. Because the incident area spread more than a mile, it was important to designate
separate branches at the different locations. The “Cove Branch” had 12 victims with one unconscious swimmer. The “Shores
Branch” was receiving 52 swimmers over time and was initiating a medical triage and victim staging area. Coordination of
the PWC staff and the multiple lifeguards on rescue boards who were still assisting swimmers was done by “Water Ops,” a
two-person crew on the rescue boat.5

In this dynamic rescue situation, the expansion of the ICS organization tree took place
quickly and in real time—likely drawn out on a white board at a vehicle-based Incident
Command Post.
The flexibility of ICS means that changes to its “textbook” doctrine can be made as long as
they are consistent with the underlying logic of the system. For example, the position of “Water
Ops” from the foregoing example does not exist within the traditional doctrine of ICS, and it is
not clear at which level of the traditional ICS organizational tree it would be found. But the IC
believed it was wise to create that feature to assist in organizing his response. Likewise, the San
Diego Incident Command chose to use geographical Branches, rather than Divisions, as
prescribed by ICS. That is okay. His ICS organization was effective, and was consistent with the
general logic of ICS scalability and division of activity.

Unity of Command and Chain of Command

Unity of Command means that each rescuer participating in an incident reports to one person
above them. This principle is crucial to avoid contradicting orders, murky information, and open
communication loops that lead to confusion and mistakes. Each rescuer should know whom they
should go to with problems, concerns, or suggestions, and from whom they should expect
directions. However, this principle should not prevent the use of Crew Resource Management or
similar tools by rescuers to promote safe and effective interpersonal communication. Lots of
informal communication take place during a wilderness EMS response, and Unity of Command
should not interfere with that. Unity of Command means that each individual understands whom
they should look to for formal communication.
Chain of Command simply means that there is an orderly hierarchy of reporting from the
lowest ranking rescuer in the field up to the IC. Much like Unity of Command lets each
individual know who their supervisor is, Chain of Command lets each individual know that
information will be passed up and down the organizational tree efficiently.

Management By Objectives
One of the hallmarks of ICS is the concept of Management By Objectives. This means that the
important action steps taken on an incident will be decided upon with some purpose, rather than
randomly. Management By Objectives helps prevent you from becoming overwhelmed.
Objectives are essentially the IC’s goals. They are broad statements of what should be
accomplished in a given period of time. Objectives differ from strategies, which state the general
plan of action for accomplishing the objectives, and tactics, which specify how strategies will be
carried out.
Objectives should be formulated to meet the SMART acronym:

Specific
Measurable
Action-oriented
Realistic
Time-bound

Stating objectives such as “raise the patient topside,” “locate the lost subject,” or “provide
medical care to the patient” are not very helpful in directing incident personnel toward
accomplishing the mission. After all, those sorts of activities are implied by the very fact that
rescuers have responded in the first place. These sorts of broad, obvious objectives do not meet
SMART criteria. They are not helpful in keeping the incident organized on track.
We can improve these objectives by making them SMART. “Raise the patient topside”
becomes: “Using a rope system, raise the patient topside by 0300.” “Locate the lost subject”
becomes: “Deploy search teams in an attempt to locate the subject by 1800.” These are specific,
detailed objectives that allow you to measure your progress toward their completion. It is then up
to the experts assigned to various positions within the ICS tree to carry them out using strategies
and tactics. A rope rescue team might choose to employ the strategy of a mechanical advantage
system to raise their patient topside. They might decide on setting up an artificial high point
using an aluminum tripod as a tactic to assist them in accomplishing that. Those specific
strategies and tactics are not for the incident managers to decide—they are for the technical
experts to decide in order to comply with the objectives that the incident managers set.
The process of Managing By Objectives generally consists of six steps. On a small incident,
where the IC is the only ICS position being staffed, and they are therefore personally overseeing
all aspects of the response, these steps are:

Step 1: Understand agency policies and capabilities.

Step 2: Assess the situation.
Step 3: Establish the objectives.
Step 4: Select an appropriate strategy to achieve goals.
Step 5: Provide tactical direction.
Step 6: Provide necessary follow-up.

On a larger or more complex incident, where the ICS organization has been scaled up and a
deeper chain of command exists, Steps 4 and 5 would be conducted by technical experts serving
as supervisors in the field.

Managing Wilderness EMS Incidents in the Field

Determine the Incident Commander
Perhaps the most important task in wilderness EMS Incident Management is to determine the IC.
As we have discussed, this individual leads the overall incident response in the field and ensures
that the mission is being met. The IC determines the structure of the ICS organization, and is
responsible for fulfilling the responsibilities of any positions that they do not establish.
Moreover, the position of IC is the only position that ICS doctrine requires on every incident,
regardless of size, scope, or duration. Clearly, the position of IC is crucial.
There are two general rules of thumb used to determine who the IC should be:

1. The first arriving individual on the scene is the default IC until relieved. If a multiperson
unit is the first to arrive, the most senior person usually becomes the IC by default.
2. The most qualified person, regardless of rank or “normal” responsibilities, should be the IC.

This issue of “most qualified” is not as clear as it may seem. Qualification is a mixture of
several factors, such as:

Experience, both generally and specific to the kind of incident being managed.
Training and credentials.
Incident scope and complexity.
Personality and leadership abilities.

This last point is often overlooked, but is crucial. An effective IC needs to be adept at the
“hard” skills of management, such as organizing, ordering, directing, and controlling resources.
But they also must be adept at the “soft” skills of leadership, such as effective interpersonal
communication, stress management, emotional maturity, and integrity. Being the IC is not about
bossing people around. It is about bringing order to chaos and helping the responders working in
the field achieve the mission through effective leadership and support.
True as that may be, in many cases the IC will be predetermined by statutory authority (eg,
the senior officer of the agency with primary jurisdiction for the response), delegated authority
(eg, a lower-ranking officer serving on that person’s behalf), or other policies. Crucially, the IC
must have the legal and political authority to make any necessary decisions. In the field, the IC is
in charge.

Establish Command
Once identified, the IC must formally establish command. This is the act of making it known that
an IC has been determined and is assuming responsibility for the incident. Generally, this is done
by making a radio broadcast to your dispatch center informing them of this, and informing them
of the location from which the IC will be operating—the Incident Command Post.

Wear Your Role

Although it may sound insignificant, it is crucial that the IC and other ICS positions wear some
type of marking to clearly denote their role. Usually this is accomplished by donning mesh vests
with positions emblazoned on them, but it can also be accomplished by helmet markings, hats, or
other similar paraphernalia (Figure 3.5). It is unwise to rely on the traditional rank insignia
found on uniforms to communicate roles and responsibilities on a wilderness EMS scene.
Although normally in charge of an agency’s day-to-day operations, a ranking officer may not be
serving in any particular ICS role on a given wilderness incident. Roles change from incident to
incident, especially among agencies that have an abundance of well-qualified personnel:
yesterday’s IC might be today’s Operations Section Chief, and vice versa.
Also consider that other agencies responding to assist you may be unfamiliar with the
individuals among your personnel and their typical responsibilities. Moreover, any individuals
responding to the scene after command has been established will need to be able to easily
identify the people in charge.

Size Up the Scene

The next step in effective incident management is to conduct a brief scene size up: collecting
information about the incident at hand to determine its scope, complexity, and challenges. Do not
assume that dispatch information is correct. Think critically about the patient’s condition, and
about challenges that are likely to affect the response, such as terrain, weather, communications,
available personnel, and any additional resources that you might need to secure. Scene size up
considerations include:

FIGURE 3.5. ICS Position Vests being worn by members of Vancouver’s North Shore Rescue, demonstrating that the
importance of “wearing your role” during incidents is indeed an international best practice. ICS, Incident Command System.
Photo courtesy North Shore Rescue.

Current and anticipated weather

Hazards and safety concerns
Initial priorities and immediate concerns
Time of day (daylight and darkness)
The nature and magnitude of the incident
Number of patients and their condition
 Number of responders and their capabilities
Communications
Entrance and exit routes for responders, ambulances, and other resources
Need for helicopters
Anticipated locations of the Incident Command Post and Staging Areas

Begin Documentation
Much like the patient care record itself, thorough documentation of incident activities will not
only help you manage the incident more effectively, but may also become relevant in legal,
regulatory, or research contexts later on. Many documents are used during wilderness EMS
incident management, including standardized forms and job aids published by the Federal
Emergency Management Agency (FEMA), U.S. Coast Guard, and National Wildfire
Coordinating Group (NWCG), that may be helpful in organizing your activities and generating
written incident action plans.
On large or complex incidents, you may wish to establish a Documentation Unit (which is
normally placed in the Planning Section) to handle this and certain other documents. On most
wilderness EMS incidents, however, doing so is not necessary, and basic documentation will be
handled by the IC or any deputies they choose to appoint.
The standard FEMA ICS forms are listed in Table 3.1 and are usually sufficient for most
wilderness EMS responses. As you can see from their titles, some forms will be used on every
mission, while other forms might be used only on certain missions of greater complexity. For
example, the 201 (Incident Briefing), 204 (Assignment List), 205 (Communications Plan), 206
(Medical Plan), and 211 (Check-In List) forms are some that you might intuitively expect to be
indispensable to almost any well-organized response. By contrast, the 220 (Air Operations) form
would be necessary only when air support must be integrated into the mission. Taking advanced
ICS classes through the training providers listed later in this chapter, and using commercially
available ICS field guides, will help you determine when and how to use these various forms.
In particular, the purpose of the ICS 206 (Medical Plan) form is frequently misunderstood.
Contrary to what its name might suggest, the Medical Plan form is not designed for planning
patient care. Rather, it is intended for use by the Medical Unit, within the Logistics Section, to
document a broad plan for providing care to injured incident responders. In fact, none of the
standard ICS forms are designed to assist patient care providers in documenting an actual care
plan for use during rescue operations. This makes sense within the logic of traditional ICS
doctrine: ICS avoids dictating the tactical elements of a mission, such as how care will be
provided to a given subject. However, the lack of a written care plan can hamper safe and
efficient wilderness EMS operations: In the unique arena of WEMS, patient care considerations
can impact many other aspects of the mission at a strategic level, such as the configuration of
teams, the kind and type of equipment needed, and the deployment of resources such as vehicles
and aircraft. For this reason, it is wise to develop at least a basic written care plan and factor it
into the larger Incident Action Plan along with other appropriate forms.

Table 3.1 Standard NIMS/ICS Forms Useful in Wilderness EMS Operations

ICS Form Form Title Prepared by
ICS 201 Incident Briefing Initial Incident Commander
ICS 202 Incident Objectives Planning Section Chief
ICS 203 Organizational Assignment List Planning Section Chief
ICS 204 Assignment List Team Assignment Form
ICS 205 Incident Communications Plan Comms Unit Leader
ICS 206 Incident Medical Plan Safety Officer/Log. Medical Unit Leader
ICS 207 Incident Organization Chart Planning Section Chief
ICS 208 Safety Message/Plan Safety Officer
ICS 209 Incident Status Summary Situation Unit Leader
ICS 210 Resource Status Change Comms Unit Leader
ICS 211 Incident Check-In List Resource Unit Leader/Staging Area Mngr.
ICS 213 General Message Any position
ICS 214 Unit Log Unit/Section Leaders
ICS 215 Operational Planning Worksheet Operations Section Chief
ICS 215A IAP Safety Analysis Safety Officer
ICS 218 Equipment Inventory Logistics
ICS 219 Resource Status Card Resource Unit Leader
ICS 220 Air Operations Worksheet Air Ops Branch Director
ICS 221 Demobilization Checkout Demob Unit Leader

These forms can be downloaded from the FEMS ICS Resource Center website.
ICS, Incident Command System.

As was discussed earlier, some agencies have modified ICS itself to make it more useful to
their particular responses, and have also modified certain standard ICS forms. This is completely
acceptable, as long as those modifications are consistent with the logic and characteristics of
ICS. One way that some SAR teams and WEMS agencies have chosen to do so is to modify the
ICS 206 (Medical Plan) form into a version suitable for care planning. The Appalachian Search
& Rescue Conference, for example, has developed a form that they call ICS 206B-SAR
(Rescue/Evacuation Plan) that is intended for this purpose.7 One could conceivably modify the
ICS 215 (Operational Planning Worksheet) form into a Patient Care Planning Worksheet or the
ICS 204 (Assignment List) into a Patient Care Needs List, for similar purposes.
Even if a modified form is not developed, it will benefit the patient and the overall operation
greatly to spend as much time on a written care plan as the operational tempo allows. Giving
thought to specific items and medications that might be necessary, special packaging
considerations and unique considerations of prolonged field care will help you prepare for the
mission both mentally and logistically. Writing those considerations down will help you more
easily incorporate them, where appropriate, into the overall response—be it in a written form
distributed within the Incident Action Plan or simply shared verbally during an initial briefing.

Account for Personnel

It is crucial to ensure that all personnel are accounted for upon their arrival at the scene, and
before the scene is cleared once the mission has concluded. Implement some type of sign-in
process to accomplish this. The simplest mechanism for doing so is a paper sign-in sheet, but
some agencies have implemented a variety of alternative approaches.
One such approach, borrowed from the fire service, is to use accountability tags. These are
small, Velcro-backed tags engraved with the firefighter’s name and unit number and affixed to
the inside of their helmet (Figure 3.6). Before entering a burning structure, the firefighter will
remove the tag from their helmet and place it on an Accountability Board located at the
command post. When exiting the structure, they remove their tag from the board and return it to
their helmet. By adhering to this system, incident managers are able to easily account for
personnel. Such an approach can easily be adapted to wilderness EMS incidents, and the system
can be modified to help construct an ICS tree.
Another approach is to construct a database of responders in a program such as Microsoft
Excel, and load it onto a laptop or tablet that can be set up in the field. By attaching a USB-
powered Radio Frequency Identification (RFID) reader to the laptop and by issuing uniquely
numbered RFID-enabled cards to responders, a very simple electronic sign-in system can be
employed (Figure 3.7). Responders simply tap their RFID card on the reader when they arrive at
the Incident Command Post or Staging Area, and the database calls up their profile and logs
them in.

FIGURE 3.6. An Accountability Command Board, manufactured by the Conterra Corporation. Photo courtesy of Conterra, Inc.

In wilderness response settings, it is wise to try and collect responders’ phone numbers and
vehicle information as a part of the sign-in process. Should a responder become lost in the woods
and fail to sign out, it may be possible to “ping” their cell phone and attempt to triangulate their
location. If there is uncertainty about a responder’s status and vehicles remain at the trailhead, it
is helpful to know if one of those vehicles belongs to the responder (suggesting that they have
become stranded in the woods) or merely belongs to other individuals using that same trailhead
access but uninvolved with the incident. This is a limitation of the accountability tag system, but
an advantage of the paper or electronic systems.

Locate Your Facilities

If you have not already done so as a part of your earlier action steps, it is now time to give some
thought to the location of certain incident facilities that you may wish to establish. The two kinds
of facilities that are generally the most helpful on a wilderness EMS incident are an Incident
Command Post and a Staging Area.
The Incident Command Post is the hub of the incident’s management activities. It is where
the IC and Command and General Staff do their work, if the incident is not so small as to require
only an IC and allow them to enter the wilderness along with the responders. The Incident
Command Post can be any type of facility, but its location is more important than its features.
Whether your Incident Command Post is a million-dollar recreational vehicle converted for the
purpose, or simply a fold-out camp table and chair that you procured from the trunk of a car, it
should be located close enough to the action so that effective supervision can be provided, but
not in a position that impedes access to the scene. It is also wise, when possible, to shield the
Incident Command Post from the public and the media so that its work can occur with discretion
and without distraction. The Incident Command Post should have good radio and cell reception,
when possible, as well as good lighting. It is wise to establish an Incident Command Post kit,
containing items such as basic office supplies, paperweights, and other tools relevant to
administrative work in an austere location.
The Staging Area is the facility where responders will be directed to park their vehicles and
assemble their gear, often to avoid clogging up narrow wilderness roads. This may also be where
ambulances are instructed to report, and where any additional specialized resources are directed
to report. This is also where responders who do not have a specific assignment should wait, to
avoid a congested command post area. As with the Incident Command Post, location is key. The
Staging Area should be far enough from the command post and incident scene to keep the
respective areas from becoming crowded and chaotic, but close enough to communicate with and
to enable responders to reach the scene or command post quickly once called. Often in
wilderness EMS, staging areas are areas of opportunity: trailhead parking areas, roadway pull-
offs, service roads, or perhaps the parking lot of a nearby country store. Sometimes, no suitable
Staging Area can be established given the location and terrain, and the scene will become quite
congested regardless.
FIGURE 3.7. Electronic Sign-in System Designed and Used by the Powell County Search and Rescue team in Kentucky’s
Red River Gorge. Each member is issued a RFID card that when tapped on the reader to the right of the laptop signs them in and
out of the incident. RFID, Radio Frequency Identification.

Both the Incident Command Post and the Staging Area should be well marked. A variety of
commercial marking devices are available for this purpose, but even a handwritten sign tacked to
a tree is sufficient. It is important for anybody responding to the scene to know where to go, and
where to find people in charge. Sign-in activities may take place at either location, but must be
supervised closely.

Establish Priorities and Objectives

It is now time to establish the overall incident priorities and objectives. The three most important
priorities of any incident are always the same, in this order:

1. Life Safety
2. Incident Stabilization
3. Preservation of Property/Environment/Resources

Once those overall priorities are understood, objectives conforming to the SMART criteria
should be formulated. This need not be a lengthy or detailed process, and often these objectives
will be somewhat obvious and implied. Only foolish ICs skip this step, however: This is their
opportunity to take stock of the information collected during the scene size up, organize
thoughts, and communicate the action plan to the personnel assembled before them. It is crucial
that all responders operating on the incident understand what the priorities and objectives are
before they deploy into the field.

Ensure Appropriate Safety and Supervision

During your Scene Size Up, you considered factors that might impact responder safety, such as
weather, fading daylight, and natural hazards. Any such safety issues that you identify must be
mitigated. For this reason, appointing a Safety Officer to specifically handle these concerns and
implement controls is generally wise. Their responsibilities include ensuring that all personnel
are dressed appropriately for the weather, have appropriate personal protective equipment for the
mission at hand, have light sources for nighttime and evening operations, are carrying enough
water, etc. A Safety Officer would typically also formulate a general safety plan, with
contingencies for inclement weather and other possible emergencies (such as a responder injury),
and ensure it is made known to all personnel.

Plan to End
From the first moments of the incident, you should anticipate its conclusion. Once you reach,
treat, and package the patient, where and to whose care will they be transferred? How will they
be transported to the hospital? At what point will you consider the incident closed? Envisioning
the desired outcomes will further assist you in planning and measuring progress toward
objectives.
Planning for the end is especially important when considering the personnel operating on the
incident. The process of sending responders home after their work on an incident is complete is
called demobilization, and you should prepare for it as soon as the incident becomes stabilized.
Demobilization is the final step in the incident response process for individuals. Consider these
questions regarding the demobilization process:

If personnel emerge from the wilderness exhausted, is it safe for them to drive home? If not,
what is the plan for ensuring that they recuperate?
Do we need to assess personnel for injuries or exposure to illness?
If the weather conditions on the incident are very hot, very cold, or very wet, should we
make arrangements for personnel to cool off, warm up, or dry off?
Will emotional support services be necessary in the aftermath of a traumatic mission?

These are some of the questions you must be prepared to find answers for when you deploy
human beings into the field.
You should also anticipate holding a debriefing, or “hotwash,” as a precursor to
demobilization. A hotwash is a structured but informal discussion of what occurred on the
incident, for the purposes of identifying lessons learned and reflecting on the successes and
challenges of the incident. It does not replace the need for an after-action review, which is a
formal document that is often prepared in the days after an incident to fully document the
successes, challenges, weaknesses, and areas for improvement of the agencies involved. Rather,
it is an opportunity for responders to share some quick thoughts on things they experienced and
observed. The term hotwash is thought to come from the practice used by some members of the
military of rinsing their rifles in hot water immediately after firing them to dislodge grit and
make them more likely to fire accurately again, short of a thorough cleaning.6 Accordingly, think
of the hotwash as a “down and dirty” review of what just occurred, to help bring the experience
to a resolution and better prepare responders for the next incident, which could come at any time.
The hotwash and demobilization processes are also your opportunity as the IC to ensure that
any critical parting information is delivered to responders, and that the incident can be closed out
in an organized manner. They are opportunities to recover any equipment that was issued, screen
for exhaustion or minor injuries, and remind personnel of the importance of activities such as
tick checks and safe driving habits on their return trips.

IMPLICATIONS FOR PRACTICE LEVELS

Just as the principles of incident management are broadly applicable to any wilderness EMS
incident, so too are they broadly applicable to various levels of practice. However, there are
some important differences as the scope of practice broadens. All responders must understand
the principles of ICS in order to operate effectively as part of the incident.

First Aid
Responders certified at the First Aid level may operate in many different roles within an ICS
structure during a wilderness EMS incident. In fact, the less specialized or extensive your
medical training is, the more flexibility the IC has in assigning you responsibilities. This
potential for such varied assignments underscores how important it is for every responder to have
at least a working knowledge of ICS.
Because wilderness EMS incidents are fundamentally about providing care to a patient, and
because their patient care skills are limited, it is likely that a First Aid provider will be placed in
one of the numerous “overhead” positions of an ICS tree, managing aspects of the response from
the Incident Command Post. These overhead roles are not afterthoughts, however, and do not
reflect a lack of value in First Aid–level skills. Indeed, many highly capable incident managers
and commanders do not come from a patient care background. They are master planners,
logisticians, administrators, operational supervisors, and communications experts who maintain
First Aid certification as a matter of practicality. Their role is to provide high-level incident
coordination, not to take care of patients in the field.
First Aid providers are just as likely, though, to be placed in the field alongside providers
with broader scopes of practice. Many Search and Rescue teams are not licensed EMS agencies,
and therefore require their members to maintain only First Aid certification. By the same token,
many EMS agencies are not certified Search and Rescue teams; though their EMTs, paramedics,
and physician medical directors might enter the wilderness, these individuals might not be
capable of performing technical rescues. As a result, it is common for the members of Strike
Teams and the Single Resource Rescuers who actually make first contact with the subject to be
First Aid providers. It is vital that these individuals have an equally comfortable knowledge of
ICS of the command structure that they are operating within.
Some roles in which a First Aid provider might be placed:

IC/Unified Commander: The person or people responsible for providing overall command
of the mission and the ICS organization. These individuals are often senior officers in their
respective agencies that have nonclinical backgrounds.
Command Staff Member: An individual serving in one of the positions that directly assist
the IC or Unified Command, such as the Public Information Officer, incident Safety
Officer, or Liaison Officer.
General Staff Member: An individual serving as the Chief of the Operations, Planning,
Logistics, or Administration/Finance sections of the ICS organization.
Section-Specific Position: An individual serving in any of the numerous positions that can
 exist within each of the organization sections, such as the Communications Unit Leader in
the Logistics Section or the Air Operations Branch Director in the Operations Section.
Strike Team Member: An individual who is a part of a group that has common roles and
responsibilities, such as a Hasty Search Team consisting of several Ground Search
Technicians that has been sent into the field to find an injured subject.
Task Force Member: An individual who is a part of a group with varied roles but a common
mission, such as a group consisting of Rope Rescue Technicians, Litter Carriers, and EMS
providers, sent into the field to access a patient and remove them to safety while care is
provided.
Single Resource Rescuer: An individual performing a task without additional personnel
alongside them, such as a Rope Rescue Technician who rappels over a cliff edge to access a
subject.

Basic Life Support

At the basic life support (BLS) level, incident management responsibilities may be differentiated
between individuals operating in the field and those operating in a communications center or
emergency operations center.
Working in communications centers, emergency medical dispatchers must be familiar with
ICS in order to provide effective communications support to responders in the field. They must
be prepared to receive consolidated messages from an unfamiliar Communications Unit Leader,
for example, rather than from the individual personnel they are accustomed to interacting with.
They must be aware of the function of a Public Information Officer in order to route inquiries
from the media correctly. They must understand the function and location of a Staging Area in
order to dispatch units to it, rather than to other areas where the arrival of those units might be
unexpected or hamper operations. Although they may not be direct participants in the ICS per se,
they must be familiar with its shape and characteristics so that they can perform their own roles
in support of it.
Working in the field, Emergency Medical Responders (EMRs) and EMTs are likely to be
placed in patient care roles alongside providers with broader scopes of practice if those
individuals are participants in the response. If they are not, the EMT may find themselves the
senior clinician in the field. In either case, they must understand the reporting lines and hierarchy
of the ICS organization so that they can operate within it effectively.
As with other levels of health care provider, EMRs and EMTs might find themselves
occupying positions at any level of an ICS organization. EMTs especially might find themselves
in some of these common positions:

IC/Unified Commander, Command or General Staff: Many individuals qualified to serve as

IC or in Command and General Staff positions are active EMTs. When ALS providers or
advanced clinicians are available as rescuers, it may be wise to task them with direct patient
care and to don your ICS vest as an incident manager.
Section-Specific Position: EMRs and EMTs may be asked to apply their skill set in the
Medical Unit of the Logistics Section, providing care to other responders; as a
Transportation Unit Leader, coordinating ambulances; or as a Medical Group Supervisor,
providing strategic leadership and support to clinicians of various levels.
Strike Team/Task Force Member: EMRs and EMTs are likely to be placed alongside other
patient care providers as a member of a treatment team.
 Single Resource Rescuer: On incidents that do not feature the involvement of providers with
broader scopes of practice, BLS providers are very likely to find themselves in the role of
single rescuers, sent to access and stabilize a patient in very austere situations. For instance,
an EMT with rope rescue qualifications may be sent over a cliff edge to begin treating a fall
patient solo.

Advanced Life Support

Advanced Life Support providers specialize in being flexible, rugged, and resourceful. As a
result, they are probably the most likely to find themselves in direct patient care roles, at low
levels within the ICS organization but with crucial responsibilities. The Paramedic training
curriculum, for example, has been designed since its inception around the premise of delivering
essential lifesaving care in austere environments. Similarly, registered nurses and respiratory
therapists have broad skill sets and educational backgrounds that make them well-suited to work
in low-resource environments ranging from critical care helicopters to home health settings.
Often, ALS providers who gravitate toward wilderness medicine also have specialized
certifications in that area, making them suitable technical advisors.
Positions in which ALS providers are likely to find themselves include the following:

Technical Expert: Given their familiarity with field care, ALS providers may find
themselves providing subject matter expertise to incident managers.
Single Resource Rescuer, Strike Team, or Task Force Member: As specialists in direct
patient care, (ALS) providers are likely to find themselves providing that care in the field, as
an individual rescuer or alongside other providers of various scopes of practice. Given that
physicians and advanced practice clinicians are found in the field relatively infrequently,
they are also likely to find themselves the leader of the patient care efforts.

Like any other member of the response organization, ALS providers must be familiar with
the tenets of ICS in order to function effectively within the incident organization.

Clinician
Within an ICS structure, an associate provider or physician is equally likely to serve in an
overhead role as to be engaged in direct patient care at a lower level in the organization.
However, their role is likely to be medical in nature regardless of its specific position in the ICS
tree. These individuals have high levels of clinical knowledge, broad scopes of practice, the legal
ability to supervise other health care providers, and often specialized training that has prompted
them to be involved in the wilderness incident in the first place. As an associate provider or
physician, you should expect to be placed in an ICS position that draws on a similar skill set to
the one you would use in your daily practice, but in a wilderness context.
There are many ways to make use of APs and physicians in an ICS structure. One notable
example comes from the National Disaster Medical System (NDMS), a division of the United
States Department of Health and Human Services that deploys medical teams to disaster sites
and major public events throughout the country (and sometimes internationally). When NDMS
medical teams deploy, they are commanded by an incident management team that deploys with
them (Figure 3.8). NDMS has created the ICS position of Chief Medical Officer, which is filled
by a physician and treated as a Command Staff position to inform the entire operation from that
vantage point.
Some additional positions in which an Advanced Clinician or Physician might be placed
include the following:

Branch Director: Within the Operations Section, a Treatment or Medical Branch might be
created to specifically coordinate the clinical care of patients. This is more likely to occur
on a complex incident that requires a particular focus on coordinating medical operations,
such as a Search and Rescue mission for multiple subjects thought to be suffering from
injuries or illness or a wilderness emergency that has produced multiple patients.
Medical Unit Leader: Within the Logistics Section, the Medical Unit is responsible for the
care of the other responders on the mission. It is common for responders to suffer subacute
injuries such as sprains, strains, stings, and heat exhaustion, and incident managers may set
up a unit dedicated to treating these presentations.

FIGURE 3.8. A sample NDMS Command and General Staff Tree, showing the placement of the Chief Medical Officer in their
ICS structure. NDMS, National Disaster Medical System.

Technical Expert: It is often beneficial to have general Subject Matter Experts available to
the Planning Section, so that they can understand and anticipate the various aspects of the
mission. As a clinician, you might be asked to help incident planners prepare for the various
clinical factors inherent to wilderness EMS missions.
Single Resource Rescuer, Strike Team, or Task Force Member: As a clinician, you might
find yourself providing patient care in the field as an individual rescuer or alongside other
providers of various scopes of practice, much as you would in your traditional practice.

Regardless of the role you are assigned to fill as a physician, physician assistant, or nurse
practitioner, you should be prepared to provide on-site medical direction within the bounds of
applicable laws, regulations, policies, and ICS hierarchy. As a highly trained provider that
occupies an elevated position in the traditional health care system, other providers and
responders on an incident will naturally look to you for guidance and leadership.

FURTHER EDUCATION
Be aware that this chapter provides only a brief and general overview of this topic. There are a
few additional steps you should take to maximize the utility of this information.

Pursue Specific Training

To truly understand and apply ICS well, it is necessary to take formal training. Specific courses
in every facet of incident command and management exist, ranging from broad awareness-level
courses to multiday position-specific courses, reflecting each level of the ICS organizational tree,
from IC to Unit Leader. Courses are available on the proper use of standard ICS forms, the best
ways to interact with emergency operations centers, and intermediate and advanced applications
of ICS principles. And, generally, these courses are free, fully funded by states and the federal
government in order to promote widespread understanding of NIMS, of which ICS is a
component. The entities in Table 3.2 offer free or low-cost training in nearly every facet of
incident management.

Table 3.2 Sources for Free or Low-Cost ICS Training

FEMA Independent Study https://training.fema.gov/is/
FEMA NIMS Resource Center https://training.fema.gov/emiweb/is/icsresource/index.htm
FEMA Emergency Management Institute https://training.fema.gov/
Center for Domestic Preparedness https://cdp.dhs.gov
Emergency Management Institute https://training.fema.gov/emi.aspx
Texas A&M Engineering Extension Service (TEEX) https://teex.org
Rural Domestic Preparedness Consortium https://www.ruraltraining.org/
State Emergency Management Agencies Various state websites
U.S. Fire Administration https://www.usfa.fema.gov/training/nfa/index.html
NWCG http://training.nwcg.gov/
U.S. Coast Guard https://homeport.uscg.mil/

This list is representative of online opportunities available as of 2017. Many additional sources can be found through web search.

Table 3.3 The Standard Basic ICS Classes Required for Many Federal Compliance
Purposes as of This Writing
IS-100.B Introduction to ICS
IS-200.B ICS for Single Resources and Initial Action Incidents
IS-700.A NIMS, an Introduction
IS-800.B National Response Framework, an Introduction

These courses are available to take online via the FEMA Independent Study Website.
ICS, Incident Command System; NIMS, National Incident Management System.
 Take as many of these courses as you can. Enrich your fund of knowledge as much as your
time allows. Even if you feel it is unlikely that you will be asked to serve in an incident
management capacity, or you prefer to remain hands-on with patients rather than working in a
command post, you will operate at a much more proficient level if you understand the bigger
picture that you are a part of. Moreover, certain ICS courses are actually required by the federal
government if you wish to be a participant in programs or agencies that receive federal funds,
such as grants. Table 3.3 lists the standard ICS courses, and denotes the ones that are required by
federal funding regulations as of this writing.

Create a Culture of Incident Management

It can be difficult to gain proficiency in incident management techniques without using them
regularly. Those who do not respond to multiunit incidents on a regular basis are likely to find
that the knowledge is highly perishable. Even among those who do respond to such incidents
routinely, effective use of the ICS is not always the norm.
The best way to avoid falling out of the habits of sound incident management is to make
them habits in the first place. Make incident management techniques and the ICS a part of your
organization’s everyday operations. For instance, you could treat each training event as a
mission, and establish the various ICS positions both as a method of ensuring a safe training
environment and to practice the very act of establishing them. Likewise, you can make sure that
every call for service or patient encounter has an IC, and that personnel accountability practices
are observed at all times. Many agencies choose to maintain accountability tag boards in their
stations, and even in each vehicle, listing the personnel on duty and assigned to various units.

Plan to Manage Incidents

The third key to successful incident management is to plan for it prior to the incident. You may
have noticed that several of the techniques described in this chapter required forethought if they
were to be used in the field. Accountability name tags and electronic sign-in databases, for
example, are resources that need to be developed and operationalized prior to an incident if they
are to be used at all.
Planning for incident management is an undertaking that requires the support of an agency’s
leadership, and the cooperation of partnering agencies. For instance, the development of an
electronic sign-in system within your own agency is most valuable when the database holds
information about each responder’s certifications, skills, contact information, and so forth.
Developing such a database and using it during responses requires the buy-in of the entire
agency. Moreover, it is not as valuable if other responding agencies cannot or do not use it, too,
with similarly rich information. The same can be said of most incident management techniques: a
system designed to help various agencies and responders work together is less powerful if just a
handful of those responders actually use and understand it.
The solution to this dilemma is to form Multi-Agency Coordinating Groups, or MAC Groups,
in which several different agencies work together to develop and support the ICS in their area.
MAC Groups meet and train together regularly, and cooperate on the development of regional
interagency protocols to implement ICS. On the federal level, one example of a MAC Group is
the NWCG, which exists to standardize and streamline the federal interagency incident
management of large wildfires. It consists of:
 Bureau of Indian Affairs (U.S. Department of the Interior)
Bureau of Land Management (U.S. Department of the Interior)
Fish and Wildlife Service (U.S. Department of the Interior)
Forest Service (U.S. Department of Agriculture)
International Association of Fire Chiefs
Intertribal Timber Council
National Association of State Foresters
National Park Service (U.S. Department of the Interior)
United States Fire Administration (FEMA)

Fortunately, the federal land management agencies that are a part of the NWCG are well
represented at the state and local levels throughout the country. In many areas, they are primary
responders to wilderness EMS incidents occurring on the lands they control. Likewise,
professional fire departments are typically heavily engaged in ICS implementation. Seeking the
partnerships of those entities that are already invested in incident management to form an
expanded local or regional MAC Group is a way you can make incident management planning a
focus of your response community. The brunt of the work has already been done for you: ICS
itself is an all-hazards interagency system that can be implemented by every agency in the
country “off the shelf.”
The importance of competent incident management to successful wilderness responses
cannot be overstated. While patient care is the core function of any wilderness EMS incident, it
should be delivered through a well-organized operation. Seek to become only as good at ICS as
you believe you should be at taking care of patients.

SUMMARY
As you learned from this chapter, the all-hazards approach of the ICS is the foundation of
wilderness EMS Incident Management—a discipline not unlike wildfire management, which
sparked its development. Once you master traditional ICS doctrine, you can confidently modify
it to fit the unique aspects that wilderness medical calls sometimes feature. Master the ICS, and
you can master the response to any wilderness EMS mission.

References
1. EMSI, Inc. History of ICS. http://www.emsics.com/#!history-of-ics/cj8s. Updated May 16, 2016. Accessed May 16, 2016.
2. National Park Service. National Park Service Reference Manual 55- Incident Management Program.
http://www.nps.gov/policy and https://www.nps.gov/policy/rm55manual.pdf. Updated June 1, 2007. Accessed May 16,
2016.
3. U.S. Department of Homeland Security. Homeland Security Presidential Directive-5.
https://www.dhs.gov/publication/homeland-security-presidential-directive-5. Updated August 10, 2015. Accessed October
29, 2016.
4. “IS-200.b - ICS for Single Resources and Initial Action Incidents.” Course Summary.
https://emilms.fema.gov/IS200b/ICS01summary.htm. Accessed August 30, 2016.
5. Sandmeyer J, Heightman AJ. Lifeguards perform multiple patient rescues and removals. JEMS. 2016.
6. Department of Defense Education Activity. “Hotwash: Clean Up and Cool Down After An Exercise.” Safe Schools
Newsletter XI. March 2011: 3. Print.
7. Koester RJ. Incident command system field operations guide for search and rescue, Vol III. Charlottesville, VA: dbS
Productions, 2014.
INTRODUCTION
In 2009, the American Board of Medical Specialties (ABMS) recognized emergency medical
services (EMS) as a board-certified subspecialty of emergency medicine.1 This development is
significant as it identifies that EMS is a practice of medicine, which, like all practices of
medicine, is founded in science. Further, the creation of EMS as a boarded subspecialty affirms
that physicians engaging in the practice require specialized training and expertise, and that the
patients who are cared for in the EMS environment have better outcomes when EMS physicians
are involved.
Historically, many programs that are in essence providing wilderness EMS (WEMS) services
have functioned without physician medical director oversight. In fact, many of these programs
have often argued that they are indeed not providing EMS care and, thus, should not be required
to have physician oversight. Yet, if a formal response team is providing emergency medical care
in the wilderness environment, they should be considered a WEMS program that structurally
looks the same as their traditional counterpart in the health care system. For the sake of this
chapter, we will consider within the definition of a WEMS program any response team or agency
that is trained, equipped, and advertising itself to be able to provide patient care at any level in
the wilderness including search and rescue (SAR) teams, ski patrols, wildland fire response units,
lifeguards, swiftwater rescue units, and all programs that provide EMS care in the wilderness
environment.
This chapter will focus on the role and relationship of a physician medical director to the
leadership and providers with a WEMS program.

WILDERNESS EMS IN THE CONTEXT OF OPERATIONAL

EMS PROGRAMS
As one considers the role of physicians in providing medical oversight of WEMS programs, it is
perhaps first necessary to provide a working definition of EMS. The medical directors council
with the National Association of State EMS Officials (NASEMSO) defines EMS as an
“integrated system of medical response” that “includes the full spectrum of response from
recognition of the emergency to access of the healthcare system, dispatch of an appropriate
response, pre-arrival instructions, direct patient care by trained personnel, and appropriate
transport or disposition.”2 Further, the council believes that “anyone participating in any
component of this response system is practicing EMS.”3
The question of the boundary between first aid and EMS often arises with volunteer SAR
programs as well as ski patrols and other wilderness rescue agencies. The leadership of many of
these programs will consider that the care provided is considered first aid and not EMS and, thus,
is not subject to state regulations. Yet, EMS is not defined by the actions performed, but more so
by a duty to act by the providers involved and the level of assessment of the patient that is
performed by the provider.
Further, the statement by NASEMSO identifies that the location of the incident is not
relevant to the definition of EMS, and, thus, a program may be considered to be engaging in
EMS services regardless of the austereness of the environment. Indeed, as pathophysiology of
disease typically knows no boundaries, patients should receive similar standards of care
regardless of the environment, understanding, and of course, the resource limitations that may be
imposed by some environments.
Understanding that there are environmental differences between traditional EMS and
WEMS, it is important to recognize that there may be a need for differences in system design and
oversight. In recognition of this need, while also promoting the importance of the role of medical
oversight in maintaining a high standard of care, the National Association of EMS Physicians
(NAEMSP) in partnership with NASEMSO published a position statement on medical direction
for operational EMS programs.3 This position addresses the role of physicians in all operational
EMS environments, which includes WEMS, ski patrols, lifeguard programs, urban and
wilderness SAR, and tactical law enforcement.
The NAEMSP/NASEMSO position on operational EMS programs identifies that the
providers who work in these environments require specialized skills, and, thus, should also
require specialized medical direction.3 Further, and most importantly, NAEMSP and NASEMSO
state that these programs “should function within and not outside the mainstream healthcare
system,” and that providers “regardless of the level of care provided or scope of practice [should]
have a qualified medical director.”3
As health care is regulated at a state level, it is ultimately up to the appropriate regulatory
authority for EMS within the state to determine the amount of oversight that is required for a
WEMS program. Some regulatory authorities will identify the line of necessary regulation at
anything above first aid. Unfortunately, however, there is no clear definition in the EMS
literature defining the threshold at which medical care exceeds first aid. Note that the
International Liaison Committee on Resuscitation did publish a consensus definition of first aid,
along with care types defined as first aid for various conditions, in 2010 and revised it in 2015.13
This may begin to influence EMS definitions in the future. In the meantime, in alignment with
the definition of EMS published by NASEMSO and the position on medical oversight published
by NAEMSP/NASEMSO, it seems most appropriate to define EMS as anything that involves an
organized response with providers who have a defined duty to act. This was also the conclusion
of a Delphi-developed consensus position statement from WEMS educators, regulators, and
clinicians, who concluded that WEMS providers having a defined duty to act should be
functioning with medical oversight.14 Finally, since EMS is by definition a practice of medicine,
as identified by ABMS, any provision of medical care provided in the EMS environment should
involve the oversight of a physician medical director.
As physicians work toward integration of oversight into an existing team it seems relevant to
explain the purpose. Physicians know too well that medicine is challenging and complex. The
physician who believes that mistakes are not possible is dangerous, as all physicians make errors
during medical decision-making. But quality and safely delivered patient care is founded on the
principle that we should learn from mistakes. Continuous analysis and study of care provided is
the cornerstone to safe patient care. The idea that we need to always be critical and reflect on our
care so that we can learn from our triumphs and errors for the improvement of patient care is
essential. Ultimately, this is the purpose for recognizing that WEMS is a practice of medicine
that requires physician oversight. The ultimate purpose of the physician medical director for a
WEMS program is to focus on patient care and provide the structure for continuous review and
improvement of the care delivered by the team.
As medicine becomes increasingly complex with specialties and subspecialties, it is relevant
to realize that WEMS is its own unique practice requiring specialized training. Ideally, medical
directors of WEMS programs will be board certified in EMS, with additional training in the
specific operational environment of the wilderness. However, it is important to recognize the
reality that there are far fewer physicians with the ideal training background than the numbers of
SAR teams, ski patrols, and other WEMS programs.
Regarding the medical component to the medical director’s qualifications, at a minimum the
medical director should be licensed in the primary state of the team, maintain board certification
in an ABMS specialty, have a working knowledge in the management of emergent diseases, and
should complete EMS medical director training. More ideal is board certification in emergency
medicine or another specialty that reflects the broad spectrum of EMS patients and their acute
presentation. Furthermore, although fellowship or board certification in EMS is most ideal, many
otherwise qualified physicians working with SAR teams and ski patrols will not have this
background. As an alternative, NAEMSP and the Wilderness Medical Society (WMS) endorse a
16-hour course that covers the basics of medical oversight for WEMS programs.6 With a core
content developed by a Delphi technique from WEMS experts,7 the curriculum is flexible to
meet the backgrounds of the students for a given class. NAEMSP also offers a 3-day medical
director’s course more focused on urban EMS, and an online version that covers the
fundamentals of medical oversight.
Regarding the operational qualifications, EMS program medical directors need to be able to
safely operate in the given environment so as to be an integrated member of the team with the
providers under their supervision. For WEMS programs, this translates to the physician needing
to complete SAR team qualifications, ski patrol training, or any other operational training
requirements as all other members of the team. Working in the environment safely with the
providers gives the physician perspective that is critical when hard decisions regarding patient
care need to be made.
Ultimately, the physician and providers need to have a working relationship to accomplish
the task of providing quality patient care. This relationship has formal structure that will often
evolve into a less formal process. Formally, EMS providers, like all health care providers, have a
defined scope of practice, which defines the level of care that the provider is allowed to provide
to the patient. As defined by the National EMS Scope of Practice document all EMS providers,
regardless of the level of care or the operational environment, have a scope of practice that is
defined by four intersecting pillars—Education, Certification, Licensure, and Credentialing.8
WEMS providers typically receive education in both wilderness medicine and traditional
EMS. Although there is currently no national standard for WEMS training curriculum, there are
programs that are nationally recognized. Further, the NAEMSP WEMS Committee is currently
leading a project to develop Delphi-driven consensus regarding training for various levels of
WMS providers. Similarly, proposed standards for some wilderness medical certifications have
been published by subject matter experts in magazines,9 in the form of minimum curriculum
standards rather than total operational scope of practice,10 and speculation as to whether an
industry standard existed,11 the answer to which, at least for WFA in this particular 2009
analysis, was “no.” The American Society for Testing and Materials (ASTM) published
minimum training standards12 and scope of practice standards13 for Wilderness First Responders
(WFR) which have been updated as recently as 2013 and 2016, respectively. However, ASTM
standards are rarely utilized in traditional medical care, and these standards have not seen
widespread acceptance or use in the EMS or wilderness medicine community. An important new
contribution to this question of standards is a recent consensus document describing “proposed
scopes of practice of wilderness EMS providers”; however, it is so recent as of this chapter
writing that its ultimate impact on WEMS remains to be seen.14 As there are currently no
universally recognized national standards dictating full scope of practice, many states require, in
addition to focused wilderness medical training, state-recognized training in one of the levels of
EMS.
While completion of education is necessary, it is the certification that the provider is
competent in the skills taught in the educational program that allows the provider to complete the
next two steps of scope of practice. While most educational programs certify the student’s
competency in the form of a final exam, the National Registry of EMTs (NREMT) provides a
national level of certification for EMS providers. Unfortunately, however, the NREMT does not
currently certify competency of training completed by any of the nationally recognized programs
that teach wilderness medical skills.
Although some states do license EMS providers, many do not, requiring the EMS provider to
gain licensure through the physician. Even in states where EMS providers are licensed, the
licensure is not independent, again requiring linkage of the EMS provider to a physician.
Finally, similar to physician credentialing in the hospital setting, it is the final step of
credentialing of the provider by the physician that affords the provider the ability to take care of
patients. Thus, EMS providers require partnership in a formal process with a medical director in
order to be able to legally take care of patients.
In addition to the formal mechanisms for linking providers to physicians, most programs
develop informal processes by which the medical director works with the providers. Ultimately,
the relationship is founded on trust and teamwork. The more the medical director operates on a
regular basis in the field with the providers, the more likely trust will be developed and direction
for patient care will be followed.
Yet, a major barrier and challenge for WEMS programs is the fact that the state regulatory
authority has the ultimate decision-making power to allow the provider to operate. In addition,
most state regulators do not understand the WEMS operational environment, necessitating the
team medical director to develop a relationship with the state regulator so that they can advocate
for the needs of the team, while also ensuring that the goals of the regulator toward delivery of
safe care to the public are met.
INDIRECT MEDICAL OVERSIGHT
EMS medical directors accomplish the goals of medical oversight through two main mechanisms
—indirect oversight and direct oversight. While direct oversight involves direct patient care that
is administered real time, indirect oversight includes all the activities of the medical director that
do not occur real time during administration of patient care.
There are three main components to the task of indirect oversight—education, quality
improvement (QI), and protocol development. These activities should continuously be in
evolution, and should feed upon each other in a looped process.
Perhaps the easiest way for physicians to get involved with a program is to offer and
participate in the initial and continuing education of the providers. Providers typically enjoy the
experience when a physician provides medical training, and this helps to develop relationships
between the physician and providers.
Like all health care providers, WEMS providers need initial and maintenance education.
Although an outside group will typically administer initial education, most ski patrols offer in-
house initial education. Physicians can often provide guest lectures and assist with skills training.
The medical director’s primary focus on educating the team will be in providing monthly and
annual continuing education. Topics covered should focus on the operational needs of the team,
which should consider the operating environment, typical patient encounters, and lessons learned
through the second phase of indirect oversight—QI.
Traditionally termed quality assurance (QA) to describe the process of medical oversight
reviewing patient care and providing remedial education, the term QI connotes a philosophy that
all providers need to be engaged in continuous improvement. Rather than looking for an excuse
to reprimand a provider as often results from QA activities, the medical director should be
reviewing care to identify the successes and cases where care could have been better. The
medical director should then ensure that successes are celebrated with lessons learned from the
review of high quality care reinforced, and cases where care could be better reviewed in the tone
of education as connoted by the process of QI.
While patient care review is the cornerstone of QI activities, the medical director’s jobs in QI
extend far beyond patient care review. Other tasks include relationship building, development of
team medical kits and decision-making regarding equipment, and leadership of the medical
aspects of team program development.
Regarding developing relationships, the medical director should be the bridge between the
team and other health care entities and persons. Seamless integration between the WEMS
program and traditional EMS programs is essential. As many SAR teams operate under the
jurisdictional authority of law enforcement, the medical director may desire to develop
relationships with law enforcement and local tactical EMS programs. Relationships with regional
air medical transport and hospitals may also be of benefit. Interagency relationships and care
transfer considerations in WEMS are discussed in more detail in Chapter 6.
The third component of indirect oversight is protocol development. EMS is a delegated
practice of medicine, which, on a regular basis, is administered in the form of written protocols.
Understanding that the science of EMS is limited and in its infancy, the science of WEMS is
even more limited. Yet, as much as possible, protocols should be founded in science and should
be evidence based. In addition, protocols should take into account the operational needs of the
environment and the resources available.
 There are many methods for organizing and formatting protocols. Typically a set of
protocols will include general patient care and operational directions, resuscitation topics
including airway management, respiratory support and cardiopulmonary resuscitation, as well as
traumatic and medical emergencies. Protocols for WEMS programs may want to put special
emphasis toward environmental emergencies and some programs may want to focus on
pediatrics or geriatrics. Depending on the needs of the program, there may be value in having a
detailed protocol book that serves as a reference and a pocket version that is user friendly for
real-time patient care in the field.

DIRECT MEDICAL OVERSIGHT

As the term implies, direct medical oversight involves the physician medical director providing
direct patient care. This may come in the form of communication via phone/radio or it may
involve the physician being physically present in the field with the providers.
Ultimately, the purpose of direct oversight is to provide a method for physician-level
decision-making in real time during patient care. It is worthwhile to note that the more a program
puts energy into building robust indirect oversight programs with education and well-developed
protocols, the less often direct oversight will be needed. Yet there are times that the clinical
situation is so complex or the circumstances are so far from the education of the provider and the
scope of protocols that physician level of care is needed to ensure the delivery of quality patient
care. It is during these times that programs should rely on direct oversight.
The medical director, or associate medical director designee(s), is ideally available at all
times during an emergency response. This may or may not be possible but should be considered
a goal of any medical direction program. Direct presence of the physician in the field with the
providers is ideal as it allows the medical director to see the scenario and interact directly with
the patient. Of course, this means that the physician is a fully operational member of the response
team, and that the medical director has the time to respond in the field during an event.
When direct medical oversight is needed, and the physician is not able to respond to the
field, there should be a mechanism for direct communication between the providers in the field
and the on-call physician. As communication in the wilderness environment can at times be
sparse, it is possible to relay information through base station communications at the base of
operations for the incident. Although physicians do not need to be communication experts, they
should have a working knowledge of radio use in the wilderness and rescue setting.
Real-time communication between the medical director and providers should be succinct and
purposeful. It is best to use a standardized script for communication. The providers should begin
with the reason for the consultation and then fill out the details. See Table 4.1 for an example of
the information needed in a medical consult.

IMPLICATIONS FOR PRACTICE LEVELS

Scopes of Practice
The National EMS Scope of Practice document defines four levels of EMS providers—
Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), Advanced EMT
(A-EMT), and Paramedic.8 The document defines the fund of knowledge for each level of
provider, and the skills that the provider may perform. Understanding that the operational
environment of WEMS is quite a bit different than the operational environment of traditional
EMS, there are programs that teach skills needed for the wilderness environment.
The National Ski Patrol’s Outdoor Emergency Care (OEC) program falls between EMR and
EMT and includes focused training for the wilderness environment.15 Also focused on WEMS
skills are programs that teach WFR and wilderness EMT. Yet, since most states do not recognize
OEC or WFR, the scope of practice for the wilderness provider typically includes traditional
EMS certification plus additional training in wilderness medical skills.

Table 4.1 Medical Consult Template

Wilderness EMS Provider Identify your name and position
Responding unit or field team name
Highest level of wilderness EMS provider at the scene with the patient
Reason for consultation
Very brief history of patient presentation
Patient’s primary complaint
Any instability with “ABCD”
Patient vital signs—heart rate, respiratory rate, oxygen saturation if available, blood pressure if
available, GSC or AVPU scale, glucose level if available
Actions taken thus far and other pertinent providers at scene if present
Thoughts on what to do next
Direct question to the physician
Medical Director Identify your name and position
Confirmation of situation/primary complaint/vitals
Provide succinct and direct orders
Wilderness EMS Provider Confirmation of the orders
Medical Director Direct question to provider if there are other questions or concerns

EMS, emergency medical services; GSC, Glasgow coma scale; AVPU, alert, verbal, painful, unresponsive; ABCD, airway,
breathing, circulation, disability.

As noted earlier, a recent consensus document developed by WEMS educators, regulators,

and clinicians has proposed scopes of practice for all levels of WEMS providers using Delphi
methodology.14

First Aid
Often considered the entry level into wilderness medicine, wilderness first aid programs are
designed for the lay public that may come across someone needing help while enjoying
wilderness activities. The level of care provided at a first aid level is not recognized by most
EMS systems, and therefore does not require medical oversight. However, the line between first
aid for the lay responder and care that reaches a threshold to be considered above first aid is
ambiguous. As the difference between lay responder first aid and EMS care is not clear, SAR
teams need to be careful in the level of care provided to patients in the wilderness if SAR team
members are only certified to the first aid level and they are not functioning with medical
oversight. Providing care that is above first aid without integration into the EMS system and
without medical oversight is dangerous as it lacks routine patient care review, and places the
program at risk of violating strict state regulations. Chapter 2 includes more information about
wilderness medical training and certification opportunities at the first aid level.
Basic Life Support
The cornerstone of most WEMS programs, basic life support (BLS) providers, includes those
with EMR and EMT certifications with wilderness foci. These individuals provide emergency
stabilization of sick and injured patients, with EMTs having more focused education on anatomy
and pathophysiology of disease than the providers at the EMR level. Within the structure of the
National EMS Scope of Practice Document, another difference between providers at EMR
compared to EMT is that EMTs are allowed to transport patients whereas providers who are
EMR are required to stabilize and wait for transport.8 However, this difference assumes that the
means of transport is an ambulance, as would be the case with traditional EMS. As transport in
the WEMS environment is often by foot, and the highest medical training available may be at the
level of wilderness EMR (WEMR), teams will need to authorize transport by alternate means for
those that are trained to the level of WEMR.
Although BLS providers typically are not authorized to administer medications, in some
states wilderness BLS providers may be allowed to assist with self-administration of a patient’s
own medications and may be able to provide lifesaving medications such as epinephrine for
anaphylaxis and aspirin for suspected acute myocardial infarction.
Historically, many SAR teams, ski patrols, and other programs that we now consider a
WEMS program have provided BLS level of care on their own without physician medical
director oversight and without integration into the overall EMS system.13 Physicians who begin
working with these teams should be sensitive to the culture shock that may occur to the team as
structure and oversight is added to patient care activities. Physicians should anticipate pushback
from some members of these teams who will view the regulatory environment of EMS as
threatening. The physician should be prepared to explain why oversight is beneficial to the team
in terms of elevating quality of care, giving the team members avenues for additional education
and skills, and protecting the team from liability exposure.
Teams that are only providing BLS level of care may argue that physician oversight is not
needed, as it is only BLS care. The physician should point out that BLS providers especially
need oversight due to probable low patient volume that translates to less experience with patient
assessment. The patient who is obviously unstable should not be a challenge for the BLS
provider, as they will know what to do to stabilize the patient with their skill set. It is the patient
who does not look obviously sick, but is sick, that may be difficult. All patient care in the
wilderness begins with patient assessment and the more experienced the provider, the higher
level and more accurate the patient assessment. Physician-directed routine patient care review
followed by focused education elevates the care of the BLS provider by most importantly filling
in the gaps in the skills of patient assessment. In addition, the argument has been made that many
of the most significant innovations in EMS of the last decade, including team-based
cardiopulmonary resuscitation and the reduction or elimination of long spine board application in
trauma care, are directed at BLS rather than advanced life support (ALS) care.15–17
Regarding the process of routine patient care review, most BLS level teams will not have
experience in patient charting. Completion of standardized patient care records is necessary for
the physician to be able to review the patient care of the WEMS providers. Although most ski
patrols complete a standardized patient encounter form, the form used by most volunteer patrols,
which is generated by the National Ski Areas Association, does not include adequate patient care
information as these forms are designed for liability protection of the ski hill and not facilitation
of patient care.
In order to overcome the barrier of BLS providers historically not completing patient care
charts, the physician will need to dedicate training time to the process of patient charting. The
chart should include a section for documenting vital signs, physical findings, and important
historical points; and should include a section for narrative. Understanding that field
documentation will be on a paper chart, there may be value to requiring completion of an
electronic chart when the providers are at base. The physician may also elect (or may be
required) to ensure that team documentation is compatible and downloaded into the local or state
EMS database.

Advanced Life Support

Within the framework of the National EMS Scope of Practice document, ALS providers are
those who operate with the scope of practice of A-EMT and Paramedic. Most ALS providers
working with WEMS programs will have previous experience working in traditional EMS. This
increases their patient contact time and gives them strong operational awareness of the linkage
between WEMS and the rest of the EMS system.
When performing their duties as traditional EMS providers, they will typically have access to
cardiac monitors, and access to a myriad of supplies and equipment. Some providers with
experience in air or critical care transport will have functioned in a virtual mobile intensive care
unit managing patients with balloon pumps and interventricular drains. Yet since the WEMS
provider has to transport all their own equipment along with their own personal survival and
operational gear, the provider will often not have access to cardiac monitors, ultrasound
machines, or other advanced EMS diagnostic or therapeutic devices. This limitation may be
challenging for some providers, and liberating for others. The physician medical director should
work with the ALS providers to show them that their skills in patient assessment are needed, and
that creativity in patient care without the bells and whistles of the equipment of traditional EMS
will help their overall patient care skills.
On the other hand, advanced EMS modalities like defibrillators, monitors, and
ultrasonography are increasingly becoming more miniaturized, more portable, and more
ruggedized. Medical directors therefore also become an important gateway to introducing
technology like this into a wilderness environment. In such work, a balance must be cast between
patient benefit and the burden on the operation to support such equipment, including financially
and physically.
Ultimately, there are dual traps with technology of this sort. There is a danger of assuming
that such equipment will never be available and missing opportunities that become available that
could be helpful in patient care and outcome. Alternately, there is an unfortunate tradition in
EMS of blindly introducing technologies into new environments without first adequately
studying their impact on patient outcome and operations.12 The medical director must balance
these considerations when evaluating technological innovations available for wilderness
environments and providers.
There are times when creativity is truly needed in the management of patients in the
wilderness environment. Patients with dislocated joints may need reduction in order to facilitate
extrication, patients with prolonged extrication time may need administration of antibiotics for
treatment or prophylaxis of infections, and providers may need to address nutrition and hydration
on a level not typical for traditional EMS environments. In all of these situations, the provider
may need to provide a level of care or perform a skill that is outside of the norm for traditional
EMS.
Providers and medical directors have often referred to this situation as an expanded scope of
practice. Yet it is perhaps more accurate to use the term “operationally specific scope of
practice.” The providers are not expanding their scope beyond what is authorized, but rather
using skills and techniques that are specific to the operational environment. Although these skills
may be outside of the norm of traditional EMS, it is still important to note that while the skills
may be important for the care of patients in the wilderness, the provider nonetheless needs
approval to perform these skills by a local medical director and the EMS regulatory authority.
Perhaps most importantly, the medical director must ensure that the providers are adequately
trained to perform the skill and understand when the skill is needed and when it should be
deferred.
Another element of WEMS compared to traditional EMS from the perspective of the ALS
provider is in the use of medications. With traditional EMS, medications are typically
administered via the intravenous (IV) route. While this may make sense for the traditional EMS
environment, it may make less sense for the WEMS environment. Establishing and maintaining
IV lines can be difficult in the wilderness environment. In the wilderness, IV lines may pull out
more easily due to extreme patient movements, the lines may crack and break due to temperature
extremes, fluids from IV bags may not flow well due to movement through the wilderness, and
there may be higher risks of needle stick injuries due to environmental complications. Protocols
should address the circumstances of the practice environment in this sense. Many systems choose
to preferentially administer medication via the oral and intranasal route.
In terms of medication choice itself, medical directors should consider intranasal fentanyl for
management of moderate to severe pain: It is easily administered, well tolerated, has a short
duration of action, making it easily titrated, and has minimal effect on blood pressure. As
discussed in multiple other chapters, ketamine is also increasingly being used for pain control, as
well as a behavioral medicine intervention, in wilderness settings. Nausea can be well controlled
with ondansetron ODT, and hydration should be able to be managed with an oral
electrolyte/sugar solution. When parenteral medications are necessary, teams should consider the
use of intraosseous lines as they are easily placed without needing to locate a vein and easy to
maintain once they are well secured. See Chapter 11 for a more complete discussion of WEMS
pharmacology.

Clinician
The physician level is the archetypal example of a wilderness clinician. While there is real value
to having multiple physicians involved in a WEMS program, it is important that these physicians
understand that they are indeed operating within the structure of EMS and not practicing
independent medicine. The WEMS program should have a single identified medical director who
can then appoint associate1 medical director(s) as deemed necessary. These associate medical
director(s) should then function under the guidance and given parameters of the medical director.
Although it may seem restrictive for physicians to be functioning under the direction of a
lead medical director, there are, nevertheless, important roles that associate medical directors can
fill in the operations of the WEMS team. Perhaps the most obvious role for an associate medical
director is assisting, and even taking leadership, of the continuing education of the WEMS
providers. As the term implies, medical education for EMS providers should be a continuous
activity. Developing and running quality education programs is a lot of work and a great role for
an associate medical director, as this will off-load work from the medical director and ensure that
the job gets done.
The other important role for an associate medical director is filling out the on-call roster for
direct medical oversight and field response. All physicians involved with the team should be
qualified for field response and available on a rotating basis. The more physicians that are
involved with a team, the less that each physician needs to be available for on-call
responsibilities, as ideally a team has a physician available at all times.
It is worth noting that there may also be a role for physician assistants (PAs) and advanced
practice registered nurses (APRNs) on a wilderness team. Ideally these individuals should be
able to fill similar roles as associate medical directors with education and response leadership.
Team leadership needs to research state regulations regarding PAs and nurse practitioners. While
some states specifically allow PAs and APRNs to operate under those licenses within the EMS
system, other states are silent, and some explicitly state that PAs and nurse practitioners are not
allowed to function in the EMS system as anything other than an EMS provider with traditional
EMS certifications.

PROGRAM ORGANIZATION/RESPONSE INCIDENT

COMMAND SYSTEM CHART
One of the challenges that the medical director should define early in their relationship with a
team is their role and function within the organizational structure of the team. Since medical
directors have multiple roles, it is helpful to define these via an organizational chart. Roles that
the medical director will typically fill are the following:

Content matter expert for the team president or chief

Team physician for force protection and health readiness
Liaison between the team and the public health/EMS/public safety system
Liaison between the team and area hospitals
Leadership of medical education for the team
WEMS protocol development
Direct supervision of WEMS providers during actual patient care
Oversight of patient care review and the QI program

Similar to defining the role of the physician in the organizational structure of the team, the
physician needs to define their role within the incident command system (ICS) for a given
response period. Although ICS traditionally teaches that an individual is only allowed to fill one
role in an ICS chart for a given operational period, in reality, the medical director may often fill
multiple roles: content matter expert, oversight of direct patient care, and force protection. The
medical director needs to be able to understand how to wear multiple hats without conflict and
the medical director needs to be able to clearly articulate to ICS leadership the importance of
their filling multiple roles during the operation, so long as their ability to effectively perform
those various roles is not compromised. In addition, the medical director needs to understand that
their expertise and role revolves around patient care. As there are many complexities and
elements to wilderness rescue, the medical director is not the appropriate person to be filling the
role of incident commander or operations chief unless they have other qualifications to do so.
FIGURE 4.1. Role of the medical director in relationship to the rest of response leadership.

See Figure 4.1 for an example of an operational chart identifying the role of the medical
director in relationship to the response.
Chapter 3 includes more information on ICS systems and their implementation in WEMS
operations.

SUMMARY
With increasing use of wilderness areas by people of all ages, there is an increasing chance for a
need to provide medical care in these environments. No longer is it acceptable to operate with the
attitude that some medical care, no matter how flawed, is better than no medical care. Further, it
is similarly not appropriate for volunteer wilderness response programs to argue that they are
exempt from oversight due to challenges in getting volunteers to commit to education and the
processes of oversight, the idea they should be covered by Good Samaritan laws, or the claim
that they are not providing EMS services and only providing “first aid” while waiting for an
EMS response. The public rightly expects that medical care provided by trained rescuers will
meet a certain standard and by definition care that is delivered to the public by a response agency
meets the definition of EMS, regardless of the environment or the level of the provider.
Ultimately, the purpose of physician oversight of a WEMS program is to ensure that the
providers deliver a high quality of patient care that is founded on the principle of continuous
learning and improvement. Regardless of the level of care provided or the scope of practice of
the providers, all individuals providing medical care in the wilderness, within the structure of a
formal response, should have their activities integrated into the traditional health care system.
Within the context of understanding the role of medical oversight for most wilderness
response programs, it is important to understand that it is not possible to accurately delineate first
aid from higher levels of care, and that such delineation that does exist differs in various regions
based on state legislation, cultural and historical patterns, and local practice. Further, it is also
important to understand that patient assessment, which is performed by all providers that engage
with a potential patient, is the cornerstone to the delivery of high quality care. When a member of
a SAR team or ski patrol determines that the individual does not need medical care, they are
engaging in patient assessment and determining that the patient is not sick. Yet it is possible that
this assessment is inaccurate and the patient is in fact sick. Integration of the care provided,
including the fundamental engagement in patient assessment, into a formalized structure of
continuous QI ensures that the providers learn from triumphs and mistakes, and minimizes the
chance for error in the next patient encounter.
Physicians engaged in WEMS medical oversight should be appropriately trained and
prepared for the position. While board certification in EMS is ideal, at a minimum the physician
should have knowledge in the management of emergent diseases and some training in EMS
system management. In addition, the physician should be trained and recognized by the response
team as a fully integrated team member able to safely deploy into the field. The physician should
be prepared to provide leadership for both indirect and direct oversight—helping with protocol
development, running the continuing education program, supervising the QI program, and
providing direct patient care by phone, radio, or in the field when needed.

References
1. American Board of Emergency Medicine. EMS–overview. https://abem.org/public/subspecialty-certification/emergency-
medical-services/ems-overview. Accessed May 13, 2016.
2. National Association of State EMS Officials–Medical Directors Council. The definition of EMS. 2012.
3. National Association of EMS Physicians and the National Association of State EMS Officials. Medical direction for
operational emergency medical services programs. Prehosp Emerg Care. 2010;14(4):544.
4. Singletary EM, Zideman DA, De Buck EDJ, et al; on behalf of the First Aid Chapter Collaborators. Part 9: first aid: 2015
International Consensus on First Aid Science With Treatment Recommendations. Circulation. 2015;132(suppl 1):S269–
S311.
5. Millin M, Johnson D, Schimelpfenig T, et al; medical oversight, educational core content, and proposed scopes of practice
of wilderness EMS providers: a joint project developed by wilderness EMS educators, medical directors, and regulators
using a Delphi Approach. Prehosp Emerg Care 2017. Published online June 28, 2017. [epub ahead of print].
6. Wilderness EMS medical director course. Available at http://wemsmdcourse.com. Accessed May 18, 2016.
7. Millin MG, Hawkins S, Demond A, et al; representing the Wilderness EMS Committee of the NAEMSP. Wilderness
emergency medical services medical director course: core content developed with delphi technique. Wilderness Environ
Med. 2015;26:256-260.
8. National Highway Transportation Administration. National EMS Scope of Practice Model. Washington, DC: Department of
Transportation; 2007.
9. Weil C, Schimelpfenig T. Wilderness First Responder (WFR) Scope of Practice (SOP). Wilderness Medicine Magazine.
March 29, 2016. http://www.wms.org/magazine/1176/WFR-Scope-Of-Practive. Accessed October 28, 2016.
10. Lindsey L, Aughton B, Doherty N, et al; representing the Wilderness Medical Society Curriculum Committee. Wilderness
First Responder: recommended minimum course topics. Wilderness Environ Med. 1999;10:13-19.
11. Welch TR, Clement K, Berman D. Wilderness First Aid: is there an “industry standard.” Wilderness Environ Med.
2009;20(2):113-117.
12. Gates S, Quinn T, Deakin CD, et al. Mechanical chest compression for out of hospital cardiac arrest: systematic review and
meta-analysis. Resuscitation. 2015;94:91-97.
13. Hawkins SC. The relationship between ski patrols and emergency medical services systems. Wilderness Environ Med.
2012;23(2):106-111.
14. Constance BB, Auerbach PS, Johe DH. Prehospital medical care and the national ski patrol: how does Outdoor Emergency
Care compare to traditional EMS training? Wilderness Environ Med. 2012;23(2):177-189.
15. Fowler R, Lehrfeld D. Resuscitation roundtable: five EMS experts offer their views on critical topics. JEMS.
2011;36(12):38-42
16. Hawkins SC. Innovations in BLS. Annual Medical Director. Cullowhee, NC: December 3, 2016.
17. Bukata R. Emergency Medicine Abstracts Podcast, March 2017. Center for Medical Education, 2017.

1For
the purposes of this discussion, “associate” and “assistant” medical directors are used interchangeably.
INTRODUCTION
A state-licensed emergency medical technician (EMT) certified as a wilderness responder
volunteers through the local county sheriff’s office on a search and rescue (SAR) team during the
summer months. One morning, the EMT receives a call from the county sheriff’s office
dispatching the SAR team to rescue a hiker who has fallen off a cliff in a remote area. Before
heading into the field, the EMT thinks through the logistics of the rescue, determines what
supplies the team might need in the field, and thinks about how the team could transport the
hiker from the remote area to a hospital. What the EMT does not think about are personal legal
duties and the potential liabilities associated with the SAR operation.
While wilderness emergency medical services (WEMS) providers need to focus on the
situation during a crisis and not allow legal concerns to cloud their judgment in the field, WEMS
personnel and the organizations under which they operate should become familiar with the legal
risks of helping distressed people in the wilderness before an emergency occurs. Doing so
minimizes the risks of ending up in expensive litigation, dealing with administrative punishment,
or even facing criminal prosecution.
This chapter offers a broad survey of the types of legal liability that could impact WEMS
personnel. Although both the law and public policy encourage WEMS to help those in distress,1
WEMS personnel and their organizations could find themselves embroiled in litigation if they do
not adhere to a basic “reasonable person” standard of care, as well as to federal, state, and local
legal requirements. As such, all WEMS personnel—from volunteer first responders with
minimal medical training, to physician medical directors—should have a basic understanding of
how legal liability could impact their efforts to help those in peril in the wilderness.
This chapter begins with a brief explanation of the U.S. legal structure to familiarize the
reader with the layers of law that apply in each jurisdiction. Next, the chapter describes the
“reasonable person” standard of care, and the practical factors WEMS personnel should consider
in order to adhere to that standard. The chapter then addresses how civil liability might arise in
the WEMS context. After offering an overview of civil litigation procedures and relevant legal
relationships as background, the civil liability section describes the types of civil liability most
likely to come up in the WEMS context: negligence, abandonment, battery, and administrative
liability. The chapter then briefly describes how criminal liability might arise as a result of
particularly egregious conduct by a WEMS provider.
After describing the types of liability that WEMS personnel could encounter, the chapter
explains the statutory protections that most jurisdictions have established to protect people and
organizations from liability. Specifically, the liability protection sections discuss EMS-specific
liability protection laws, liability protection statutes for volunteers, Good Samaritan legislation,
and sovereign immunity statutes that protect government actors, and often government
employees and volunteers as well.
Note that this chapter does not delve into the certification and legal licensing requirements
for WEMS personnel due to the complex and state-specific nature of those requirements. WEMS
personnel, however, should become familiar with the licensing and/or certification requirements
of the state(s) in which they work to ensure they comply with the law. The chapter also refrains
from advising WEMS personnel, or their organizations, on how to mitigate liability risks through
insurance protections, liability releases, or other practical methods, because every WEMS
provider and organization will require a different risk-management strategy. An attorney hired by
a particular WEMS organization can provide the kind of specific risk-management guidance
necessary to address the organization’s unique situation.

OVERVIEW OF THE U.S. LEGAL SYSTEM

The “Law” that applies to WEMS personnel in the United States consists of several layers. At
the highest level, WEMS personnel must follow federal laws. These laws apply to everyone in
the country. The body of federal law has four components:

The Constitution: A founding document with many amendments that provides the
groundwork for the American legal system;
Statutes: Broad laws passed by Congress, the legislative branch of the federal government,
that must comply with the Constitution;
Administrative Regulations: Detailed rules adopted by the executive branch of the federal
government (ie, the President’s administration) designed to help implement statutes; and
Case Law: Legal opinions written by federal appellate court judges that interpret what the
Constitution, statutes, and administrative regulations mean, as well as describe the judge-
made form of law called common law. Appellate courts review cases and publish legal
opinions after a judge or jury in a trial court (the courts with which most people are most
familiar) renders a decision in a case.

Unless specific provisions state otherwise, the Constitution, statutes, and administrative
regulations apply uniformly across the country. Case law written by the U.S. Supreme Court (the
country’s highest appellate court) also applies to the entire nation. Case law written by the circuit
courts of appeals (the lower appellate courts) only applies in the geographic region, known as a
jurisdiction, governed by the circuit court of appeals that authored the case.
Like federal law, state law consists of constitutions, statutes, administrative regulations, and
case law. State constitutions provide the legal foundation for all other state laws. State
legislatures pass statutes, the governor’s administration implements those statutes through
administrative regulations, and the state appellate courts interpret the constitution, statutes, and
regulations.
Much of the substantive law that applies to WEMS personnel is passed at the state level, and
can accordingly vary widely from state to state. As such, WEMS personnel, and particularly the
leaders of WEMS organizations, should familiarize themselves with the statutes and regulations
governing the state or, in some cases multiple states, in which they provide WEMS services.
WEMS personnel should additionally become familiar with the local laws issued by
counties, municipalities, and other forms of local government. Like Congress and the state
legislatures, local legislative bodies pass ordinances and other types of local laws that may
directly apply to WEMS. Often, local laws will address the unique features of a particular area in
a way that federal and state laws do not. In the WEMS context, local law might explicitly
address conduct in rural wilderness areas with a degree of specificity that does not exist at the
state or federal level.

THE REASONABLE PERSON STANDARD OF CARE

Before thinking about the different kinds of legal liability that may apply in the WEMS context,
WEMS personnel should understand the “reasonable person” standard of care. Articulations of
this standard vary from jurisdiction to jurisdiction, and often depend upon a variety of factors
specific to an individual. Such factors may include a WEMS provider’s level of medical training,
whether the provider carries a particular certification or license, the relevant geographic area,
and/or the type of action taken by the provider that gave rise to the need to define the reasonable
person standard.
Recognizing that the reasonable person standard can manifest in many forms based on the
aforementioned (and other) factors, two general articulations of the reasonable person standard
are worth noting: (i) the standard for a reasonable nonprofessional person and (ii) the standard
for a reasonable professional. When performing a function that does not require a professional
license, certification, or training—such as preparing food for a SAR team or locating a patient in
the wilderness—a WEMS provider should follow the reasonable person standard by acting as a
reasonably prudent person would under the same or similar circumstances.2 When performing
functions that require a professional license, certification, or training—such as providing
medical care—the WEMS provider should follow a professional reasonable person standard by
acting with such care, skill, and diligence as people with the same or similar training would
ordinarily exercise under like circumstances.3
To think about these variations of the reasonable person standard in a practical way, a
WEMS provider might consider: (i) his or her level of training; (ii) the unique facts of a
particular emergency situation; and (iii) how a reasonable person with the same or similar
training would act in the same or similar circumstances.
Consider a hypothetical situation: If a licensed EMT is called into the woods to treat a hiker
with a possible broken arm, the provider should think how a reasonably prudent EMT with the
same or similar training would act when treating a hiker in the woods with a possible broken
arm. Factors to consider during this hypothetical reasonableness analysis include, but are not
limited to:
 The scope of practice permitted under the applicable certification or licensing scheme;
The extent of the patient’s injuries and the type of care that may be needed;
Safety of the WEMS providers, their teams, the patient, and any others involved in the
emergency situation;
The patient’s decision-making capacity and his or her ability to consent to treatment;
The risks of performing a particular procedure;
The scarcity or availability of medical equipment;
The risks of administering care in the particular location;
Lack of access to definitive medical care; and
The risks of different types of evacuation methods.4,5

Of course, factors a WEMS provider may consider during a reasonableness analysis will
vary depending on the context. For example, a WEMS provider might consider the scope of
practice permitted by the particular jurisdiction’s laws governing epinephrine administration
and/or automated external defibrillator (AED) use if the WEMS provider thinks that a given
scenario calls for epinephrine or an AED.
Notwithstanding the specific laws that apply to a particular WEMS provider, complying with
the appropriate reasonable person standard of care can reduce liability risks by preventing a
lawsuit altogether, or by providing a defense if litigation occurs. The reasonable person standard
will also come up throughout the remainder of this chapter as it relates to specific types of legal
liability.

TYPES OF LIABILITY IN THE WEMS CONTEXT

Legal liability comes in many forms and can result in difficult consequences for the liable party.
Fortunately, WEMS personnel can avoid most legal liability by understanding and complying
with the laws that apply in their jurisdiction and by adhering to the appropriate reasonable person
standard of care.
The body of WEMS-specific law is notably limited, likely because WEMS as a discrete field
is still fairly new, and because the incidence of WEMS-related incidents resulting in published
case law and reactive legislation is quite low. Recognizing the dearth of law that directly
addresses WEMS scenarios, the following sections describe different categories of liability that
could apply in the WEMS context, providing real-world examples when possible, and
hypothetical applications when salient case law does not appear to exist. Due to the variability of
state and local laws, the general statements in these sections may not apply in every jurisdiction
or to every WEMS provider. As such, the remainder of this chapter aims to familiarize different
types of WEMS personnel with the legal vocabulary and types of liability that could apply to
them, with the caveat that such applicability will largely depend on the specific laws of the
governing jurisdiction.
The liability sections begin with the most common category of liability seen in the WEMS
context: civil liability. As background, the civil liability section first offers a primer on civil
litigation procedures and discusses how the legal relationships between people and organizations
can impact civil liability. It then describes the rare types of federal civil liability claims that could
come up in the WEMS context, including Constitutional claims under Section 1983 of the U.S.
Code and claims brought under the Federal Tort Claims Act (FTCA). The civil liability section
goes on to describe the more common forms of civil liability that could arise at the state and
local levels: negligence, abandonment, battery, and administrative liability. The final portion of
the liability section briefly describes how criminal liability could come up in the WEMS context.
The near-total absence of criminal law related to WEMS personnel, however, renders the
criminal law section largely speculative; it is also a reassuring statement about the exposure to
the risk of criminal liability experienced to date by WEMS personnel.

Civil Liability—In General

Civil liability is defined as a legal obligation to pay money to a person as compensation for that
person’s loss or injury.6 Civil liability can arise under federal, state, or local law. The most
common type of civil liability that comes up in the WEMS context is tort liability. A person may
be liable in tort if his or her act or failure to act causes someone else to sustain a loss or harm.7
Common torts include trespass, slander, battery, infliction of emotional distress, and—
particularly important to the WEMS context—negligence.
Before turning to the principles of ordinary negligence law, the next subsections provide an
overview of the procedures that make up a civil law suit as well as a brief description of how
legal relationships between WEMS personnel and organizations can influence civil liability.
Familiarity with these procedures and legal relationships will help the reader understand what an
individual WEMS provider, a medical director, or the organization under which an individual
provider operates might have to do if sued in civil court.

Anatomy of a Civil Law Suit

This section briefly describes how a civil law suit progresses through the court system.
Understanding the legal terminology and high-level procedures described below will help the
reader comprehend how the types of civil liability described later come to fruition in practice.
After an unfortunate incident, a person (or the alleged victim’s attorney) who believes he or
she suffered harm as a result of another’s action or omission might contact the alleged defendant
(person or organization whose act or omission allegedly caused the harm) about a pending law
suit. Although a lawsuit has not officially begun, these early communications could offer an
opportunity for settlement (resolution of the case by way of a negotiated agreement outside of
court) that could minimize the alleged defendant’s financial exposure. A WEMS provider, or an
organization under which WEMS personnel operate, can hire an attorney after receiving initial
communications from an alleged victim to determine whether settlement might be a good option
in a given situation.
If early settlement does not occur, or if settlement discussions never begin at all, a civil
lawsuit officially starts when a plaintiff (the alleged victim) files a complaint (document asserting
legal reasons for the suit, known as claims) against the defendant(s) in the appropriate court. The
plaintiff must file the complaint with a court that has the authority to decide the stated legal
claims. For example, if the plaintiff’s claims arise under federal law, the plaintiff should file the
complaint with the federal court located in the geographic area in which the events that gave rise
to the claims occurred. Analogously, if the plaintiff’s claims arise under state law, the plaintiff
will file a complaint in a state court with authority over the relevant geographic area.
After the plaintiff files a complaint in the proper court, the defendant has the opportunity to
file an answer to explain why the defendant should not be liable for the plaintiff’s claims. The
defendant’s reasons why liability should not attach, as presented in the answer, are known as
defenses.
After both parties—the plaintiff and the defendant—have filed their initial documents with
the court, their lawyers will likely file motions, discovery requests, and other procedural
documents aimed simultaneously at (i) resolving the case before trial and (ii) preparing for trial if
pretrial settlement does not occur.
If the case goes to trial, the plaintiff and defendant’s respective attorneys will present
evidence—such as witness testimony, tangible exhibits, photos, maps, etc.—in court to support
their legal arguments. Depending on the case, a trial may occur in front of a jury (as often seen
on television dramas) or in front of only a judge. The plaintiff’s attorney will present the
plaintiff’s case first, then the defendant’s attorney will present the defendant’s side of the story.
After each side has had an opportunity to present its case, the jury or the judge will consider
the law, the facts, and the legal arguments to determine who wins. A plaintiff has the burden to
prove a civil case by a preponderance of the evidence. This burden of proof, also known as the
51% rule, requires the plaintiff to present evidence showing that it is more likely than not that the
plaintiff’s legal arguments are correct in order to win. If the plaintiff wins, the judge or jury will
determine the amount of damages (money ordered to be paid to a person as compensation for
that person’s loss or injury)8 the defendant will have to pay the plaintiff. If the defendant wins,
then the plaintiff does not receive damages.
If the losing party is unsatisfied with the result of the trial, that party may appeal the trial
court’s decision to the appropriate appellate court. The appellate process differs from the trial
process in that appellate courts decide issues of law instead of issues of fact. As such, the
attorneys for the plaintiff and the defendant do not present evidence to the appellate court
through witness testimony or exhibits. Instead, the attorneys file written briefs, then answer
questions from a panel of judges about the case’s legal issues during a hearing known as oral
argument. The appellate court will consider the parties’ briefs and oral arguments, in addition to
the law as applied by the trial court, and will then issue an opinion deciding the legal issues
presented on appeal. Appellate opinions contribute to the body of judge-made law.
If the party that loses on appeal is unsatisfied with the appellate court’s decision, that party
may attempt to appeal the case again, this time to the highest appellate court in the jurisdiction—
often, but not always, called the Supreme Court.* While the lower appellate courts are required
by law to hear every appeal that comes before them, the Supreme Court may elect to review or
not review a case depending on a variety of factors. These factors include, but are not limited to,
whether the case presents a new legal issue, whether the case is particularly important from a
public policy perspective, and whether the case is properly positioned to result in an opinion that
will benefit the body of judge-made law.
If the Supreme Court decides to hear the case, the plaintiff and defendant’s attorneys will file
a second round of appellate briefs and conduct oral arguments before the Supreme Court. The
Supreme Court will consider the legal issues presented and will author a legal opinion ultimately
deciding those issues and often ending the case.
Note that the general procedures described above assume a simple case in which one plaintiff
sues one defendant in a single jurisdiction. In practice, civil litigation is often much messier. For
example, jurisdictional questions could arise if, say, a federal firefighting team from one state is
deployed to fight a fire on state-owned land in another state. In addition, a plaintiff could sue not
only an individual WEMS provider, but also that provider’s employer, medical director, or the
entity for whom the provider volunteers under a theory of respondeat superior (ie, a type of
vicarious liability whereby the supervisor or overseeing organization is liable for the acts of its
employee or volunteer).9 A defendant could also elect to bring its insurance provider into the
case to help reduce the defendant’s potential damages. Various procedural maneuvers by the
parties’ attorneys can complicate a civil lawsuit as well. Understanding the basic anatomy of a
civil lawsuit as described above is important, however, because the procedures and terminology
involved will come up in the following sections discussing the types of civil liability that may
apply in the WEMS context.

Impact of Legal Relationships on Civil Liability

In addition to understanding general civil litigation procedures, the reader should recognize that
the legal relationships between WEMS personnel and the organizations under which they operate
can impact how civil liability might manifest in a given situation. Physician medical directors
may supervise field WEMS personnel; field WEMS personnel may volunteer with, or work as
paid employees for, governmental, nonprofit, and private groups; and WEMS field personnel
could relate to each other as members of a team. These and other relationships become important
when assessing what individuals or organizations might be liable for their own actions or for the
actions of others.
For example, in jurisdictions that require physician medical directors for EMS organizations,
the medical director has a supervisory legal relationship with the field provider.10 This means that
a field provider’s actions will not be considered the action of the medical director per se, but the
medical director could be liable for his or her own conduct while acting in the supervisory role,10
and may still be found responsible or to have shared responsibility for certain actions taken by a
medical field provider. EMS personnel employed by a government agency such as the National
Park Service, or by another government organization—such as a special district, county, or
municipality—are often considered agents of the employing government organization.10 Under
agency law principles, the acts or omissions of an EMS provider could be viewed as acts or
omissions of the employer organization itself.10 An agency relationship can thereby create
vicarious liability for the employer in the event that the employee field provider is found
personally liable under a host of different legal theories.10 Relationships between WEMS field
personnel acting as a team can also impact how civil liability arises, particularly when team
members have different levels of medical training, when one team member acts as a supervisor,
or when the team receives instructions from a remote physician.
WEMS personnel, and particularly WEMS organizations and supervisors, should recognize
the varying relationships between individual and organizational components of their own WEMS
system to fully understand the possible sources of liability that could drag field personnel,
supervisors, and organizations to court.
With these relationships, and the general civil litigation process in mind, the following
section describes the most important type of civil liability to understand in the WEMS context:
negligence.

Ordinary Negligence
The most important legal concept to understand in the WEMS context is negligence. Ordinary
negligence “is conduct which falls below the standard established by law for the protection of
others against unreasonable risk of harm.”11 Negligence law continues to develop over time
through judge-made common law. Although statutes and regulations often refer to negligence,
and expand or limit how the concept may apply in certain situations, case law written by
appellate courts defines the term and explains how its elements apply in practice. As with all law,
the law of negligence varies by jurisdiction. This section addresses the topic generally, but the
reader should consider conducting additional research to better understand how the concept
applies in his or her particular location.
To prove a negligence claim and receive monetary damages from a negligent defendant, a
plaintiff must establish four elements by a preponderance of the evidence. These elements are:

1. Injury: The plaintiff has suffered an injury or other harm;

2. Duty: The defendant owed a duty to the plaintiff to take due care against causing the injury
or harm suffered by the plaintiff (most often, the duty of care equates to the appropriate
reasonable person standard);
3. Breach: The defendant breached an existing duty by either acting carelessly or failing to
act; and
4. Causation: The defendant’s breach actually and proximately caused the plaintiff’s injury or
harm. A breach actually causes harm when the harm would not have occurred but for the
breach. A breach proximately causes harm when the breach is so closely connected to the
resulting harm, and of such significance, that the law is justified in imposing liability on the
actor.12(p197),13

The following hypothetical example demonstrates how an ordinary negligence claim might
be argued in the WEMS context. Imagine that a skier is partially buried in an avalanche and
injures her leg. Her companions call 911 and the local sheriff’s office dispatches a SAR team,
one member of which is a licensed EMT, to help. During the rescue, a member of the SAR team,
upon instructions from the EMT, fails to appropriately stabilize the patient’s leg. The patient
eventually has the leg amputated at the hospital.
The patient sues the EMT for negligence. She argues each of the four elements of the
negligence claim as follows:

1. Injury: The alleged victim suffered severe leg injuries that resulted in amputation;
2. Duty: The EMT owed the plaintiff a professional duty of care by virtue of being a certified
health care provider on a formal SAR team that was formally dispatched to the call;
specifically, the EMT was required to act in a way that an ordinarily prudent EMT with
similar training would act in the same or similar circumstances;
3. Breach: The EMT breached the duty of care by instructing the other team members to treat
the alleged victim’s leg injury in a careless way;
4. Causation: The patient would not have had her leg amputated but for the EMT’s breach of
the professional duty of care, it was reasonably foreseeable that amputation would result
from the EMT’s conduct, and the EMT’s conduct was so closely connected to the
amputation that the EMT’s liability was justified.

Robust bodies of case law interpret each of the four elements of negligence under myriad
sets of facts. In the limited body of WEMS-specific case law, however, the parameters of each
element of negligence have yet to take on consistent forms. For now, the unique facts and
circumstances of each particular case (like the facts presented in the above hypothetical) along
with applicable law limiting negligence liability in the WEMS context (discussed in detail later
in this chapter) will guide how courts apply the four elements of negligence in WEMS scenarios.
As the reader will notice in the sections that follow, the ordinary negligence concept
frequently arises within more specific categories of civil liability that could impact WEMS
personnel.

Federal Civil Liability

Section 1983
Government bodies that provide WEMS services and individual WEMS personnel volunteering
for, or employed by, governmental entities could face federal civil liability under Constitutional
claims brought by an injured plaintiff pursuant to Section 1983 of the U.S. Code (“Section
1983”).14 Section 1983 provides a way, known as a cause of action, for a plaintiff to sue a
defendant who, acting under the authority of state or local law, deprives the plaintiff of his or her
rights under the federal Constitution or federal statute.15 Typically, a plaintiff will file a case in
federal court under Section 1983 against an employee or volunteer working on behalf of a
government entity by alleging that the person acting under the government’s authority deprived
the plaintiff of his or her federal rights.15
Despite their availability, constitutional claims brought under Section 1983 do not appear to
be a major liability concern for WEMS personnel. For example, in the broader EMS context, the
parents of a boy who choked on a grape and died despite receiving care from EMTs employed by
the City of Philadelphia lost their Section 1983 suit.16 The plaintiff’s parents argued that the
EMTs’ negligence violated their son’s rights to life, liberty, personal security, and bodily
integrity without the due process of law guaranteed by the Fourteenth Amendment to the
Constitution.
In deciding the case in favor of the State of Pennsylvania, the City of Philadelphia, and the
individual EMTs who responded to the parents’ call, the Third Circuit Court of Appeals held that
“there is no federal constitutional right to rescue services, competent or otherwise.”16,17
“Moreover,” the Third Circuit reasoned, “because the Due Process Clause does not require the
State to provide rescue services, it follows that [this court] cannot interpret that clause so as to
place an affirmative obligation on the State to provide competent rescue services if it chooses to
provide them.”16
For WEMS purposes, this Third Circuit decision indicates that the federal Constitution does
not require state or local governments, or those personnel who volunteer or receive compensation
from those governments, to provide rescue services in the wilderness. And, even if a state or
local government chose to provide such rescue services, the Constitution does not appear to
require those services to be “competent.” The decision also demonstrates that Section 1983 does
not pose a significant liability threat to WEMS personnel working under the authority of state or
local governments.

The Federal Tort Claims Act

The FTCA gives an injured plaintiff the opportunity to sue the federal government, as well as
employees and volunteers acting on behalf of the federal government, for the negligent acts or
omissions of the government-affiliated defendant(s).18 A plaintiff may file a claim in federal
court under the FTCA if the act or omission of the government-affiliated defendant would
otherwise subject a non-governmental defendant to civil liability under the laws of the state or
locality in which the allegedly offensive conduct occurred.19 A federal court will not hear a claim
under the FTCA, however, if a government-affiliated defendant exercised due care in executing a
federal statute or regulation, or if the government-affiliated defendant was exercising a
“discretionary function” when the allegedly injurious act or omission happened.20
 Although the FTCA provides a theoretically viable avenue for plaintiffs to sue WEMS
personnel in federal court, claims brought under the FTCA against government-affiliated WEMS
personnel have seen little success to date. In Kiehn v. United States, for example, the Tenth
Circuit Court of Appeals held that it did not have the authority to hear a case brought under the
FTCA after a hiker fell off a cliff and was rescued by National Park Service rangers.21 In so
holding, the Tenth Circuit reasoned that the park rangers made a policy decision that qualified as
an exempt “discretionary function” under the FTCA, and therefore the FTCA did not apply,
when the rangers decided how and when to evacuate the injured hiker by helicopter.21
Although both Section 1983 and the FTCA could, in theory, subject WEMS personnel to
federal civil liability, the few WEMS and broader EMS cases that have made it to the federal
appellate court level under Section 1983 and the FTCA demonstrate that WEMS personnel
should not be overly concerned about incurring federal civil liability under these statutes.
Instead, as discussed in the following section, WEMS personnel should focus on the types of
liability they could more likely face under state and local law.

State and Local Civil Liability

Negligence
As discussed previously, negligence “is conduct which falls below the standard established by
law for the protection of others against unreasonable risk of harm,”12 and consists of four
elements: (1) Injury, (2) Duty, (3) Breach, and (4) Causation.
Negligence principals apply to different categories of WEMS organizations and personnel in
different ways. For individual WEMS providers acting in the field, factors such as the person’s
level of training, the scope of the individual’s practice (often determined by local statutes, local
ordinances, and local physician medical oversight), and whether the person carries a professional
license or certification will help define the standard of care, the breaching of which would result
in exposure to negligence liability.
For organizations, negligence liability can arise due to careless policies and poor record
keeping. It can also arise under the theory of vicarious liability on account of the negligent
actions of the individuals acting on behalf of the organization. Individual WEMS administrators
and supervisors, such as county medical directors, may face negligence liability by failing to
comply with the appropriate reasonable person standard while performing administrative or
supervisory duties. Sources of negligence liability that medical directors and other administrators
could face include:

Negligent training of field personnel;

Negligent supervision and retention of field and other personnel;
Negligent management practices regarding controlled substances such as opioid
medications;
Negligent reporting; and
Negligent protocol/policy preparation and execution.10

Due to the individual and context-specific nature of negligence law, understanding how the
reasonable person standard guides a particular WEMS provider’s conduct is crucial when
assessing how to avoid negligence liability. Although little negligence case law exists in the
WEMS context to offer guidance, the following case provides one example of how complying
with the reasonable person standard helped ski patrol members successfully defend themselves
against a plaintiff-victim’s negligence claim.
In Butler, a New York appellate court upheld the trial court’s finding that neither the
defendant ski patrol members, nor their employer ski resort, were liable for negligence after the
ski patrollers helped a skier who injured his shoulder on the slopes.22 Upon promptly responding
to the skier’s call for help, the ski patrol team splinted the skier’s injured shoulder, transported
him down the mountain on a toboggan, then transferred him to an ambulance that arrived at the
hospital about 2 hours after the injury occurred.
The skier sued the ski patrol members, as well as the employer ski resort, under a vicarious
liability theory, alleging that the ski patrollers’ negligence caused the skier to suffer permanent
nerve damage in his arm. The trial court held, and the appellate court affirmed, that the ski
patrollers acted reasonably under the circumstances and therefore neither breached the duty of
care nor caused the plaintiff’s nerve damage.22
Butler demonstrates that compliance with the reasonable person standard of care can protect
WEMS personnel and their organizations from negligence liability. The plaintiff skier in this
case could not prove his negligence claim by a preponderance of the evidence because the ski
patrollers did not breach their duty to act as reasonable ski patrollers with similar training would
act in the same or similar circumstances.

Abandonment
Abandonment in the broader medical context occurs when a professional, like a physician or
paramedic, establishes a provider/patient relationship by beginning to administer care to a
patient, then negligently stops providing care at a time and in a manner that renders the patient
worse off than the patient would have been without the professional’s actions.5
To date, few, if any, cases address abandonment in the WEMS context. This lack of
precedent does not mean, however, that abandonment could not occur in a WEMS-related case.
For example, a hypothetical hiker injures her leg on a backcountry trail. An off-duty paramedic
walking in the area discovers the injured hiker. Although the off-duty paramedic does not have a
provider/patient relationship with the hiker, simply because of licensure as a paramedic, the
paramedic establishes such a relationship when beginning to treat the hiker’s leg injury with the
hiker’s consent. The paramedic then unreasonably concludes that the hiker has a minor ankle
sprain and should be able to walk to a car. The paramedic leaves the injured hiker on her own.
After limping back to her car, the hiker drives to the emergency department and finds out that her
ankle is broken and, because she walked out of the wilderness based on the off-duty paramedic’s
advice, the ankle will require surgery.
The hiker in this hypothetical situation could theoretically claim abandonment because the
off-duty paramedic established a provider/patient relationship with her by beginning to treat her
ankle with consent, then negligently stopped providing care at a time and in a manner that
rendered the hiker worse off than she would have been without the paramedic’s actions.
When determining whether a WEMS provider has impermissibly abandoned a patient, many
factors could weigh in favor of or against the alleged victim’s abandonment case. These factors
may include:

Whether the patient consented to the cessation of treatment;

Whether the patient voluntarily dismissed the provider;
Whether the provider reasonably believed care was no longer required;
 Whether the provider died or became disabled during the course of the rescue;
Whether the provider gave the patient reasonable notice of the provider’s impending
withdrawal and then continued treatment until a new caregiver arrived on scene; and/or
Whether further efforts by the provider would put the provider or the provider’s team in
danger.23

Although abandonment appears to be an unlikely source of liability for WEMS personnel,

considering the factors listed above when deciding to stop administering care in the wilderness
can help ensure compliance with the reasonable person standard, avoid negligence, ensure ethical
standards of treatment, and prevent a possible abandonment case.
One common misperception about abandonment in the WEMS context is that a physician at
the scene of an emergency in the wilderness risks abandonment liability if that physician begins
providing care, then transfers care to EMS personnel. This concern is based on the principle that
a provider may only hand over care to someone of equal or greater training. Because
nonphysician EMS personnel have less training than a physician, the logic behind the concern is
that the physician could face an abandonment claim if he or she transfers care to an EMS team.
Although individual EMS providers typically have less training than physicians, EMS teams
operate under the supervisory authority of a medical director or online medical control. As such,
a physician’s transfer of care to an EMS team directed by a physician constitutes a transfer to a
provider of equivalent credentials. Therefore, an on-site physician (known as an “intervening
physician” in many jurisdictions) should not generally be concerned that transferring care to
EMS personnel will expose the on-site physician to abandonment liability.23 Although literature
from the American College of Emergency Physicians and the American Medical Association
supports this reassurance, physicians should nonetheless refer to state and local EMS laws to
ensure they understand the nature of EMS oversight and care transfer in their specific
jurisdictions.23

Battery
Most people think of criminal law when they hear the term “battery.” Indeed, the American
justice system treats battery as a wrong sufficiently egregious, sufficiently threatening to the
public interest, sufficiently in need of deterrence, and so unreliability handled by the private
sector that the system classifies it as a crime against the public.12(p197) Battery, however, can also
be a tort that can subject the batterer to civil liability.12(p197) The tort of battery occurs when:

1. The defendant performs an act;

2. The defendant performs the act with the intent to cause bodily contact with the plaintiff of a
type that tends to be harmful or offensive; and
3. The defendant’s act to plaintiff causes harmful or offensive contact.12(p197-198)

Few, if any, examples of battery occurring in the WEMS context exist. However, like
abandonment, it is not outside the realm of possibility that a person receiving assistance from a
WEMS provider in the wilderness could sue the provider for handling the patient in a way that
he or she deems offensive.
The most common defense to battery is consent.12(p206) For example, a surgeon with the
patient’s consent to perform abdominal surgery cannot be held liable for battery when the
surgeon cuts into the patient’s body.12(p206) When providing medical treatment in the field that
could harm the patient or that the patient could consider offensive, the WEMS provider
administering such treatment should consider asking for the patient’s consent before performing
the action. Receiving such consent could protect the WEMS provider from a future battery claim.
One of the most common concerns for WEMS providers relative to battery is when a
patient’s capacity to consent is in question. Consider a suicidal patient in the wilderness. Clearly
such a patient should not be allowed to complete the intended suicidal act after WEMS
responders arrive and begin delivering care, nor should the suicidal patient be allowed to remain
in the wilderness and refuse care while stating he or she is actively suicidal. However, some
WEMS providers are concerned they will expose themselves to charges of battery if they restrain
such a patient against the patient’s will—or even touch such a patient—especially since the
normal apparatus of involuntary commitment cannot be completed in a wilderness setting. It is
important, in this context, to realize that a patient who is suicidal by virtue of presumed mental
illness (depression) is not considered capacitated to refuse care.24 Accordingly, prudent,
reasonable, and non-harmful steps needed to restrain the suicidal patient against his or her will
would most likely be seen as reasonable care, rather than battery, in the sense that the patient is
not capacitated to refuse care and an ethical mandate exists to transfer that patient to a health care
facility.

Administrative Liability
In addition to civil liability decided by the court system, WEMS personnel can also face civil
penalties for violating administrative regulations and, sometimes, local ordinances. Recall that
the executive branch of the state government promulgates administrative regulations to help
implement the broader laws contained in statutes. As such, administrative regulations specify
how certain parties should conduct themselves, and the consequences those parties might face by
failing to meet the conduct requirements.
In Colorado, for example, the “Emergency Medical and Trauma Services Act” broadly
regulates various kinds of defined EMS personnel, including those who respond to wilderness
emergencies.25 The statute defines “EMS provider” as a person who holds a valid certificate
issued by the administrative agency known as the Colorado Department of Public Health and the
Environment (CDPHE). The administrative regulations passed by CDPHE to implement that
statute more particularly define categories of EMS personnel, including EMTs, Advanced EMTs,
paramedics, graduate-level EMS personnel, and medical directors, as well as defining their
respective scopes of practice.26 The regulations also delineate how EMS personnel carrying
various credentials can lose their state-issued certifications and/or face other sanctions such as
fines and remedial training obligations by “failing to follow accepted standards of care in the
management of a patient, or in response to a medical emergency.”27
The reader should note that administrative liability generally only applies to regulated actors.
As such, WEMS personnel such as volunteer first responders trained only in wilderness first aid
are not likely to encounter civil administrative liability.

Criminal Liability
Criminal law—codified in statutes and regulations, and interpreted in case law—requires people
to abstain from committing certain actions known as crimes. If a person allegedly commits a
crime, the government will bring charges against the alleged criminal. Like the civil litigation
process, criminal court procedures require lawyers for the government and the alleged criminal
to present evidence supporting or denying criminal charges. If the evidence shows beyond a
reasonable doubt that the defendant has committed a criminal act, then the court will sentence the
convicted criminal to punishment commensurate with the severity of the crime. Criminal
punishments include fines, community service, mandatory attendance at educational programs,
probation, and jail or prison sentences.
The lack of criminal case law in the WEMS context, as well as the public policy favoring
rescue, indicates that field WEMS personnel, as well as their supervisors and organizations, very
rarely, if ever, face criminal liability for actions performed while providing WEMS. If criminal
liability was to arise in the WEMS context, however, it could come in the form of criminal
negligence charges.
Unlike civil negligence, criminal negligence requires that a person fails “to perceive a
substantial and unjustifiable risk that” a particular result or harm “will occur or that such
circumstances exist.”28 The substantial and unjustifiable risk “must be of such nature and degree
that the failure to perceive it constitutes a gross deviation from the standard of care that a
reasonable person would observe in the situation.”28
In practice, this heightened negligence standard could come into play if, for example, a SAR
team leader ordered her team to hike above timberline during an electrical storm even though an
alternative and less-exposed route was obviously available. The substantial risk of lightning
striking the team could qualify as a risk of such nature and degree that the failure of the team
leader to perceive it could be construed as a gross deviation from the reasonable person standard
of care. The team leader’s decision could therefore result in her criminal negligence liability if
her team followed her instructions and was struck by lightning as a result.
Even under this hypothetical situation, however, the team leader would likely be able to
defend her decision to take the exposed route due to the extreme nature of the surrounding
circumstances, such as the immediate need for rescue and the rapidly changing nature of the
weather. As such, even in this hypothetical case, the government would probably choose not to
pursue criminal charges against the team leader because of the difficulties in proving a criminal
negligence case beyond a reasonable doubt.
All in all, WEMS personnel who follow the reasonable person standard of care and do not
purposefully cause harm to their fellow medical care providers or to the people they endeavor to
assist should not be concerned with criminal liability.

Liability Connected to Controlled Substance Management

In light of the opioid abuse epidemic that has swept across the United States in recent years, the
U.S. Drug Enforcement Agency (DEA) and similar state regulatory bodies have begun cracking
down more stringently on opioid management and administration practices. The federal
Controlled Substances Act (21 USC §§ 801-890), the DEA administrative regulations
implementing that act (21 CFR Parts 1300-1316), state drug statutes, and state administrative
regulations implementing those statutes make up the body of law that medical directors and EMS
administrators should consider when setting internal policies on how to manage controlled
substances. Failure to comply with applicable drug management laws could lead to a variety of
penalties ranging from the loss of the offending agency’s ability to order and administer opioid
medications to criminal liability.

LIABILITY PROTECTIONS IN THE WEMS CONTEXT

Public policy encourages WEMS personnel to help those in need of EMS in the wilderness.1 As
such, many statutes and regulations limit or even eliminate certain types of legal liability for
WEMS providers. The next four subsections describe relevant categories of statutory liability
protections.

EMS-Specific Liability Protections

About half of the states across the country specifically protect at least some EMS personnel from
civil liability by statute.29 Like all state law, EMS liability protection statutes vary in their scope
and application. The first question to ask when determining whether an EMS liability protection
statute applies to a particular WEMS provider is: Who qualifies as an EMS provider under the
given law?
Some EMS-specific laws define an “EMS provider” as a person who holds a valid license or
certificate issued by the state body that regulates EMS.30 According to this definition, the liability
protection laws for EMS personnel would not apply to unlicensed WEMS personnel such as
volunteer first aiders who do not hold state-issued credentials. By contrast, jurisdictions like
California allow their EMS-specific liability protection statutes to broadly apply to “emergency
rescue personnel” including officers, employees, and members of (i) a fire department or fire
protection entity; (ii) the State; (iii) a city, county, or political subdivision of the state; or (iv) a
private fire department, whether that person is a volunteer, partly paid, or fully paid.31 These
disparate definitions indicate that a WEMS provider should become familiar with the EMS-
specific liability protection statute in his or her location before relying on that statute for liability
protection. It is also important to recognize that many individuals who participate in WEMS
operations, such as ski patrollers, wilderness guides, and volunteers from the general public or
nonprofit organizations, may not qualify as EMS personnel in the context of these legal
protections, depending on state law.
If an EMS provider and/or the provider’s organization falls under the applicable statute’s
purview, the statute typically protects EMS providers who (i) do not act in a grossly negligent,
reckless, or willful and wanton manner; (ii) provide emergency care within the scope of their
employment or the scope of their volunteer role; and (iii) act in good faith.32 Each component of
these general requirements will now be addressed in turn.
First, a WEMS provider may enjoy the liability protection offered by EMS-specific liability
reduction statutes if the provider complies with the reasonable person standard of care rather than
acting with gross negligence, recklessness, or in a willful or wanton manner. Gross negligence
constitutes the middle ground between ordinary negligence—requiring the basic reasonable
person standard of care described earlier in this chapter—and “willful, wanton, and reckless”
conduct, which requires either an actual intent to harm, or a conscious disregard for the safety of
another person.33,34 Although courts have struggled to pin down a consistent definition of “gross
negligence,” one source describes this concept as “a lack of [even] slight diligence or care.”35
Avoiding gross negligence and willful, wanton, and reckless conduct can help put a WEMS
provider who meets the applicable definition of an EMS provider in a position to enjoy liability
protection under an EMS-specific statute.
Second, an EMS provider must act within the scope of his or her duties (whether paid or
volunteer) to benefit from EMS-specific liability reduction laws. Similar to the definition of who
qualifies as an EMS provider, the scope of a particular provider’s role will often appear in state
statute, in a state administrative regulation, or in a local ordinance. In New Jersey, for example,
the scope of an EMS provider’s employment is codified by statute and requires a “connection
with the actual rendering of life support services” including basic life support functions, cardiac
monitoring, and cardiac defibrillation.36 Colorado, on the other hand, breaks down the scope of
practice for each distinct category of EMS professional in administrative regulations
implementing the Colorado Emergency Medical and Trauma Services Act.37
Finally, most EMS-specific liability protection laws require that the EMS provider act in
good faith. Acting “in good faith” means the provider acted with honesty of purpose and without
the intent to harm.38
By adhering to the appropriate reasonable person standard of care, or at the very least,
refraining from acting in a grossly negligent, willful, wanton, or reckless manner, a qualifying
EMS provider who administers care in a wilderness setting may benefit from the liability
protection offered by state EMS-specific liability protection statutes.39

Volunteer Liability Protection Statutes

WEMS volunteers enjoy several kinds of statutory liability protection due to public policies
favoring rescue and encouraging volunteerism.1 For one, volunteers benefit from federal
volunteer protection laws. In addition, some state volunteer protection laws mirror the federal
law to provide an additional layer of liability protection.
The Federal Volunteer Protection Act exempts volunteers from liability for acts or omissions
done by the volunteer on behalf of a nonprofit organization or a government entity.40 The
liability exemption for volunteers only applies if: (i) the volunteer was acting within the scope of
his or her volunteer responsibilities at the time of the act or omission; (ii) the volunteer was
properly licensed, certified, or authorized by the appropriate authorities for the activities or
practice in the state in which the harm occurred, and the activities or practice were within the
scope of the volunteer’s responsibilities to the organization; (iii) the harm was not caused by the
volunteer’s willful or criminal misconduct, gross negligence, reckless misconduct, or a
conscious, flagrant indifference to the rights or safety of the harmed individual; and (iv) the harm
was not caused by the volunteer operating any type of vehicle for which the state requires a
license and insurance.40
In practice, this federal law will protect individual volunteer WEMS personnel working
under the direction of a nonprofit organization or government entity (like a county, city, or a
special district) from liability for torts like negligence. This protection should apply so long as
the volunteer acts within the scope of his or her responsibilities to the relevant organization,
maintains the required certification or licensure, does not render harm due to severe or
intentional forms of neglect or misconduct, and does not render harm while operating a motor
vehicle (like a car, helicopter, or airplane). Note that only individual volunteers, and not the
organizations supervising a volunteer’s work, can benefit from this form of liability protection.40
In much the same way as the federal Volunteer Protection Act limits volunteer liability under
federal law, state volunteer protection laws protect volunteers from negligence liability under
state law. For example, Washington’s volunteer protection statute mirrors the federal law, and
additionally requires any nonprofit organization that engages a volunteer who might benefit from
the statute’s liability limitation to carry certain dollar amounts of liability insurance.41

Good Samaritan Laws

Named after the biblical parable of the Good Samaritan,42 “Good Samaritan Laws” offer liability
protection to certain rescuers who provide assistance at the scene of an emergency. The common
law provides that there is no general duty to provide assistance to someone in peril.43 In addition,
general tort law principles state that “one who voluntarily chooses to aid another owes that
person a duty of care; a failure to exercise such care may result in legal liability.”43 The common
law absence of a duty to act in an emergency, coupled with the risk of incurring tort liability if
one does decide to help, disincentives people, particularly those with medical training who
would be held to a professional reasonable person standard, from helping others in emergency
situations.43
To address this disincentive to help, particularly for those with medical training, states began
passing Good Samaritan Laws in the mid-20th century.43 By exempting certain rescuers from
ordinary negligence liability, Good Samaritan Laws encourage volunteer rescuers to help in
emergency situations. Although most Good Samaritan Laws do not require a person to help
another during an emergency,44 their existence provides an incentive, in the form of liability
protection, that encourages such action.
All fifty states have passed some form of Good Samaritan Law by statute.43 The substance
and wording of these laws, however, vary widely across the country.45 In general, though, Good
Samaritan laws apply when:

1. the person providing care does not otherwise have a duty to act46;
2. the volunteer provider is not compensated, and does not expect to be compensated, for his
or her actions47;
3. the volunteer provides care at the scene of an emergency, rather than in an emergency room
or in some other clinical setting48;
4. the provider acts in good faith10; and
5. the provider does not act with gross negligence or in a willful, wanton, and reckless
manner.49

In some states, Good Samaritan Laws specifically protect physicians and other trained
medical professionals.10 In others, these laws apply only to those who render aid with limited or
no medical training.50 A useful online reference consolidating and summarizing every state’s
Good Samaritan Law, with a wilderness focus and with some commentary and editorial
interpretation and highlighting, can be found on Recreation Law’s website.45 However, for
definitive understanding of specific state law, the reader is urged to consult the applicable state’s
statute directly.
Elaborating upon the general criteria listed above, most Good Samaritan laws, unless stated
otherwise, protect those rescuers who do not have a preexisting duty to help in the emergency
situation. For example, a New Jersey court refused to apply that state’s Good Samaritan Law to
an on-duty police officer who responded to the scene of an accident because the officer already
had a duty to provide rescue services.46
The second criterion listed above (the absence of compensation) has caused much debate
within the wilderness medicine and EMS communities, specifically around the definition of the
term “compensation.” As in a wilderness area on land, a provider who cares for a patient on an
airplane during a flight administers such care in a remote, austere, wilderness environment. An
airplane scenario therefore illustrates how the compensation debate can complicate the Good
Samaritan analysis. (Indeed, some of the most dramatic wilderness interventions have been done
in airplane compartments.)51 Say an off-duty WEMS provider voluntarily provides care on an
airplane, and then accepts a free airplane ticket—or even just a seat upgrade and a bottle of
bubbly—has he or she received “compensation” in a way that eliminates the opportunity for
Good Samaritan protection? Whether a gift is considered “compensation” will depend upon the
specific facts of the case and applicable law in the jurisdiction.52
One common question in the compensation analysis is whether the provider intended to bill
for the rendered care. For example, simply withholding a bill that the provider would have
otherwise issued may demonstrate that the provider intended to bill for the care, even if that
provider never received any money. This evidence of intent could render Good Samaritan
protection inapplicable. Further demonstrating the gray area around the compensation criterion, a
particular Good Samaritan law may or may not apply if the evidence indicates that the provider
did not intend to be compensated, but nonetheless received a minor gift after rendering care.
In light of the uncertainty around what will qualify as “compensation,” WEMS providers
who render unplanned, altruistic care for which they may wish to invoke Good Samaritan
protection in the event of a legal challenge (and particularly when they think legal challenge is
possible or likely) should strongly consider declining money, gifts, or anything else that could
fall under the “compensation” umbrella. If the compensation is minor, it is presumably not worth
the risk; and as compensation becomes more significant, the risk that it will compromise Good
Samaritan protection also grows in significance.
The third criterion (that care be rendered at the scene of an emergency) is straightforward
enough in the wilderness context not to require additional commentary.
As stated earlier in the context of EMS-specific liability protection statutes, acting “in good
faith,” in order to meet the fourth criterion for Good Samaritan Law application, means the
provider acted with honesty of purpose and without the intent to harm.38
Fifth, and finally, individuals hoping to avail themselves of a typical Good Samaritan law
may not act in a grossly negligent, willful, wanton, or reckless manner. As detailed above in
connection to EMS-specific liability protection statutes, gross negligence is a heightened form of
negligence that demonstrates the actor’s utter disregard of prudence amounting to a complete
neglect of the safety of others.53 Willful, wanton, and reckless conduct involves either an actual
intent to harm, or a conscious disregard for the safety of another person.54 So long as the actor
does not act with gross negligence, or willfully, wantonly, or recklessly, the actor may receive
the benefit of liability protection from most Good Samaritan Laws. A rough guide for EMS in
terms of negligence is that the further the EMS provider strays from published guidelines or
protocols (like Advanced Cardiac Life Support [ACLS] guidelines, Wilderness Medical Society
[WMS] consensus guidelines, or local protocols), the less likely that provider will be protected
under the jurisdiction’s Good Samaritan Law.52
A few states’ Good Samaritan statutes specifically refer to WEMS personnel. For example,
the Colorado Good Samaritan Law exempts volunteer SAR units and volunteer ski patrollers
from civil liability for their acts or omissions taken “in good faith as a result of the rendering of
emergency care” so long as the acts or omissions were not grossly negligent, willful, or wanton.49
Similarly, Connecticut’s Good Samaritan Law exempts ski patrol members, in addition to
emergency service personnel more generally, from ordinary negligence liability so long as the
rescuer has completed an approved first aid course and provides first aid in an emergency
situation.55 Even without a specific statutory protection for WEMS personnel, however, the
general protections offered by most Good Samaritan Laws will likely apply similarly in the
WEMS context as they would in other out-of-hospital emergency situations.

Sovereign Immunity Statutes

Government entities—such as the counties, municipalities, agencies such as the National Park
Service, and state entities like special districts—often receive liability protection from state and
federal sovereign immunity laws. These laws “limit actions for which governmental (that is,
sovereign) agencies may be sued.”10 by raising the threshold for liability from ordinary
negligence to gross negligence or willful and wanton misconduct.10,29 Sovereign immunity laws
usually apply to both the governmental entities themselves, and to individuals who work or
volunteer for those government entities.10,29
Sovereign immunity laws may apply in the WEMS context when, for example, a county
EMS department dispatches paramedics to help at the remote scene of an accident. Just such a
scenario occurred in the Delaware case of Sadler v. New Castle County. The plaintiff in that case
fell off a waterfall and suffered a spinal injury. New Castle County dispatched several
paramedics to help. The paramedics were employed by a private EMS organization. They parked
the ambulance about a quarter mile from the accident site and hiked in with as much medical
equipment as they could carry, including a long backboard, cervical collar, and an oxygen unit.
After stabilizing the patient, the paramedics discovered that evacuation would be difficult due to
the lack of helicopter access to the site and due to the rocky terrain between the site and the
ambulance. The paramedics decided that evacuating the patient by way of the river below the
waterfall presented the best option. During the trip down river, the patient lost all sensation
below his chest. The paramedics transported the patient to the nearest hospital where he received
additional medical care. Despite treatment, the patient ended up as a quadriplegic.56
The victim-plaintiff sued the County, the private entity that employed the paramedics, and
the individual paramedics for negligence. Delaware’s sovereign immunity statute, however,
protected the County and the private entity contracted by the County to provide EMS from
liability. The statute may have also protected the individual paramedics if the trial court
determined that the paramedics’ actions did not constitute gross negligence or willful, wanton,
and reckless conduct. The result of the trial, however, is not publically available.56
This example demonstrates how a sovereign immunity statute, or any immunity statute for
that matter, can protect WEMS personnel and provider organizations from negligence liability.
Even if a WEMS provider could be found to have acted with ordinary negligence, the immunity
statute would protect that provider, as well as the provider’s organization.

CONCLUSION
This chapter provides a broad overview of the American legal system, the types of liability that
might apply in the WEMS context, and four types of statutory liability protections. The reader, at
the very least, should remember the following:

Complying with the appropriate reasonable person standard of care is a good way to avoid
many types of legal liability.
Negligence is the most important liability concept in the WEMS context. Complying with
the reasonable person standard can help eliminate the risk of acting negligently.
The law varies from jurisdiction to jurisdiction. A WEMS provider’s general familiarity
with the applicable laws (federal, state, and local) that apply in his or her jurisdiction can
help the provider understand and avoid relevant liability risks.

Acknowledgments
Thank you to Dr. Seth Collings Hawkins for the opportunity to author this chapter. Thank you to
Catherine Hansen-Stamp for the mentorship, research tools, and helpful feedback during the
drafting process. Thank you to Carl Weil for his experience-based perspective on the intersection
between WEMS and the law.

References
1. Cal. Health & Safety Code §1799.107(a) (2015) (“The Legislature finds and declares that a threat to the public health and
safety exists whenever there is a need for emergency services and that public entities and emergency rescue personnel
should be encouraged to provide emergency services.”).
2. Restatement (Second) of Torts, §283; Kionka EJ. Torts in a Nutshell. 5th ed. St. Paul, MN: West Academic Publishing;
2010:61; see Blatz v. Allina Health Systems, 622 N.W.2d 376, 384 (Minn. Ct. App. 2001) citing Page Keeton W. Prosser
and Keeton on the Law of Torts. 5th ed. St. Paul, MN: West Academic Publishing; 1984:§ 37 at 236.
3. Blatz at 384 citing City of Eveleth v. Ruble, 225 N.W.2d 521, 524 (Minn. 1974).
4. Iserson K, Heine CE. Ethics of wilderness medicine. In: Auerbach PS, ed. Auerbach’s Wilderness Medicine. 7th ed.
Philadelphia, PA: Elsevier; 2017:2262.
5. Langer CS, Auerbach BSS. Medical liability and wilderness emergencies. In: Auerbach PS, ed. Auerbach’s Wilderness
Medicine. 7th ed. Philadelphia, PA: Elsevier; 2017:2253.
6. Definition of “damages” and definition of “civil liability.” In: Garner BA, ed. Black’s Law Dictionary. 8th ed. Eagan, MN:
Thomson West; 2004:416, 933.
7. Kionka EJ. Torts in a Nutshell. 5th ed. St. Paul, MN: West Academic Publishing; 2010:2.
8. Definition of “damages.” In: Garner BA, ed. Black’s Law Dictionary. 8th ed. Eagan, MN: Thomson West; 2004:416.
9. Definition of “vicarious liability.” In: Garner BA, ed. Black’s Law Dictionary. 8th ed. Eagan, MN: Thomson West; 2004.
10. Ann “Winnie” Maggiore W. Legal issues. In: Cone D, Brice JH, Delbridge TR, Myers B, ed. Emergency Medical Services,
Clinical Practice and Systems Oversight. 2nd ed. New York, NY: Wiley; 2015.
11. Restatement (Second) of Torts, § 282 (1965); see Shapo MS. Principles of Tort Law. 3rd ed. St. Paul, MN: West Academic
Publishing; 2010:101.
12. Goldberg JCP, Zipursky BC. The Oxford Introductions to U.S. Law: Torts. Oxford: Oxford University Press; 2010:72.
13. Definition of “proximate cause.” In: Garner BA, ed. Black’s Law Dictionary. 8th ed. Eagan, MN: Thomson West; 2004:
234.
14. See, eg, Green v. City of New York, 465 F.3d 65 (2d Cir. 2006) (Fourth Amendment case brought under Section 1983 when
a patient capable of refusing treatment actually refused, but was treated and transported to a hospital despite refusal).
15. 42 U.S.C. § 1983 (2015).
16. Brown v. Pa. Dep’t of Health Emer. Med. Servs. Training Inst., 318 F.3d 473, 478 (Pa. D. & C.3d 2003).
17. See Salazar v. City of Chicago, 940 F.2d 233, 237 (7th Cir. 1991) (“Government generally has no constitutional duty to
provide rescue services to its citizens, and if it does provide such services, it has no constitutional duty to provide
competent services to people not in its custody.”); Bradberry v. Pinellas County, 789 F.2d 1513, 1517 (11th Cir. 1986)
(“The Constitution, as opposed to local tort law, does not prohibit grossly negligent rescue attempts nor even the grossly
negligent training of state officers.”); Archie v. City of Racine, 847 F.2d 1211 (7th Cir. 1988) (en banc); Jackson v. City of
Joliet, 715 F.2d 1200 (7th Cir. 1983).
18. 28 U.S.C. § 2671 (2015).
19. 28 U.S.C. § 2672 (2015).
20. 28 U.S.C. § 2680(a) (2015).
21. Kiehn v. United States, 984 F.2d 1100 (10th Cir. 1983).
22. Butler v. New York State Olympic Regl. Dev. Auth., 2003-16250 (N.Y. Sup. Ct.3d 2003).
23. Barishansky RM, et al. “Is there a doctor in the house?” Addressing Bystander physician involvement on scene. Available
at http://www.emsworld.com/article/10324273/is-there-a-doctor-in-the-house-addressing-bystander-physician-involvement-
on-scene. Accessed November 25, 2016.
24. Selde W. Know when and how your patient can legally refuse care. J Emerg Med Serv. Available at
http://www.jems.com/articles/print/volume-40/issue-3/features/know-when-and-how-your-patient-can-legal.html. Accessed
November 25, 2016.
25. Colo. Rev. Stat. § 25-3.5-101, et seq. (2015).
26. 6 Colo. Code Regs. §§ 1015-4 to 1015-9 (2015).
27. 6 Colo. Code Regs. §§ 1015-3, 6.2.14 (2015).
28. New York Penal Law § 15.05 (2015) (defining “criminal negligence”).
29. Nagorka FW, Becker C. Immunity statutes: how state laws protect EMS personnel, June 1, 2005. Available at
http://www.emsworld.com/article/10323938/immunity-statutes-how-state-laws-protect-ems-personnel. Accessed June 21,
2017.
30. See C.R.S. § 25-3.5-103(8) (2015) (defining “EMS Provider” under Colorado law).
31. Cal. Health & Safety Code §1799.107(d) (2015).
32. Shin RK. Protection against liability for emergency medical service personnel. J Emerg Manag. 2010:8(3):17.
 33. See, eg, 745 Ill. Comp. Stat. 10/1-210 (2015) (definition of “willful and wanton conduct”).
34. 745 Ill. Comp. Stat. 10/1-210 (2015) (definition of “willful and wanton conduct”).
35. Definition of “gross negligence.” In: Garner BA, ed. Black’s Law Dictionary. 8th ed. Eagan, MN: Thomson West, 2004;
1062; see Green v. Ingram, 608 S.E.2d 917, 923 (Va. 2005).
36. De Tarquino v Jersey City, 800 A.2d 255 (N.J. Super. Ct. App. Div. 2002).
37. 6 CCR 1015-3, chap. 2, §§ 5-9, implementing C.R.S. § 25.3.5-101, et seq. (2015).
38. Definition of “good faith.” In: Garner BA, ed. Black’s Law Dictionary. 8th ed. Eagan, MN: Thomson West, 2004:713.
39. See, eg, Malone v. City of Seattle, 600 P.2d 647 (Wash. Ct. App.) (1979) (statutory immunity for paramedics protected
defendant EMS providers from negligence liability); Fisher v. Sierra Summit, Inc., F058735 (Cal. Ct. App. 5th 2011) (ski
patrollers immune from negligence liability under prehospital emergency field care immunity statute).
40. 42 U.S.C. §14503 (2015).
41. Wash. Rev. Code § 4.24.670(1)(a)-(e) (2015).
42. The Holy Bible, Luke 10:25-37.
43. TransCare Maryland, Inc. v. Murray, 431 Md. 225, 233 (Md. 2013).
44. Compare Vt. Stat. Ann. tit. 12, § 519(a) (creating a duty to act in an emergency if doing so would be reasonable and would
not endanger the actor).
45. For a comprehensive list of state Good Samaritan Laws, see https://recreation-law.com/2014/05/28/good-samaritan-laws-
by-state/.
46. Praet v. Borough of Sayreville, 527 A.2d 486 (N.J. Super. Ct. App. Div. 1987) (holding that New Jersey Good Samaritan
Act did not apply to a police officer because the officer had a preexisting duty to rescue).
47. See, eg, Wash. Rev. Code § 4.24.300 (2015) (“Any person, including but not limited to a volunteer provider of emergency
or medical services, who without compensation or the expectation of compensation renders emergency care at the scene of
an emergency or who participates in transporting, not for compensation, there from an injured person or persons for
emergency medical treatment shall not be liable for civil damages resulting from any act or omission in the rendering of
such emergency care or in transporting such persons, other than acts or omissions constituting gross negligence or willful or
wanton misconduct. Any person rendering emergency care during the course of regular employment and receiving
compensation or expecting to receive compensation for rendering such care is excluded from the protection of this
subsection.”).
48. Minn. Stat. Ann. § 604A.01(b) (2015) (defining “scene of an emergency” as an area, including ski areas and trails, outside
of a hospital, other institution with hospital facilities, or a doctors’ office).
49. Colo. Rev. Stat. § 13-21-116 (2015).
50. See, eg, Minn. Stat. Ann. § 604A.01 (“person” covered by Good Samaritan Law does not specifically include physicians or
other licensed medical personnel).
51. Wallace WA. Managing in flight emergencies: a personal account. BMJ 1995;311(7001):374-376
52. Augustine J. Good samaritan statues: when do they protect you? Emergency Physicians Monthly. Available at
http://epmonthly.com/article/good-samaritan-statutes-when-do-they-protect-you/. Accessed November 16, 2016.
53. Green v. Ingram, 608 S.E.2d 917, 923 (Va. 2005).
54. See, eg, 745 Ill. Comp. Stat. § 10/1-210 (2015) (definition of “willful and wanton conduct”).
55. Conn. Gen. Stat. § 52-557(b)(b) (2015).
56. Sadler v. New Castle County, 524 A.2d 18 (Del. Super. Ct. 1987).

*The highest federal appellate court is the United States Supreme Court. Many states designate their highest appellate courts as
“Supreme” courts as well. Not all states, however, follow this naming convention. For example, in New York, the trial court is
called the “supreme court” and the highest appellate court is called the “Court of Appeals.”
INTRODUCTION
The British Medical Association defines a patient “handover” (or “handoff”) as the “transfer of
professional responsibility and accountability for some or all aspects of care for a patient, or
group of patients, to another person or professional group on a temporary or permanent basis.”1
Patient handovers or handoffs are also known as “transitions of care.” The components of a
patient handoff can be roughly divided into the three following steps:

1. The physical movement (or transfer) of a patient from one care venue to another
2. The verbal transition of care
3. The written transition of care

Each patient transition of care represents an ominous opportunity for error. This potential
was highlighted in the Institute of Medicine (IOM) report To Err is Human: Building a Safer
Health System, which acknowledged that medical errors account for between 44,000 and 98,000
deaths annually.2 Additional sources note that ineffective patient handoffs represent a critical
patient safety concern, with up to 80% of these serious medical errors resulting from
miscommunication between caregivers during the transfer of patients.3 A high number of errors
occur in high-acuity fields of medicine, including emergency medicine and intensive care.2
Although not specifically mentioned in these references, the common high acuity of out-of-
hospital patients and the frequency of patient handoffs occurring between traditional emergency
medical services (EMS) and hospital-based emergency medicine providers suggest a potential
for miscommunication between out-of-hospital and hospital-based providers. It would then
follow the potential for similar miscommunication between wilderness EMS (WEMS) and
subsequent downstream providers, be they traditional EMS providers or hospital-based
providers.
This chapter will focus on the interface between WEMS providers and other health care
providers represented by the traditional EMS system or the hospital-based system. Such
transitions of care represent potential breaches in safety for patients, and therefore, it is critical
that all health care providers practice deliberate and effective communication strategies. The
scope of this problem, as described in the available literature, will be discussed, followed by
examples of potential transition of care strategies and illustrations of best practices in patient
transitions of care. Having a clear understanding of the scope of practice and capabilities of all
health care providers caring for a patient may act to facilitate communication. In other areas of
this text, the scope of practice of WEMS providers has been described. This chapter will define
the scope of practice of traditional EMS providers for wilderness providers not intimately aware
of the traditional EMS provider’s scope. Finally, implications for all WEMS practitioners will be
considered.
For the purposes of this chapter, WEMS will be defined as all elements of the patient-care
team that provide structured search, rescue, and medical care in the wilderness environment.
Traditional EMS is defined as an EMS provider or EMS service practicing in a rural, suburban,
or urban setting and not practicing in the wilderness environment. The traditional EMS provider
is assumed to have a common set of resources, including medical resources and, with the
exception of nontransport services, will additionally have resources necessary to transport the
patient to definitive care, by either ground or air.

CAREGIVER INTERFACES AND TRANSITIONS OF CARE

The Tenuous Nature of Transitions of Care

The need for effective communication is not unique to medicine alone but is vital to other high-
risk, high-stake professions. Much of the evidence-based guidelines for improving in-hospital
handoff and teamwork have come from these other industries (eg, aviation, National Aeronautics
and Space Administration, nuclear power plants). Despite the notable differences among these
fields and medicine, there exists a common thread, the need for effective and efficient
communication.4
Multiple US and international agencies have identified the tenuous nature of transitions of
care. The IOM comments “it is in inadequate handoffs that safety often fails first.”5 The Joint
Commission, an independent, not-for-profit organization that accredits US health care facilities,
introduced efforts to improve communications dating back to 2006. The goals of this project
have included improving “effectiveness of communication”6 and “implementing a standard
approach to ‘handoff’ communications.”7 The World Health Organization’s (WHO) “High 5
Initiative,” introduced in 2007, was an international effort to improve patient safety by
addressing five challenges to patient safety, one of which was “communication during patient
care handovers.”8

What Is Known About Out-of-Hospital Communication?

It is clear that the dangers surrounding transitions of care and the potential breaches in patient
safety are not unique to the hospital-based environment. Bigham et al. reviewed EMS patient
safety literature from 1999 to 2011. They found that out of 88 studies referencing patient safety,
6 identified miscommunication as a safety concern.9 Evans et al. studied EMS patient handoffs to
hospital-based trauma teams, noting that up to 9% of information verbally passed on to hospital
providers was not documented in either the hospital record or the EMS written report and was
therefore considered “lost.” Additionally, discrepancy occurred between verbal and written
communication in 7 out of 25 (28%) instances, including allergy status and sites of injury. Most
commonly missed areas of documentation included patient presenting signs and symptoms as
well as out-of-hospital therapies provided.10 Shields et al. reviewed an Australian study
observing patient handoffs over a 7-day period and noted that patient verbal reports fell into two
categories, defined as “detailed handovers” and “minimal handovers.” These researchers went on
to examine the implications of each handover and discovered that the type of patient verbal
report had significant implications on subsequent patient care, noting that the detailed patient
verbal reports lead to “decreased nursing time and enhanced patient care,” whereas minimal
verbal reports lead to “poor patient care.”11
Dawson et al. reviewed the medical literature attempting to identify patterns associated with
EMS to hospital handovers that could be improved. The authors reviewed literature between
2001 and 2012, identifying 17 articles addressing out-of-hospital transitions of care.12 Concerns
identified in patient handoff were divided into the following categories:

1. Professional relationships, respect, and barriers to communication: 11 out of 17 studies

discussed the importance of social and human factors (behavior, communication,
professionalism, and a working relationship) because it pertains to transitioning care. Poor
communication was found to be rooted in behaviors, such as a lack of active listening and
poor eye contact, as well as relational problems, such as mistrust and misunderstanding.
Lack of trust on the part of receiving emergency services staff, or even a perceived lack of
trust, can undermine effective out-of-hospital or EMS to hospital communication. Multiple
studies also specified the importance of the receiving providers being non-judgmental.
Equally important is the principle that receiving staff should feel comfortable asking
questions and clarifying details. The transferring providers should invite clarifying
questions to promote a dynamic transition of care.12 Specifically, in a 2012 study, Bost et al.
noted that increasing trust and being more receptive during handover may enhance
identification of signs and symptoms, minimize delays in treatment, and ultimately prevent
adverse outcomes. Furthermore, Bost et al. recognized the benefits of teams having a shared
mental model in which members of both teams are aware of “each team member’s
knowledge, skills, attitudes, strengths and limitations.”13 Familiarity with providers during
handoff, use of common language or a “cognitive picture,”14 and allowing for dynamic
conversation were all strategies that broke down communication barriers.
2. Need for structure or handover tool: Dawson et al. discovered nine studies in the EMS
literature that identified the use of structured handover tools. Multiple studies examined the
mnemonic tool MIST (Mechanism of injury/illness, Injuries, Signs/Observations,
Treatment). Additional studies utilized a modified form of MIST.15 Although these revealed
mixed results with limited statistical significance and power to determine the utility of
MIST, several of the studies found mnemonics in general to be useful tools to assist in
patient handoff. Others suggest a tool similar to SBAR (Situation, Background, Assessment,
Recommendation) called ISBAR (Introduction/Identification, Situation, Background,
 Assessment, Recommendations), which may be best suited for the deteriorating patient.12
The authors state that this tool provides staff with a rapid, more consistent, and direct
handoff that covers the most vital patient information. This tool has been endorsed by the
Australian Resuscitation Council12 and the WHO16; however, its efficacy in emergency care
still requires validation. In 2007, Budd et al. conducted a survey that found that 53.3% of
UK Ambulance services utilized standardized handoff alerts (prior to EMS arrival) for
trauma patients. Furthermore, their survey study showed the 86.7% of services are familiar
with the mnemonic ASHICE (Age, Sex, History, Injuries, Condition, Expected time of
arrival).17 Most authors suggest that a handover tool has benefits, especially in providing
inexperienced providers with guidance and direction that highlights essential information
necessary for downstream providers when performing a patient handoff. Additionally,
handover tools that are agreed upon by both sending and receiving providers may eliminate
the hierarchy of medicine that can be detrimental to effective communication.
3. Multiple/repeated handovers: In the reviewed literature, seven studies found that multiple or
repeated handovers contributed to lost or changed patient information. The authors noted
that a team-to-team handover minimized contradicting stories and reduced the number of
unanswered questions. One Australian study showed that 91% of the time, paramedics
handed a patient over at least twice.18 Paramedics preferred transitioning care to a team of
physicians and nurses when patients are of higher acuity levels and wanted to ensure that
they were communicating directly with personnel of greater clinical experience.12
4. Education and training in handovers: In one study, 19% of queried EMS providers report
having formal training in patient handoffs. Of the remaining 81% of providers, 83% felt that
formal training in patient handovers was necessary.19 Despite limitations and mixed results
noted in many studies reviewed, education and training consistently promoted confidence in
junior providers, which “fosters a sense of trust and respect among staff.”12,13,20–22
Multidisciplinary simulation and communication training are beneficial, especially for
providers who are caring for critically ill and rapidly deteriorating patients.
5. Vital signs: Despite traditional EMS education emphasizing the importance of vital signs,
eight studies noted a gap in obtaining, verbalizing, or documenting vital signs by the
transferring team, as well as acknowledgment of receipt of vital signs by the receiving
staff.12 Vital signs are an essential part of both out-of-hospital and in-hospital evaluation and
assessment. Incomplete communication of abnormal vital signs or concerning primary
survey findings can directly lead to adverse patient outcomes secondary to delays in care.
Simulated studies have found that information, such as vital signs, primary survey, and
blood sugar measurement was lost in 40% to 50% of patient handoffs.21 Similarly, Carter et
al. performed a video analysis of trauma handoff from out-of-hospital to emergency
department (ED) staff. This simulated study revealed that only 72.9% of the out-of-hospital
information was documented by receiving personnel. Information regarding hypotension,
out-of-hospital Glasgow coma score, and pulse rate was only documented by receiving staff
approximately 50% of the time.23 General observations, such as changes in patient
condition, mental status, vital signs, and primary survey (airway, breathing, circulation,
disability), should be included as part of a comprehensive transition of care. Observing,
documenting, and reporting these signs and symptoms are a fundamental component of out-
of-hospital care, including WEMS. Mechanisms must be established to ensure accurate
transition of these findings to receiving providers.
6. Documentation and other data formats: In addition to the verbal and physical transfer of
 care, out-of-hospital providers should provide written report and/or electronic
documentation of all pertinent out-of-hospital care. Such written documentation acts as a
“legacy of care” that exists well beyond the verbal transfer of care, offering a record of the
wilderness provider’s efforts for all downstream out-of-hospital or in-hospital providers.
Studies have shown that although emergency medical providers may not always refer to the
documented out-of-hospital report,13,18 when used it may reduce information loss and need
for repeated handoffs.15 This documentation can be used longitudinally throughout the
patient’s care (ie, on the inpatient services) to preserve continuity of care.23,24 Short of
directly contacting the WEMS team, documentation is the only form of communication
available to the inpatient providers regarding out-of-hospital assessment and intervention.
Other interview-based studies found agreement among out-of-hospital providers that the
practice of using gloves, sheets, or scraps of paper to document patient information
contributed to the loss of important data (eg, vital signs or medications).10 Providers found
value in utilizing checklists25 or other preformed documentation that provides space for
initial observations/assessment and trending vital signs.

Woods et al. also reviewed similar literature between 2000 and 2013. These authors
identified 21 primary studies relating to out-of-hospital transitions of care. In this review, the
authors identified and prioritized 32 subthemes relating to EMS handoff including “active
listening,” “relationships between clinicians,” “information retention,” and, particularly relevant
for WEMS providers, “environmental impacts.” This group of authors interlinked these
subthemes into four major themes, including communication, context (environment),
interprofessional relationships, and standardization of handover (including mnemonics).26
Addressing the importance of patient safety as it pertains to the transfer of care between
EMS providers and receiving facilities, the National Association of EMS Physicians (NAEMSP)
released a position statement in 2014 highlighting many of the themes reviewed by Dawson et al.
and Woods et al. This position statement, which is also supported by the American College of
Emergency Physicians (ACEP), Emergency Nurses Association (ENA), National Association of
Emergency Medical Technicians (NAEMT), National Association of State EMS Officials
(NASEMSO), identifies the handoff process as a critical opportunity to improve patient safety,
reduce medicolegal risk, and integrate EMS into the health care system. The position statement
emphasizes the need for both verbal and written/electronic communication, which includes key
patient information (Box 6.1). Additional information may include basic patient demographics,
patient allergies, other time parameters (on-scene time, transport time, etc.), past history, and
baseline medications. Furthermore, NAEMSP calls for mutual and shared respect between out-
of-hospital and hospital providers. This mutual respect calls for dynamic communication with
active listening as well as opportunities for questions to be answered.27

Minimum Key Information per National Association of EMS

Box 6.1
Physicians (NAEMSP) Position Paper on Transfer of Patient Care
• Vital signs
• Treatment interventions
• Time of symptom onset (for time-sensitive illnesses)
• Copies of results of medical testing performed by emergency medical services (EMS)

Adapted from Transfer of Patient Care between EMS Providers and Receiving
Facilities. Prehospital Emerg Care. 2014;18(2):305-305.
Impact on the Wilderness EMS Provider
Scant literature exists on WEMS systems in general, with no literature found discussing
transitions of care between WEMS providers and traditional EMS or hospital providers. All
literature that was identified analyzes transitions of care between traditional EMS and emergency
medical personnel or, alternatively, address in-hospital transitions of care. Although little
literatures on this topic exist, many of the underlying issues in communication that exist between
traditional EMS and hospital providers or within hospitals can be speculated to occur within the
paradigm of a WEMS system, because many of the stresses that exist in other areas of the health
care system are present in equal or greater measure in a WEMS setting. Additionally, the WEMS
provider may fall prey to the same “hygiene-poor” communication environment that a traditional
EMS provider encounters in the hospital. WEMS patients requiring hospital admission may be
subject to multiple transitions of care. For example, a multisystem trauma patient calling 911 for
assistance could receive initial care instructions from an emergency medical dispatcher, and then
from first aiders on-scene, passing to the primary WEMS team responding to and caring for the
patient in the wilderness, to the ambulance team transporting the patient to a helispot, to the air
medical crew transporting them to a hospital and transferring care to ED staff, with final
transferal of care to the medical or trauma service caring for the patient in the hospital. Finally,
although WEMS education is unique and not all flaws of the traditional EMS education process
can be assumed to exist in WEMS education, traditional EMS education does not always
adequately prepare its providers for transitions of care, so it is possible that the WEMS education
process also does not consistently educate providers in patient handoffs and communication. As
hospital medicine and traditional EMS have begun to focus on adapting communications skills,
the WEMS system must also value the importance of transitions of care and the lessons learned
from nonrelated professions with high consequences for failure.

TRADITIONAL EMS PROVIDERS’ SCOPE OF PRACTICE

Understanding the scope of practice of traditional EMS will directly impact the communication
and language utilized during patient handovers. Owen et al. examined perceptions by paramedics
and receiving hospitals during handover. The authors suggested a need to develop a shared
understanding of team members’ roles among parties involved in handoff.14 A shared
understanding can be achieved via common experiences, such as interdisciplinary training and
multiagency simulated exercises. The ability to tailor a handoff to meet the medical knowledge
of the receiving team in a handoff is crucial to a successful transition of care.
Although federal recommendations regarding provider scope of practice exist for Emergency
Medical Responders (EMRs), Emergency Medical Technicians (EMTs), Advanced EMTs
(AEMTs), and paramedics through The National EMS Scope of Practice Model,28 ultimate
determination of a provider’s scope of practice is a delicate interplay between numerous factors.
Provider scope of practice in traditional EMS is determined by the state, based on The National
EMS Scope of Practice Model. In addition, depending on the given state’s structure, final
practice may be further amended by a regional or local medical director. Intimate knowledge of
the responding traditional EMS providers’ scope of practice is necessary for the WEMS provider
as well as administrators and medical directors. Familiarity with traditional EMS scope of
practice will aid the WEMS provider’s ability to request providers with appropriate levels of
care. Local availability of varying levels of out-of-hospital care will have a significant impact on
logistics and coordination of the patient’s transition of care.
The federal guidance regarding traditional EMS scope of practice is an essential starting
point for WEMS providers to understand; however, this described scope of practice may not
reflect the actual scope of practice of the EMS providers encountered. Although the following
can act as a guide, it is imperative that WEMS providers spend time learning the scope of
practice for the providers most commonly encountered in their response area. The certifications
are listed here in order of hours of training required to obtain the certification. However, as
discussed in the Introduction section, this is considered a horizontal rather than vertical
hierarchy.

Emergency Medical Responder

The EMR is the foundational scope of practice described in the traditional EMS system. This
provider is trained in simple and immediate lifesaving skills for critically ill or injured patients
(Box 6.2). This may include basic airway management, hemorrhage control, and use of an
automated external defibrillator (AED). The EMR usually works within a system of care that
includes other scopes of practice. Although the EMR may be present during patient transfer, this
scope of practice is typically not the primary care provider during the transport phase of care.
After initiating care, the EMR usually transfers care to a higher level provider. The traditional
EMR scope of practice is limited to a very minimal pharmacologic formulary, in many cases
including provision of medications for force protection alone.

Emergency Medical Technician

In a horizontal hierarchy stratified by hours of training, the EMT is considered the first provider
with a scope of practice capable of transporting a patient in the federal model of EMS scope of
practice (Box 6.3). The EMT is trained in basic, noninvasive interventions necessary to stabilize
critical and emergent patients. In many EMS systems, EMTs comprise the largest portion of
providers, and it is possible, especially in rural settings, that a WEMS provider may interface
with a traditional EMT.

Minimum Skills of the Traditional Emergency Medical

Box 6.2
Responder (EMR)28
Airway and Breathing—insertion of airway adjuncts into a patient’s oropharynx (such as nasopharyngeal or oropharyngeal
airways), use of positive pressure ventilation devices (such as bag-valve masks), suction of the upper airway, supplemental
oxygen therapy
Pharmacologic Therapies—use of unit dose auto-injectors for force protection alone (such as MARK 1)
Medical/Cardiac Care—includes provision of CPR and use of automated external defibrillators
Trauma Care—manual stabilization of suspected cervical spine
fractures or extremity fractures, hemorrhage control, emergency
moves

Box 6.3 Minimum Skills of the Traditional EMT28

Airway and Breathing—insertion of airway adjuncts intended to enter the oropharynx or nasopharynx and use of positive
pressure ventilation devices including BVM but also including manually triggered ventilators and automatic transport
ventilators
 Pharmacologic Therapies—assisting the patient in taking their own prescribed medications, administering a limited number
of over-the-counter medications when appropriate, including oral glucose for suspected hypoglycemia or aspirin in chest
pain of suspected ischemic origin
Medical/Cardiac Care—see above scope for Emergency Medical Responder (EMR)
Trauma Care—application of splints for fracture stabilization

Advanced Emergency Medical Technician

The AEMT’s scope of practice includes all of the above-listed basic skills sets as well as limited
advanced skills and limited pharmacologic formulary intended to reduce morbidity and mortality
from acute medical or traumatic emergencies. The major difference between the AEMT and the
EMT is the ability to provide limited advanced skills and to provide limited pharmacologic
interventions. These therapies are limited to lower-risk, high-benefit skills that can be provided
safely in the out-of-hospital environment with medical oversight and limited training (Box 6.4).

Minimum Skills of the Traditional Advanced Emergency Medical

Box 6.4
Technicians (AEMTs)28
Airway and Breathing—insertion of airways that are NOT intended to be placed in the trachea (such as blind insertion
airway devices) and tracheobronchial suctioning of a previously intubated patient
Expanded Assessment Skills
Pharmacological Therapies—establishment and maintenance of peripheral intravenous or intraosseous access, administration
of the following therapies:
• Intravenous fluids (nonmedicated)
• Sublingual nitroglycerine (in chest pain of suspected ischemic origin)
• Intramuscular epinephrine (in anaphylaxis)
• Glucagon and dextrose (in hypoglycemia)
• Inhaled β-agonists (in asthma)
• Narcotic antagonists (in suspected opioid overdose)
• Nitrous oxide (for pain relief)

It should be noted that, of all the traditional EMS scopes of practice, the most variability has
been noted in this particular scope. Although currently named AEMT, this scope was historically
known as Intermediate EMT, and this moniker may still be used in some locations. The recent
development of the AEMT scope of practice is an effort to better standardize the prior scope of
practice of the Intermediate EMT, which, depending on the model adopted, may have offered
more advanced skill sets, such as intubation. It is important that the WEMS provider recognize
this variability and investigate the local abilities for this provider in the traditional EMS system.

Paramedic
The paramedic’s scope of practice is intended to provide basic and advanced skills focused on
the acute management and transportation of the broad range of patients accessing the traditional
EMS system (Box 6.5). This includes all of the above-listed therapies as well as invasive
procedures and pharmacologic interventions. These skills are based on advanced assessment
capabilities and the formulation of a field impression. The major difference between a paramedic
and an AEMT is a broader education in background science and the ability to perform a larger
set of advanced skills. These therapies hold a greater risk and are more difficult to attain and
maintain competency in.

Box 6.5 Minimum Skills of the Paramedic28

Airway and Breathing—endotracheal intubation, percutaneous cricothyrotomy, decompression of the pleural space, gastric
decompression
Pharmacologic Therapies—external and parenteral administration of approved prescription medications, access of
indwelling catheters and implanted central venous IV ports, administration of medications by IV infusion, maintenance of an
infusion of blood products
Medical/Cardiac Care—perform cardioversion, manual defibrillation, and transcutaneous pacing

Although the traditional EMS provider’s scope of practice is discussed earlier, it should be
noted that the scope of practice does not describe the provider’s requisite knowledge base
necessary to perform the listed skills. Table 6.1, adopted from the National EMS Scope of
Practice Model, is intended to demonstrate the knowledge level of each scope of provider for
various patient populations.
In the federal model of EMS scope of practice, all of the above-listed traditional EMS
providers work under some degree of medical oversight. This medical oversight may be
intimately integrated into the EMS provider’s service, offering direct oversight, or may function
at a regional or state level. Regardless of the system structure, in most cases, a physician is
involved at some level in guiding the medical care provided. See Chapter 4 for a more complete
discussion of medical oversight in WEMS.
The above-listed scopes of practice should be recognized as a starting point and may not
represent the scope of traditional EMS providers in a given geographic location. Given the
state’s ability to alter these scopes and, in some circumstances, the additional ability of a local or
regional medical director to amend providers’ practices, a WEMS provider should work to gain
intimate knowledge of the scope of practice in their response area. For instance, in some
traditional EMS settings, EMTs are allowed to establish and maintain intravenous access and, in
other traditional EMS settings, AEMTs provide opioid pain medications, both practices
exceeding the federal scope of practice for these respective provider categories.29,30 Additionally,
not all of the listed traditional EMS providers may be available, and the WEMS provider should
identify the most likely traditional EMS providers encountered in their operational environment.
Others, such as nurses, PAs, advanced practice registered nurses (including nurse
practitioners), or physicians, may be involved in the care of patients in traditional EMS system.
These resources may be available to the WEMS provider depending on the location in which the
wilderness provider practices and the makeup of the surrounding EMS system.

Table 6.1 Knowledge Base for Traditional Emergency Medical Service Providers
Versus Patient Acuity
Emergency Medical Emergency Medical Technician (EMT) and
Responder Intermediate EMT Paramedic
Critical Simple Fundamental Complex
Emergent Simple Fundamental
Lower acuity Simple

Adapted from National Highway Traffic Safety Administration. The National EMS Scope of Practice Model. Washington, DC:
Department of Transportation/National Highway Traffic Safety Administration; 2005.
 It should be noted that a common feature in most of the traditional EMS system is the brevity
of patient-care interactions, especially in comparison with the WEMS system. Although some
elements of the traditional EMS system have prolonged patient interactions, even these are
frequently not as long in duration as that of the WEMS system. Because of the duration of
patient interactions within the WEMS system, WEMS providers are typically trained to provide
prolonged field care. This is not typical in most of the traditional EMS system, and wilderness
providers must recognize this fundamental difference in WEMS and traditional EMS scope of
practice.

MODELS OF WILDERNESS EMS INTERACTION WITH

TRADITIONAL EMS OR HOSPITAL PROVIDERS
It is evident throughout the reviewed literature that understanding providers’ roles and scopes of
practice is a key to successful transitions of care. In the WEMS setting, providers have an even
greater challenge when addressing transitions of care given a broader range of potential handoff
interactions. To prepare and train for successful patient handoff, WEMS systems should examine
potential models of interaction with traditional EMS, nontraditional EMS, or hospital-based
providers. There stands to be a large variety of potential interactions that a WEMS system may
encounter, including but not limited to the following:

1. Traditional EMS (basic life support [BLS] or advanced life support [ALS] via public or
private EMS systems)
2. Air medical transport (helicopter/fixed wing EMS, federal/state-based or private air
transport with or without EMS providers)
3. Direct WEMS to hospital transport (via intra-agency or interagency transport)
4. Non-EMS transportation (federal/state law enforcement, military/National Guard, Civil Air
Patrol)
5. Disaster Teams (federal Disaster Medical Assistance Teams [DMATs], urban search and
rescue teams [US&R teams])
6. Professional international/federal/state/regional/local medical transport services (United
Nations, U.S. Coast Guard, SAR, US&R)
7. Non-governmental organizations, corporations, and international agencies (Red Cross,
Global Rescue)

In terms of direct patient transport by WEMS to a hospital, WEMS systems may directly
transfer the patient to the hospital via their own transport vehicle or WEMS providers may
continue medical responsibility for a patient while utilizing another agency for physical
transportation (eg, chauffeur, driver assignment). The latter of the two is frequently utilized by
critical-care EMS agencies and/or hospital-based providers (ie, during interfacility
transportation). It may be in the patient’s best interest to have WEMS maintain continuity of
care, as suggested by reviewed literature from the traditional EMS domain. Ultimately, the
ability of WEMS providers to assist in patient transport to definitive care should be addressed at
the state and local level. To facilitate this continuity of care, WEMS providers may need to be
certified in their respective traditional EMS scope of practice. These circumstances could require
local policies and logistics defining when the provider has transitioned from wilderness protocols
to traditional EMS protocols and how medical direction interacts with providers across this
spectrum of care. In this setting, the transition of care may not be a physical handoff between
providers but rather a transition among the protocols guiding care, medical direction, and
potentially, the provider’s scope of practice.
WEMS systems should examine their own local practices and operational procedures
regarding evacuation and transport of patients from the austere environment to definitive care.
Identifying local standard operating procedures is essential in developing, educating, and
improving best practices for transitions of care. Via the literature reviews of Dawson et al.12 and
Wood et al.,26 it is clear that providers (both sending and receiving) need to respect the scope of
practice of involved parties in order for successful transitions of care. Quality improvement
projects should be centered around identifying the most common modalities used for patient
delivery as well as improving effective communication among those agencies.

“BEST PRACTICES”: IDENTIFIED METHODS TO

IMPROVE PATIENT SAFETY DURING TRANSITIONS OF
CARE
The following section will discuss potential solutions to each of the above-identified dilemmas
regarding transitions of care or potential considerations for certain WEMS providers. As is
consistent throughout this textbook, these solutions will be loosely listed under the headings of
“First Aid,” “Basic Life Support,” “Advanced Life Support,” and “Clinician”; however, most of
the best practices could be applied to all scopes of practice. Listed solutions have been
transmuted from the available traditional EMS or hospital literature or discovered through
conversations with WEMS practitioners31,32 and should be considered within the context of the
individual WEMS provider’s practice. Although many of these suggestions will be applicable on
a wide scale, some may not be relevant given either geographic or operational limitations of an
individual out-of-hospital or wilderness system of care.

First Aid Providers

This designation is intended to include providers certified at the first aid level, guides, and other
non-EMS credentialed outdoor leaders. In the hospital setting, best practices have called for
improving transitions of care via standardized handoff tools. In the United States, the Joint
Commission Center for Transforming Healthcare has established tools that guide hospitals
through a stepwise process in order to measure performance, identify barriers, and suggest
solutions to improving performance in regards to handoff communications. This provides health
care systems with specific steps to assist in implementing programs intended to improve
communication.3
Verbal communication occurs in primarily two different modalities in out-of-hospital care.
The first is via telecommunication (radio, phone, etc.) and is intended to either alert receiving
facilities of incoming patients or access on-line (direct) medical oversight. The second form of
out-of-hospital verbal communication is the patient handoff, which is an in-person transition of
care, usually accompanied by formal and actual transfer of patient-care responsibilities.
The goals of each type of communication are different and vary slightly.
Telecommunications are used in order for the sending provider to inform the receiving provider
of an impending physical handover of care. More importantly, this prearrival notification alerts
receiving providers of an incoming patient’s needs and allows mobilization and activation of
hospital-based resources. In traditional EMS, the alert system is most utilized for time-sensitive
illnesses and injuries. The in-person verbal handoff is used to provide a comprehensive transition
of care that is immediately followed by a transfer of patient responsibilities onto the receiving
party.
Multiple mnemonic-based, verbal handover tools exist that may improve and standardize
traditions of care. Some of these tools have been adapted to and/or from written documentation
standards. Table 6.2 identifies some of the more commonly discussed verbal tools highlighted in
recent literature as well as those commonly known to wilderness or traditional EMS providers. It
is important to note that many of these tools are used for or adapted from other professions that
demand comprehensive communication. No single tool has been identified as a universal
standard of practice for use in out-of-hospital care. Certain tools have been suggested to provide
some benefit to the transition of care, yet none have been rigorously studied, especially in the
WEMS environment.
In an out-of-hospital, focus group study, Meisel et al. acknowledged the benefits of verbal
handover tools but cautioned against overutilization of binary style or “closed-end” reporting.
Such verbal reports may limit the ability of EMS providers to act as patient advocates. The
authors advocate for a “balance between closed and open-ended reporting.”43 Ideally, a verbal
handover tool with correlating documentation is not just a checklist but rather a skeleton
structure or outline that enhances out-of-hospital providers’ ability to translate a patient’s story
into a succinct yet comprehensive transition of care.
Given the differences between WEMS systems, it is likely that no single handoff tool will be
universally accepted. Furthermore, given the variety of services that any one WEMS system may
transition care to, different tools may be more suitable for different receiving providers.
Ultimately, the development of a handoff tool should be a collaborative effort with equal input
from operators of both the sending and receiving parties. Lastly, the implementation of such a
tool should be a dynamic and fluid process that involves continuous reevaluation and
restructuring, with an end goal of improving efficient, accurate, and effective communication.

Basic Life Support

BLS providers should work to implement all the same tools as those described above for first aid
providers. The BLS level is where written documentation first becomes critical from an EMS
perspective. As described earlier in this chapter, accurate written documentation is a necessary
component of an effective transition of care. WEMS written documentation acts as a legacy of
the care provided by the WEMS system and is the only means of communication from WEMS
providers to all of the various “downstream” providers also caring for the patient. Not only does
out-of-hospital documentation allow for continuity of care, but the out-of-hospital record also
acts as a legal document, recording the patient’s condition on scene and at the destination as well
as the actions taken to improve the patient’s condition. Additionally, out-of-hospital
documentation acts as a tool for educational and quality assurance purposes. Documentation of
wilderness medical care has data power that can be utilized to refine and advance wilderness
medical practices. Multiple authors recommend a standardized approach for both verbal and
written patient-care information.8,12,15,23,24,27,44 Some of these studies go as far as to advocate for
national or more universal standards to documentation.44 Standardization of WEMS
documentation could allow for pooling of relatively rare events. Such pooled data may assist
leadership and policy makers in educational or quality assurance initiatives. When applicable,
out-of-hospital documentation also acts as an administrative resource for billing purposes.
In traditional EMS, the National Emergency Medical Services Education Standards outline
the core curriculum surrounding documentation at the EMT level.45 Minimum information
suggested by the education standards include patient specific data (including chief complaint,
initial assessment, vital signs, patient demographics) and administrative details (including
incident report, time unit notified, arrival time at patient, time unit left scene, arrival at
destination). All documentations should include a narrative section that allows the reader to
understand with clarity the circumstances of the patient’s illness or injury. This section is
especially important for WEMS providers because the environment of the incident may be
foreign to the health care provider receiving the patient in transfer. Additionally, the environment
has dramatic impacts on the patient’s condition and, in some cases, may be the primary etiology
of the patient’s injury or illness. Recommended best practices for narrative documentation from
the National Emergency Medical Services Education Standards are listed in Box 6.6. Out-of-
hospital documentation may take various forms, from traditional, hand-written, or checkbox
formats to computerized forms. Regardless of the documentation mechanism, all patient
information is confidential and subject to regulation through the Health Information Portability
and Accountability Act of 1996 (HIPAA). The National EMS Education Standard EMT
Curriculum highlights the importance of a basic outline for out-of-hospital documentation. Many
of the verbal handoff tools discussed in the previous section can serve as mnemonic guides for
the written documentation narrative.

Table 6.2 Verbal Communication Tools

Mnemonic Description Background/Use
Hospital-Based Tools
SBAR33,34 Situation, Background, Assessment and Developed from the US Navy into medical tool
Recommendations by Kaiser
Recommended by the Joint Commission’s
Institute for Healthcare Improvement and the
National Australian Clinical Handover Initiative
Institute for Healthcare Improvement, and
National Australian Clinical Handover Initiative
I-PASS35 Illness Severity, Patient Summary, Action Items, Studied as a resident transition of care tool
Situation Awareness and Contingency Plans, Demonstrated statistically significant decrease in
Synthesis by Receiver medical errors and preventable adverse events
Extensive training process required for use of the
tool
Out-of-hospital Based Tools (both In-Person and Pre-Arrival)
SOAP ± SAMPLE36 Subjective, Objective, Assessment, Plan ± Well known to most EMS providers
Signs/Symptoms, Allergies, Medications, Past
Medical History, Last Ins/Outs, Events Leading to
Injury/Illness
ASHICE17 Age, Sex, History, Injuries, Condition, Expected Out-of-hospital Notification
Time of Arrival Commonly used in England and Wales
ISBAR12,37–39 Identification, Situation, Background, Assessment Variation of SBAR, emphasizes need to introduce
and Recommendations patient and identify providers involved in
transition of care
Potential benefit in transitioning care of an
acutely decompensating patient
 (De)MIST40,41 Demographics, Mechanism of injury/illness, Adopted from Military Medicine originally used
Injury or illness found, Signs,a Treatment given in civilian trauma
Limited Data to support use
Familiar to providers (especially UK, Australia)
IMIST-AMBO20,42 Identification, Mechanism/medical complaint, May reduce need for clarifying questions, reduce
(combination of MIST Signs,a Treatment—Allergies, Medications, duration of handoff, and lead to fewer repetitions
and ISBAR) of handoff
Background (PMHxb), Other (Social)

a
Signs—includes vital signs, Glasgow coma score, and primary survey.
bPMHx—past medical history.

National Emergency Medical Services Education Standards Best

Box 6.6
Practices in Narrative Documentation

• Descriptive, not conclusive

• Include pertinent negatives, not just positives
• Record relevant observations about the scene
• Avoid radio codes
• Only use standard abbreviations
• Documentation of sensitive nature should include the source of the information
• Follow state reporting requirements
• Every reassessment should have a recorded time with findings

A focus group study by Meisel et al highlighted the need for technology to “close gaps in
information exchange.”43 In the traditional EMS setting, laptops as well as other portable devices
have become commonplace. Advancements in technology and the development of handheld
application-based operating systems, such as smartphones, tablets, and personal digital assistants,
have made electronic documentation in the austere environment a consideration. Free
application-based software allows providers to document comprehensive patient information in
an electronic device, without need for wireless of cellular connection. Run reports can be saved
into the device for transmission when an internet connection is available. Additionally, pictures
from camera-enabled devices can be attached to electronic runs sheets. Once connected to the
internet, out-of-hospital electronic medical records can be e-mailed and shared with receiving
providers. Even though the software is available, WEMS leadership will need to address many
logistical concerns, including secure transmission of patient-identifying data to prevent breaches
in patient confidentiality, availability, and cost of cellular- versus satellite-based
telecommunications, collaboration with local intercept/transport agencies, weatherproofing and
ruggedizing of electronic devices, battery life, and policies for addressing lost or stolen
hardware. Lastly, WEMS services would need to establish contingency plans given the
possibility for device failure.
Paralleling the obstacles faced between other austere realms of out-of-hospital medicine,
agencies, such as Federal Emergency Management Agency (FEMA), US&R Task Forces may
serve as models for documentation best practices (see Figure 6.1). US&R medical specialists
face many of the same challenges as WEMS providers. US&R documentation forms, which may
also be used for transfer of care documentation, are designed specifically to meet the unique
needs of the US&R provider, including a section on “Entrapment Time” given that patients
encountered by US&R providers commonly require confined space rescue. Additionally, on the
back of the form is extra space for narrative notes on medical history, medications, examinations,
interventions, and patient course as well as additional tables for vital signs and medications
administered. There is space to record multiple vital signs and multiple medication
administrations on this one document.46 Other nontraditional out-of-hospital providers, such as
military combat medics, have specifically designed documentation “cards” based on the Tactical
Combat Casualty Care (TCCC) curriculum (see Figure 6.2). These cards were originally
developed in 2007 by 75th Ranger Regiment medics and used during the Iraq and Afghanistan
conflicts. The data from these casualty cards “enabled the most comprehensive study on out-of-
hospital care rendered in a combat unit to emerge from these conflicts.”47 These cards were
endorsed by the Committee on TCCC and adopted by the Department of the Army. Importantly,
improvement to these cards have been made because of changes in TCCC as well as continued
monitoring and feedback of the out-of-hospital data.47 The cards used by the Army were
designed by field-level providers with intimate understanding of their unique operational milieu.
Development of out-of-hospital documentation, especially in the austere environment, should be
a collaborative effort that focuses on meeting national, state, or regional policies; best patient
practices; operational ease of use and addresses unique nuances of the environment of practice.
Most importantly from this narrative, they should provide a mechanism to easily feedback their
information into research and practice innovations and should be developed by or in conjunction
with the actual field providers using them.

FIGURE 6.1. Federal Emergency Management Agency (FEMA) urban search & rescue (US&R) patient documentation
example. From Federal Emergency Management Agency (FEMA). National Urban Search and Rescue (US&R) Response System
- Field Operations Guide. 2003;(September):122.
http://www.fema.gov/pdf/emergency/usr/usr_fog_sept_25_2003_color_final.pdf

FIGURE 6.2. Tactical Combat Casualty Care (TCCC) Card. From Kotwal RS, Butler FK, Montgomery HR, et al. The Tactical
Combat Casualty Care Casualty Card. TCCC Guidelines Proposed Change 1301. J Spec Oper Med. 2013;13(2):82-87.

Overcoming the challenge of documenting during a WEMS operation provides another

opportunity to maximize patient safety. With the exception of receiving providers who actively
listen to the verbal handoff, the written handoff is the only voice that will be heard regarding the
WEMS care. This is especially true when a patient has multiple transitions of care. Excellent
documentation leads to exceptional continuity of care.
One additional practice that may facilitate patient transitions of care, and could be applicable
to all scopes of WEMS providers, is pre-event communication and development of professional
relationships between wilderness and traditional EMS agencies. The purpose of such
relationships includes sharing policies and protocols, particularly those that are unique and not
shared across all agencies. Although this may not be possible in all circumstances, given that a
WEMS service may have a broader response range than corresponding traditional EMS services
and may interface with multiple such agencies, when possible, this practice offers an opportunity
for system leadership and members to better understand each other’s practice, policy, and
protocols. Given that mutual understanding and reciprocated respect have been demonstrated to
be important foundations to effective communication, the practice of pre-event communication
should be encouraged. This may take multiple formats and could not only include conversations
between system leadership and members, but may also include hosting joint trainings between
organizations with the expressed purpose of testing communication strategies and discovering
agency specific novel practices. For example, depending on the mechanism of accessing a
patient and the scope of providers attending a patient with chest pain, WEMS providers may not
have the capacity to perform higher level diagnostics, such as 12 lead electrocardiograms.
Receiving traditional EMS providers must be sensitive to the resource restrictions commonly
encountered in WEMS. Additionally, WEMS providers are commonly taught to practice
improvisation, and such improvised therapies may be foreign to traditional EMS providers, who
may be more familiar with a much more protocolized and nonimprovisational practice. Finally,
as discussed in prior sections of this chapter and discussed elsewhere in this book, although
common goals of care exist between wilderness and traditional EMS, the means of
accomplishing these goals may be different. Without communication prior to interface, these
differences could be confusing to receiving EMS or hospital providers. Examples may include
some of the patient packaging practices that may be standard for a WEMS agency but could be
novel to a traditional EMS agency. For instance, given that hypothermia is a nearly ubiquitous
concern in wilderness medicine, most WEMS providers will be familiar with some iteration of
the hypothermia wrap described in Chapter 13. Such patient packaging methods may not be
common to the traditional EMS provider receiving the patient. Additionally, given that WEMS
providers may have prolonged patient evacuations and need to address all of a patient’s needs
during this phase of care, the WEMS provider commonly considers methods to account for the
patient’s basic needs, including urination, defecation. These needs are not commonly addressed
in traditional EMS given the relatively short transport times (usually measured in minutes to 1–2
hours) when compared with WEMS operations (often measured in hours or even days).
As described elsewhere in this chapter, a common knowledge of the scope of practice
between all providers in the WEMS system and the traditional EMS system is essential for
effective communication and transfer of care. It is, therefore, imperative that the WEMS provider
understand with clarity the abilities and availabilities of responding traditional EMS providers. It
is equally essential that traditional EMS providers understand the abilities of WEMS providers.
Additionally, the realm in which each type of EMS professional practices may not be well
understood, and this misunderstanding could lead to miscommunication. It is certainly possible
to obtain understanding of each other’s scope of practice and common policies or protocols by
researching available local or state resources. An alternate mechanism of determining this
information is pre-event communication and collaboration as well as interagency trainings.

Advanced Life Support

The recommendations for first aid and BLS providers above all apply equally well to the ALS
level. However, it is at this level of care that issues of patient abandonment become particularly
significant. Patient abandonment may be defined as “the unilateral termination of patient care
and the provider/patient relationship when a patient requires the ongoing management of said
provider.”48,49 Abandonment is considered a form of negligence that includes termination of care
without the patient’s consent. Legally, abandonment requires the following:

1. Establishment of a provider/patient relationship through the initiation of care by the

provider in question and
 2. Cessation of that care OR transfer to a provider of lesser training when the patient care
requires a higher level of training.48,49

Additionally, as with all negligence cases, the person claiming abandonment must show
proof of harm as a direct result of the provider’s actions or omissions.50 (See Chapter 5 for a
more comprehensive discussion of abandonment.)
Given the above-listed models of interface between WEMS and the traditional EMS systems,
it is possible to envision wilderness ALS providers transitioning care to traditional EMS BLS
providers. If the ALS wilderness provider has initiated care outside of the receiving EMS
provider’s scope, abandonment may become a concern because the ALS provider may transfer
care to a provider of lesser training. If ALS providers have not initiated ALS care that the
receiving traditional BLS EMS providers cannot monitor or sustain, abandonment likely has not
occurred.
Many other, more specific situations may occur, and it is imperative that ALS-credentialed
WEMS providers discuss these situations with local medical authorities and consider the legal
potential for patient abandonment. However, regardless of the legal presence of patient
abandonment, ALS-credentialed WEMS providers must consider the medical and ethical needs
of the wilderness patient on a case-by-case basis, and be prepared to continue management of the
patient through transfer to definitive care, should the patient’s needs demand ongoing support
from wilderness ALS providers.

Clinician
The entirety of the discussion about various caregiver considerations applies to the WEMS
provider credentialed at the clinician level. They must be aware of communication needs and
tools, documentation, patient privacy, and all the other considerations discussed. Importantly, the
concerns regarding patient abandonment are equally important to this level of provider. As this
level of provider may initiate care well outside the wilderness or traditional EMS provider’s
scope of practice, it may be imperative to maintain patient contact and provide active patient care
through transfer to definitive care, especially if advanced therapies have been initiated in the
wilderness setting. Although most EMS providers operate under the supervision of a medical
director or other similarly situated physician, a clinician in the wilderness setting should at least
verify that such supervisory control is in place and consider talking to the supervisory physician,
before transferring care to the EMS providers. Such measures may reduce the clinician’s risk of
having to defend against an abandonment claim.
The 7th edition of Auerbach’s Wilderness Medicine notes, “The best risk management tool is
to assume that physicians who either implicitly or explicitly agree to treat a patient create a duty
to provide continuity of care.”36 Given these circumstances, and as noted in Chapter 5, physicians
can reduce their risk of liability for abandonment under the following circumstances:

The physician and patient mutually consent to terminate the relationship

The patient dismisses the physician
The patient no longer requires care, recovers, or dies
The physician dies or is disabled
Further rescue efforts would place the rescuer’s life in danger
The physician gives the patient reasonable notice of his or her intent to withdraw from the
care of the patient and, particularly in an emergency, continues to treat the patient until
 another qualified health care provider takes over the case.”36

Clinicians who inappropriately terminate the patient–physician relationship may face liability
under an abandonment theory, as well as breach of contract and professional negligence,
depending on the circumstances. Elsewhere, hospital-based physicians have noted to the
importance of WEMS information conveyed to hospital staff during patient handover.51

SUMMARY
All health care providers, including WEMS providers, must actively seek opportunities to
improve patient safety. Medicine in general has recognized improvements in communication and
facilitating transitions of care as essential components to reduce preventable adverse events and
improving patient care. Evidence from both in-hospital and other similar professions can help
guide further out-of-hospital and WEMS efforts to improve transitions of care. Paramount in the
transition of care is respect and trust between providers. Shared knowledge regarding scope of
practice is essential to tailor successful patient handoffs. WEMS leadership must be aware of the
level of care traditional EMS providers in a given region can provide in order to request
appropriate intercept/ transfer providers. Effective communication grows with confidence and
field experience. Training and education of junior providers will facilitate confident verbal
handoffs, which will, in turn, foster trust and respect among providers. Along with education,
implementation of a standard handoff tool may circumvent presumed assumptions between
providers as well as minimize complications unnecessarily arising from the “hierarchy of
medicine.” A reasonable starting place would be developing previous studied in-hospital and
traditional EMS models/tools for communication during handoff. Simulated practice and
rehearsing the transition of care from backcountry providers to front country providers are
equally important. Without working relationships developed through multiagency and
interdisciplinary training, WEMS risks contributing to the epidemic of adverse events. On the
other hand, given the complex web of interfaces WEMS providers are already adept at
navigating, our industry could emerge as leaders in a growing technology of medical interface
best practices and innovations.

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44. Jensen SM, Lippert A, Østergaard D. Handover of patients: a topical review of ambulance crew to emergency department
handover. Acta Anaesthesiol Scand. 2013;57(8):964-970. doi:10.1111/aas.12125.
45. National Highway Traffic Safety Administration. National emergency medical services education standards: emergency
medical technician instructional guidelines. 2009:9-12. https://www.ems.gov/pdf/education/National-EMS-Education-
Standards-and-Instructional-Guidelines/EMT_Instructional_Guidelines.pdf.
46. Federal Emergency Management Agency (FEMA). National Urban Search and Rescue (US&R) Response System—Field
Operations Guide. 2003;(September):122. http://www.fema.gov/pdf/emergency/usr/usr_fog_sept_25_2003_color_final.pdf.
47. Kotwal RS, Butler FK, Montgomery HR, et al. The Tactical Combat Casualty Care Casualty Card. TCCC Guidelines
Proposed Change 1301. J Spec Oper Med. 2013;13(2):82-87.
48. Maggiore WA. Patient abandonment: what it is—and isn’t. J Emerg Med Serv. 2007.
http://www.jems.com/articles/2007/09/patient-abandonment-what-it-an-0.html.
49. Maggiore WA. Patient abandonment part two. J Emerg Med Serv. 2008. http://www.jems.com/articles/2008/02/patient-
abandonment-part-two.html.
50. From the website, http://www.nolo.com/legal-encyclopedia/what-patient-abandonment.html. Accessed June 19, 2016
51. Trahan K. Leveling Up: from the Operating Room to the Backcountry. NOLS Blog. Available at
https://blog.nols.edu/2017/06/21/operating-room-to-the-backcountry. Accessed August 3, 2017.
INTRODUCTION
Once we leave home and maintained roads, we are probably entering wilderness or “out of
doors.” We are now hours or days or even weeks from traditional emergency medical services
(EMS), which we would otherwise count on for care. We are no longer in the golden hour or
range of reasonable response by a traditional ambulance team. We are now on our own, so we
should be prepared with our own training, medical devices, and associated gear.
In the wilderness, we have three common considerations. First, few of the items the urban
user would wish for are ever available in backcountry or wilderness location. Second, the need
and opportunity to improvise is great. Third, today many items have been made smaller, more
available, and now more affordable. The good news is that with a little preparation effort and for
a few dollars more you can be better prepared to give care without noticeably increasing the
weight of your medical kit or its cost. This chapter will help you look at these items. I will also
cover items that may keep you out of trouble: the emergency survival gear often referred to as a
part of the “ten essentials.” I have separated the medical items into the six categories Wilderness
Medicine Outfitters (WMO) uses to teach medical kit contents. The fifth category of medicines is
found primarily in its own chapter, Chapter 11. Categories seven (survival), eight
(improvisations), and nine (evacuation) are outside of the six medical kit contents, but are so
closely associated that we will cover them. Preplanning for these categories is far better before
they may be needed. Remember the old line, “proper prior planning prevents pitifully poor
performance.”1 We hope this chapter will help you chose your items wisely. Please note, a very
few items will be marked with an asterisk* indicating we recommend they only be used after
training and instruction with physician involvement and having a written authorization protocols
from a physician.
Many other items are also more useful with competent training. The Wilderness First Aider
(WFA, 16 to 32 hours) will have only basic training compared with the Wilderness First
Responder (WFR, usually 72+ hours) or Wilderness Emergency Medical Technician (WEMT,
usually 250+ hours). A “clinician” caregiver could be physician or highly trained and
credentialed nonphysician with great improvisational, medical understanding and heavy trauma
and illness coping skills. Other wilderness emergency medical services (WEMS) credentials
include the Academy of Wilderness Medicine Fellow, with another 100+ hours. There may also
be the rare Master Fellow, with many hundreds of hours of specific additional training in this
genre, a degree established in 2005. Different educational and certification opportunities in
WEMS are discussed in more detail in Chapter 2.
Wilderness is analogous to improvisation, which does not often lend itself to high-grade
evidence. Hence, much shared here is acknowledged as opinion based on the author’s own 60+
years’ experience in wilderness medicine and WEMS.

DISCUSSION OF WEMS EQUIPMENT

Choosing what gear to take requires careful deliberation and planning. Medical gear comes with
a price, weight, and space. It is helpful to have it “on your shelf” ready to go when needed rather
than rushing to a store at the last minute before a trip. Sometimes duplicates in different locations
are valuable. WMO instructors usually have a WMO Seven Essential Survival packet in each
backpack so there is no need to question where one’s survival kit is. This approach is often
helpful for basic medical items. Inclusion of all items should be carefully weighed against variety
of factors: area traveled, seasonal conditions, method of carrying, size of group, distance/time to
traditional EMS, and anticipated risks (Figure 7.1).

FIGURE 7.1. WMO Seven Essentials Survival Packet. For additional information go to
http://wildernessmedicine.com/product/survival-essentials-kit (Courtesy of Carl Weil and http://wildernessmedicine.com, ©
2016.)
Categories, Selection, and Organization
While categorization has proven helpful for students to learn what to include in their medical
kits, some items cross over from one category to another. An example would be a triangle
bandage, which can be in Orthopedics for an ankle brace, in Wounds for a packing or dressing,
or Personal Protective Equipment (PPE) as mask for either your patient or yourself.
Selection of medical gear is often trip specific and can be designed for anticipated conditions.
Examples include the following:

Desert cactus spines, especially cholla cactus, could require forceps or a handled comb.
Sunburn (or anticipation of more serious burns) could require aloe gel/hydrogel/watergel.
Skiing could reasonably be expected to result in broken bones, meaning more extensive
splinting material might be packed.
Hypothermia would indicate the need for heat packs.
Biking might result in road rash abrasions, requiring tweezers for gravel removal, scrub
brush (even just a toothbrush) for cleaning, water treatment tabs for disinfecting, and Tefla
gauze pads for less painful dressing.

Look for multiuse items, items that others have found useful in the operational environment.
Quantities needed and price are some of the consideration factors of what to include in the kit.
Organize equipment by categories in different colored, numbered, or named clear-sided
bags, pouches, or compartments to be easier to locate during emergency. Each bag could include
nitrile gloves to save hunting for or forgetting them. Pint and quart zip freezer bags are
inexpensive and more durable than ordinary sandwich bags for this use.
Size of all gear, especially that of little use for most outdoor ventures, is usually a factor best
held small. It is said you can only pack so much in a 5-lb sack before it explodes. The number of
people with you, the number of days, your level of skill, how much you want to spend, and the
method of carrying it all are decisive. The size of your kit will vary by preference and level of
training. Advances in training seem to bring a bell curve of kit size, with the less critical and
improvisational items eventually being left at home than carried in a backpack.
Typical guidelines for minimum kit sizes are 1 lb for day hike for four people, 2 lb for
overnight trip for four people, and 3 lb weekend kit for four people. Medical or rescue packs
often weigh 5 to 10 lb (Figure 7.2). Military field medics often carry 90 to 100 lb medical gear
plus 35 lb personal gear. In consequence, they commonly experience foot, ankle, knee, and
shoulder injuries one might expect from carrying such a heavy weight.

Personal Protection Equipment

PPE is slightly altered for backcountry purposes. Nitrile gloves may be used and are unchanged,
but the medical-grade glasses with drip shields and side shields are often replaced with wrap-
around light-tint sunglasses or mountaineering goggles. A smaller breathing shield is usually
carried instead of a larger mask. A larger pocket mask is a better seal and protection, yet takes
six times more space, costing twice as much (Figure 7.3). Some might carry a plastic disposable
apron used in food services, whereas others will improvise with the patient’s own Gortex or rain
jacket. A bar of mild soap is a great cleaner (emulsifier). Some like liquid soaps, but unless they
are double-bagged, they can leak in your pack. Although it is rarely talked about except in the
light-hearted Zombie-invasion scenario, some might include defensive weapons here. High-
quality training for these is an absolute must.

FIGURE 7.2. WMO Optimist, Bare Bones, Advanced Care. (Courtesy of Carl Weil and http://wildernessmedicine.com, ©
2016.)
FIGURE 7.3. Shield and mask. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)

Airway
Basic airway equipment in the wilderness is a mask or shield to keep infectious organisms in the
patient and avoid exposing rescuers to them. Size 100 oral pharyngeal airway (OPA) will fit
most adults. Add a size 80 for large children and small adults. We suggest the Guedel style OPA.
A new OPA is NUZON (Figure 7.4) with three times the price but one adjustable size. Nasal
pharyngeal airways (NPAs) are questionable because there are too many sizes (26) and lube is
required. Our favorite bag valve mask (BVM) is Pocket BVM by PerSys Medical, sometimes
called the Israeli or micro BVM (Figure 7.5). It is the size of a medium tuna can, is made of
silicone, and could be cold sterilized for reuse. It weighs 453 grams. Note it does take effort to
repack unless you watch their video or you sandwich bag the mask separately. The easiest-to-use
new airway is the supraglottic i-gel (Figure 7.6). It has two sizes fitting most adults, and no
laryngoscope is needed for its 30-second insertion. H & H Medical Company produces the Bolin
Chest Seal, three valves in line for small storage space, and a modestly priced chest
decompression needle.* On November 15, 2015, H & H Medical released an enhanced
pneumothorax needle of a Veress style, similar to a trocar, which should prevent catheter
collapse issues* (Figure 7.7). Manual suction pumps such as Rescue-Vac and others found on
many ton rigs in the EMS gear carry or jump bag will rarely be in a backpack kit, so we will
improvise with the patient’s cut-off drink bladder hose for suction. Aluminum O2 set-ups are at
base camps and rescue caches but rarely carried to the field. If carried, rescue crews typically
have two E cylinders in a pack by themselves or a modified C with other gear in a multi-item
rescue pack. The size, function, output, and price of O2 concentrator still make them impractical
for most applications in the backcountry.
FIGURE 7.4. Adjustable OPA NUZON. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)
FIGURE 7.5. Compact BVM—Israeli. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)
FIGURE 7.6. i-gel. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)
FIGURE 7.7. Chest decompression needle, enhanced pneumothorax needle, and Bolin Chest Seal. For additional information go
to https://buyhandh.com/collections/chest-seals-and-needles/products/enhanced-pneumothorax-needle (Courtesy of Carl Weil.)

Some expedition or advanced WEMS kits have additional advanced items: tool set for
suturing comprising needle holder, Addison tissue forceps, Kelly hemostat, curved Metzenbaum
scissors, plus a variety of internal and external suture packets. If there is concern for the need to
intubate (Figure 7.8), you may be carrying laryngoscope parts for the EENT Corpsman Set from
CMF Inc., consisting of fiber optic blade (mac or miller) and handle complete at 4 oz. You
probably will also carry two of each #6, 7, 7.5, and 8 endotracheal (ET) tubes. With a shortened
#6 ET tube, Kelly hemostats, #10 scalpel, and a News Tracheal Hook such as offered by H & H
and you have an improvised cricothyrotomy kit very close to those also offered by H & H.2

FIGURE 7.8. CMF Inc.’s EENT Corpsman Set. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)

Wounds
Hemorrhage control products are critical. During the Vietnam era, a sanitary napkin with tails
was called the “Blood Stopper” and became the new battle dressing. Military conflicts often
bring new products, such as the first compression bandage, the Israeli-developed compression
bandage, followed by the far superior American-made, Cinch Tight and H Compression
bandages from H & H used by the United States Marine Corps (USMC) (Figure 7.9). Clone
compression bandages are available, but usually cost as much or more sometimes with less
durability and efficacy. Although a compression bandage can be improvised, they are slower and
less effective than the factory ones, which have a tensioning mechanism.
FIGURE 7.9. Cinch Tight and H compression bandages. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)

Tefla plastic-covered gauze makes abrasion wound care less painful for the patient, and
several 3 × 4 pieces should be in each kit. If you are working around or responding to hunting
camps, you may choose to carry three XSTAT 30s (three is their recommended number).2 These
are injectable plastic pellets in large (6-inch) syringes cleared by the Food and Drug
Administration (FDA) in December 2015 for gunshot wounds. XSTAT 30 is not intended for
many areas of the body, such as the chest, abdomen, pelvis, or tissue above the collarbone. The
sponges in XSTAT 30* can be used for up to 4 hours, according to the FDA. Cinch Tight and H
Compression bandages with a hemostatic agent do not have those restrictions.
The tried and true original hemostatic agent QuikClot (QC) in any of its several forms has
saved many lives. Even in its original heat-producing form, a retrospective study with 103
seriously wounded military and civilians showed all who received prompt field application
survived. The use of hemostatic gauze (QuikClot Combat Gauze; Z-Medica LLC; www.z-
medica.com) in prehospital civilian care is safe and highly effective, with success rates of 95%.
This is from the retrospective Mayo Clinic study, which included 203,301 Gold Cross
Ambulance and 8,987 Mayo One Transport records; 52 patients were treated with hemostatic
gauze in the prehospital setting.3
Other common hemostatic agents are Chitosan, ChitoSam, or HemCon all made with shrimp
shell material of varying percentage. On my request, SAM Medical had a study conducted in
Taiwan, showing there were no iodine allergy issues with their ChitoSam production.
A chemically treated gauze called ActCel Hemostatic Gauze has been in dental use to control
bleeding for years with good anecdotal results.
Tourniquets have once again gained favor in a way not seen since the American Civil War.
Of course, amputations were common surgical interventions then, and we hope less so today
with modern surgical techniques. You should use a tourniquet when bleeding is heavy, especially
in patients on anticoagulants, antiplatelet agents, or hemophiliacs. This includes bleeding
suspected to be arterial, which cannot be rapidly controlled with a compression bandage, giving
concern for hemorrhagic shock. Full amputations often have some crushing effect that slows
down blood loss, while partial amputations often have a “torn or nicked” artery than cannot
constrict as easily and need serious help to control. In the urban setting and many combat
situations today, the patient is rushed to the hospital for surgery within 30 minutes. When
tourniquets are left on for longer than 4 hours (some say 6), we have a different situation leading
to potential limb loss. H & H Medical have done work indicating that a good compression
bandage will stop many horrific bleeds without a tourniquet.2
Most advanced care givers are sure they can improvise a fine tourniquet, but Lyles et al. in
2015 suggested improvised tourniquets may not be as efficacious as commercial ones. This
study, which looked at two types of improvised tourniquets versus the commercial Combat
Application Tourniquet (CAT), showed the improvised tourniquets to be inferior.4 However,
quality training, and most importantly practice with proper materials (strong 1-to-2-inch webbing
with strong twisting stick), could change that outcome. Although CAT may be the most popular,
H & H has the smallest, the Tourni-Kwik 4 (TK4) (Figure 7.10), which performed with
equivalent efficacy to the CAT in United States Navy testing.5 In this particular Navy testing, the
operators ranked Bound Tree Medical’s Mechanical Advantage Tourniquet (MAT) as their most
favorite, with CAT and TK4 coming to a close second.

FIGURE 7.10. TK4. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)

Traditional EMS textbooks discuss 60-cc bulb syringes for irrigation, but it is rare to see
more than a 20-cc syringe in a backpack. The syringe is usually a Luer Lok style with injection
needles for epinephrine (22 ga), antibiotics (18 to 16 ga), and large-bore plastic wound irrigation
tips plus smaller dental irrigation metal side port tips. Occasionally, some providers will have a
60-cc Luer Lock for irrigation and 5 to 20 cc for injections. Katadyn has an irrigation needle tip
for their “BeFree” hollow fiber either with pint or quart soft squeeze bottles, which with the
addition of their chlorine dioxide tablets (MP1) give a great backcountry wound irrigation with
local water (Figure 7.11).
Medical tape in a WEMS kit needs to be strong with more glue than found on the cheaper
brands. I recommend Johnson and Johnson (J&J) or the upper-price-point athletic brands in the
1.5 inch × 10 or 15 yd cloth rolls. The cheaper tapes have significantly less glue, so they do not
hold as well. Prepping the skin with benzalkonium chloride (BZK) wipes both cleans and
disinfects, reducing risk of infection and removing skin oils for better adhesion. Sepp applicators
of tincture of benzoin (TB) will give even better adhesion. Caps on bottles of TB are prone to
leak and may destroy your pack. Although we recommend Sepp applicators, if buying in bottles,
transfer contents to high-quality small bottles like Nalgene travel bottles. Providers should still
double zip bag all liquids for more pack protection. A field improvisation of TB is tree sap.

FIGURE 7.11. BeFree wound irrigation. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)

“Superglue” products (Krazy Glue and other brand names) are less expensive than various
medical-grade glues such as Dermabond, which are specifically designed and FDA approved for
wound closure. All these cyanoacrylates compounds work similarly, using the water from the
skin to create a strong bond. Some patients find nonmedical glues are more irritating and create a
“burning” sensation, likely because of solvents present in them but excluded from medical
formulations. According to its creator, Dr. Harry Coover, Super Glue was used in the Vietnam
War to help close wounds on soldiers.6 But as Forgey points out, “cleaning is more important
than closing.”7 That is critically true with glues that contribute to a bad infection reaction if
germs are sealed in. Although acetone and finger nail polish remover often remove the glue,
some glues are difficult to remove. Clean scrupulously first. We recommend using a bioclusive
dressing like Tegaderm as a covering to allow vapor out yet prevent infectious agents from
entering a wound.
A comprehensive dental kit can be built for less than $100 and used after only a few hours
training that could relieve a lot of pain by installing a filling, replacing a crown, doing an
emergency root canal, replacing an avulsed tooth, or removing a tooth.
Moleskin used to be the standard, and still may be the only, blister prevention product
available in thin form. We suggest using it in a laminated blister treatment package with Spenco
Second Skin, adhesive knit, and TB to hold the protective pack together. Two top blister
products today are Comped and Liquid Bandage, both from J&J. Little known but really great
products are Engo patches, which are uniquely applied to shoes, sandals, or boots themselves to
keep the blister from forming (Figure 7.12).
Sucking chest wounds can be treated with a plastic ziploc bag taped on all four sides, leaving
the lowest or downhill corner untapped to allow venting (Figure 7.13). In Wyoming, the
Asherman chest seal was created by a former Navy SEAL and since 2000 is owned and sold by
Rusch. Although there are a few similar devices today, the three in-line valved H & H Bolin
Chest Seal is our favorite and was preferred to the Asherman seal in a United States Navy study
(see Figure 7.7).8

FIGURE 7.12. ENGO, COMPEED, and liquid bandage. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)

Triangle bandages are far more versatile if they are 45 × 45 × 63 inches at a minimum, made
out of sheet-like material (tight-weave muslin) versus cheap-kit cheesecloth. You can cut four
corners off an old worn-out bedsheet and the two short edges are already hemmed. Washing
them with hot water and a little bleach followed with a hot dryer, then folding them to a small
package and putting in a zip bag makes them almost sterile and very useful. WMO prints key
points on their triangles in bright block letters (Figure 7.14). Bandanas, although handy for some
camp and personal chores, are too small for the many medical uses triangle bandages serve. Red
or orange are used by some for emergency signaling, with blue or black for heat-absorbing
headwear and white for heat-reflecting headwear.

FIGURE 7.13. WMO chest seal.

FIGURE 7.14. WMO triangle. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)

Duct tape, Gorilla tape, or other strong-adhesive tapes can be very handy in many
improvisational situations yet should be used with caution on the skin as they may have
damaging effect. When thinking of better skin care, Tefla- or plastic-covered gauze is best for the
first wound gauze layer as it is far less painful to remove. Nonlatex Band-Aids in 1-inch and
gauze pads of 4 × 4 inches can be made both smaller or into different shapes like eye patches so
fewer items need be bought and carried. The same is true with the 1.5-inch athletic tape
mentioned earlier, as it can be cut or torn to smaller sizes from the 1.5-inch size carried. The
newest entry in this field would be wound-closure sheets of clear plastic covered in heavy glue,
available from several sources. In its simplest form, it is a temporary wound closer for limbs or
torso, folded or rolled sheet to close an open wound on limbs or torso approximately 8 × 7
inches. It helps keep contamination out and blood in, and can be used to seal open lung air
passage ways.9
Other items of dual use would include 5 × 9 inches abdominal pads or individual wrapped
sanitary napkins and small tampons for intended use or for epistaxis/nose bleed and for modest
wound packing. The Rhino Rockets, solely for nose bleeds, are rarely carried backcountry but
could be carried by a WEMS team if felt to be particularly helpful in a given operational
environment, yet this is a single-use item that can be improvised by multiuse ones. A spare
diaper could also be a large abdominal wound pad. Coban, COFLEX, and various stretch self-
adhesive rolls offer better bandage securing than mere roll gauze. Many vet products are cheaper
and are as effective as higher-priced items intended for humans, although application of
veterinary products in an EMS environment may not be permitted by a medical director. There is
a place for elastic wraps, but not as frequently as some seem to use them, because they do not
have a predictable amount of support or compression as solid cloth rolls do.
 If actual wound closure is necessary after thorough cleaning and is permitted by the
provider’s scope of practice, it can be done with suturing, stapling, or with a multimedia wound-
closure processes, taught by some wilderness EMS schools, that takes far lower level of skill
than suturing.* With regard to suturing, aside from the small discussion earlier in this chapter,
we will not go into details of equipment needed because entire books are dedicated to this topic,
this is typically a clinician-level skill only in the civilian EMS environment, and choosing and
carrying a variety of suturing material possibly needed is a complex and clinician-dependent
decision. Staplers* are more likely to be available to a broad array of EMS provider types by
scope of practice and may have more usefulness in a wilderness environment in balancing
amount of different equipment that must be carried versus chance of necessary use. While
Ethicon has made staplers in operating room pistol size for years, they are not as reasonably
sized for field use as is 3Ms, which is only 3 × 1 × 0.5 inches. One also needs the staple remover,
which is packed in a 2 × 1 × 4 inches case, as infection could require early staple removal. There
are some staple size variations. Commonly, regular 5.4 × 3.6 mm or the wider 7 × 4 mm skin
staples are used.10 Implications for various provider types are discussed below because wound-
closure techniques have a wide variety of scopes of practice in EMS.
In the context of wounds in general, a more complete discussion of wound management can
be found in Chapter 21.
The advantage of a multimedia wound closure (TB, steri strips, semipermeable membrane,
and a protective pad) over staples and sutures is that suturing is a perishable skill and more
invasive as well as more prone to infection with removal issues in case of infection. Even the
easier applied staples are more complex in case of infection compared with multimedia closure.

ORTHOPEDICS
Splinting can effectively be done with the classic structural aluminum malleable (SAM) splint or
carefully selected clone version. The original SAM splint, made by SAM Medical, can be used
for many fracture instabilities including upper arm, lower arm, open book pelvis, lower leg,
ankle, hand, and cervical spine. Decades after the original SAM splint was introduced, SAM
Medical produced an XL 1-inch wider version great for bigger people. Both SAMs and well-
made clones have a thicker foam side which is placed next to the skin. Properly built, these
splints can be effective casts. With best technique and practice they can be built in minutes. You
could really push the improvisational “envelope” or in this case a “tube sock or sweat shirt
sleeve” with a Meade-Weil heavy mud splint design, allowed to dry and harden, which can be a
particularly useful way to replicate a more traditional splint or cast built with plaster.11
There are many more common local material items that become improvised padded splints
such as pack stays, tent pole sections, sticks, and others. Part of wilderness medical training is
learning to “see” materials that have a second use. Although various splints such as wire ladder,
inflatable, vacuum, cardboard, and padded board exist in standard EMS services, they are rarely
viewed as appropriate in wilderness use as they are bulky, awkward, often costly, and not
backpack-friendly.
There are several femur traction devices ranging from commonly used, complex, awkward,
expensive, and bulky, to the time-tested Kendrick Traction Device (KTD) weighing in at 20 oz
and costing around $125 (Figure 7.15). Traction splints such as the KTD can effectively be
improvised, with component practice again, using a longitudinal member, parachute cord, web
belt, and several solid triangles, with a resulting improvised traction splint shown to be
potentially as efficacious as a commercial product.12 Once again this improvisation requires good
training and a lot of practice, as well as having worked and studied the actual KTD. As noted in
Chapter 21, there is great controversy about the application of traction splints by EMS in general;
see that chapter for a more complete discussion of general traction splint use in the wilderness.
There are several improvised methods for cervical collars. Ambu makes today’s strongest
and most secure adjustable factory collar called the ACE, which includes four locks. This chapter
author has used the same one for training for 14 years, having almost worn off the Velcro
without collar failure (Figure 7.16). However, as noted in Chapters 21 and 24, cervical collars
are no longer considered of utility for WEMS operations.
For long responses or responses to extended treks, where a sprained or possibly a minor
fracture ankle could occur, a once-use-only device, such as one from Cramer or Mueller like
Active Ankle, could be in your kit. This allows the ankle to flex forward, not sidewise.
Wilderness Medicine Training Center (WMTC)’s field guide describes an Active Anklestyle
brace from a SAM splint and tape with WMTC’s unique design (Figure 7.17).13
In the context of orthopedic injuries in general, a more complete discussion of trauma
management can be found in Chapter 21.

FIGURE 7.15. KTD. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)

FIGURE 7.16. AMBU ace collar. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)

Medications
Medications are covered in detail in Chapter 11. A few equipment-specific thoughts are added
here.
There are specialty medications in many outdoor fields. Some are treatments and others are
helpful for prevention. For decades, diphenhydramine was considered to be the first drug for
anaphylaxis. In more modern pharmacologic management, epinephrine is now the first-line drug
as soon as a condition is defined as anaphylaxis. In the context of WEMS equipment, I feel
epinephrine should be a standard part of every WEMS medical kit. Loratadine (Claritin) and
ranitidine (Zantac) can be administered together as H1- and H2-receptor histamine blockers,
respectively, in the hope of synergism blocking H3 and H4 receptors with little drug interaction
with other medications. As of 2016, loratadine is the only antihistamine allowed by the Federal
Aviation Transport Administration (FAA) for pilot use, which could be critical for self-rescue
from a remote area where one must stay mentally sharp whether evacuation involves air or not.
This would be equally critically important to know for a WEMS pilot. Diphenhydramine is a
sleep inducer and used for a primary effect rather than side effect in many sleep medications, and
hence it can be counterproductive to rescue operations which always need clear thinking.
Few like the feel of DEET (N,N-diethyl-meta-toluamide), which is acknowledged to melt
plastic and nylon but does also keep away mosquitoes, which may be the world’s largest killer
by means of infectious disease transmission (see Chapter 20.1 for further discussion of infectious
diseases in the WEMS environment). Picaridin may be preferable for WEMS operations as it has
fewer negative issues and in 20% formulation or stronger may outperform DEET. Unlike DEET,
however, picaridin is odorless, nongreasy, and does not dissolve plastics or other synthetics.
Permethrin is a synthetic form of the naturally occurring insecticide, pyrethrum, which comes
from the Chrysanthemum genus. It is not a repellent but an insecticide washed into clothing.
Cold and heat packs are often used in EMS operations. See Chapters 13 and 14 for more
complete discussion of the management of cold and heat injuries, respectively. Cold packs are
rarely carried for the reason that they are not reusable and are rarely needed because there are
often other cold options in all but tropic or summer desert locations. Heat packs exist in several
forms. The acetate gel/liquid reusable unit has dozens of uses commonly while delivering up to
an hour of very warm heat. Wrap them in cloth or the toe half of an old sock to keep from
damage by means of contact with the side of boiling water pan when reactivating. Bring the
water to a covered boil and then let it cool by putting it in a small plastic box to prevent any
accidental triggering. The one-time-use iron sand packets work slower at altitudes over 2,400 m
(about 8,000 ft) and should be shaken for a longer time out of their package to work faster.
Although MRE (Meals, Ready-to-Eat) hydrogen heaters are light and highly effective, they must
be carefully used away from open flames and care must be taken not to burn the patient.
FIGURE 7.17. Walking ankle splint. (Courtesy of the Wilderness Medicine Training Center and Paul Nicolazzo. Adapted from
Nicolazzo P. Wilderness Medicine Handbook, 4th ed. Winthrop, MA: Wilderness Medicine Training Center; 2016. Available at:
http://www.wildmedcenter.com/.)

Personal medications* should be easily accessible in one’s own EMS pack. A second set in a
separate pouch should be with another person in the event medications are lost, damaged, or
destroyed.
BZK wipes are in many kits for cleaning and disinfection. Many carry these as opposed to
the older, now less-favored alcohol pads, which seem to dry out faster.
All FDA-approved medications since 1979 show an expiration date14; however, many are
effective after the “x date.” It is considered good practice to replace items so they are in date.
That becomes a different discussion often with more legal implications than medical ones. For a
more complete discussion of the legal, medical, and pharmacologic considerations of drug
expiration, see Chapter 11.

Tools
Medical tools and survival items are analogous to flavors of ice cream—some like vanilla, some
like chocolate, or so goes an adage. Yet there are 52 other flavors at some stores, like butter
brickle. I will show you the chocolate and vanilla flavors and an occasional orange mandarin,
knowing you will sort through and possibly find a different flavor than any flavor we share, but
we hope it is an effective starting point. And, of course, medical tools vary widely depending on
the operational environment in which the WEMS works and responds.

Intravenous Fluids and Accessories

For basic intravenous (IV) fluids, you will need drip sets, catheters, and a few bags of normal
saline or Lactated Ringers. There is greater discussion of these medication delivery tools in
Chapter 11. Foley catheters are rarely needed or used during backcountry trips, but are critically
needed during long trips, and so Silastic catheters in 12 French (F), 14F, and 16F might be
carried in prolonged medical operations kits.
Multitools are handy and easily carried if not too large or too small to be weak and hard to
hold. True multitools would include the SOG small power pliers with its tweezers-tipped needle
nose and one side off set points good for many medical tasks such as cactus spine and porcupine
quill removal. The needle-nosed ones can improvisationally serve as suture needle holder and
can be used in a set of two SOGs for staple removal. Gerber makes pointed-nose model with
replaceable carbide wire cutter inserts. Double-toothed multitool saw blades such as Kershaw’s
are said to be the best improvised choice for the rare field amputation.15 Trauma shears are
sometimes seen in advertisements cutting pennies for two reasons: first, the American penny is
made of copper and hence is softer and easier to cut; and second, and perhaps more importantly,
you would buy a new pair more often because cutting the penny will destroy them! Today’s
steel-core pennies could even slightly damage Leatherman’s $70 Raptor shear, which has the
heaviest blade in a multitool available today. Some carry a rescue knife as a smaller item than a
trauma shear. Two good examples of multitools are SOG and Gerber (Figure 7.18), who have
needle nose pliers that can be used for suturing, splinter removal, or, with two multitools, staple
removal. Leatherman’s Raptor shears—with its folded, small-sized, solid, large, locked open size
with glass punch, metal cutter, and heavy trauma blades—is unique and worth considering
(Figure 7.19).
 The only three full-feature rescue knives of which we are aware are from Skedco, Gerber,
and Schrade. Skedco’s German steel, half-serrated blade, double locker, rescue folder knife may
be the highest quality knife of the three. Gerber’s Hinderer Rescue and Schrade’s Rescue are
both double locking, folding, and fully serrated. All three uniquely have the rarely needed glass
pinch and frequently needed blunt, patient-safe blade with oxygen wrench key and web cutter.
Many so-called rescue knives with a sharp point are patient liabilities that should never be used
with a patient to avoid being accidently cut. A few other “rescue knives” have a good blunt tip
blade but not the other features, some of which are very useful. There are few true rescue knifes
that are more useful, having at least six features: a web cutter, a patient-protective blunt tip, a
partially serrated and locking blade, an oxygen wrench key slot, and a glass punch. Figure 7.19
shows the three I found that have all of these features: Gerber’s Hinderer, Schrade’s Rescue, and
Skedco’s Rescue. Gerber’s Hinderer is made in the United States, whereas Skedco has top
German steel. Schrade’s product is made in Taiwan and has an assisted opening with double
locks that work in open and closed positions, which is a rare feature.
Tweezers are handy, yet in the multiuse concept, hemostats or pointed-nose multitools like
SOG’s Power Pliers can do the job. If you find yourself having a cheaper pair of tweezers, you
can first file the points to make the legs the same length, and then polish them on a whetstone,
giving you a fine-quality tool good enough for tiny cactus spines.

FIGURE 7.18. SOG and Gerber multitools. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)
FIGURE 7.19. Top: Hinderer’s, Skedco’s, Schrade’s rescue knives. Bottom: Leatherman Raptor multitool. (Courtesy of Carl
Weil and http://wildernessmedicine.com, © 2016.)

A magnifying glass is handy, both medically (to see small items needing removal such as
splinters or thorns) as well as in a survival context, for fire starting. See Chapter 12 for a more
complete discussion of survivalism in WEMS operations. The small Fresnel plastic magnifying
lens is sometimes free from target pharmacies for their eyesight-challenged customers to read pill
bottle directions.
Space blankets range from the approximately $1.95 versions available at retailers like
Walmart (good only for shredding in high wind to confuse enemy radar) to high-quality ones
with reinforced fibers going 90 degrees to each other with over 200-lb strength, like the well-
known Space Brand All-Weather blanket. Sealed reflective vapor bags are more expensive than
the shirt-pocket-size economy versions, but they hold up better. They range from $15 (Space
Brand) to $48 (Blizzard Brand) double-wall box construction used by some British troops
(Figure 7.20).
Safety pins as a tool have value. Although one wilderness medicine applications suggest
their use in maintaining an airway, in our opinion this should not be a planned EMS intervention
—an OPA should be purchased and used for this purpose. If you or your team is bothered by the
size or weight of carrying three OPAs, you could buy and carry one NuZone adjustable 80 to 110
OPA.
Automatic external defibrillators (AEDs) are not on most lists, yet in backcountry it is likely
the only tool that can save one from a real cardiac event. You might see one on a well-equipped,
top-tier, guided trip catering to older adults. The smallest, lightest FDA-approved AED currently
available is the HeartSine (2.4 lb), with the best dust and water protective durability rating, 56 ip
(International Protection marking, indicating a very high level of dust and water protection),
measuring 8 × 7.25 × 1.9 inches. It retails for around $1,000. Reconditioned units are sometimes
available at one-third to one-half price reduction. The Swiss have a proven-quality, non–FDA-
approved AED called FRED at less than one-half the HeartSine size and weight. For a more
complete discussion of the appropriateness and use of AEDs in WEMS operations, see Chapter
22.

FIGURE 7.20. Blizzard bag double-wall box reflective construction and all-weather two-direction reinforced Space Brand
blanket. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)

Pulse oximeters are very useful if you are trained to understand their results and limitations.
Pulse oximeters are now durable and very small (eg, 1.5 × 1 × 2 inches), with top quality units
costing under $45. The actual use of pulse oximeters during WEMS operations are discussed
further in Chapters 20 and 15.
Thermometers are helpful especially with self-care, as it is hard to assess one’s own
temperature by touch. Most modern thermometers are electric, with the associated failures and
battery issues in the wilderness environment. Glass thermometers, on the other hand, are subject
to breakage or fluid separation in the high heat. The basic inexpensive fever temperature strip,
with its low cost, no battery, durability, and small size, is a reasonable choice, but does not show
hypothermic low levels and may lack the accuracy, which in most cases is not an issue even
though some protocols seem to have an obsession with such precision and are desired for EMS
operations.
Special-use tools could include limited-use items such as mist bottle that can be carried to
cool a patient, although it is probably better to use the multiuse drinking bladder system, which
most people in every group carry today. Not only does this multiuse item hydrate its owner, but
it is also a mist spray for evaporative cooling hyperthermic patients, irrigating wounds with mild
pressure and in an emergency can be used for rectally hydrating the unresponsive patient (with
their own drinking system). A 10- or 20-cc sterile lurlock syringe can be used for drug delivery,
for better wound irrigation with a wound irrigation needle, and for dental work with a special
dental irrigation needle.

FIGURE 7.21. WMO 4 oz. stethoscope. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)

While the Sawyer Extractor is somewhat controversial in terms of its efficacy, it has
anecdotal cases of beneficial use with stings and insects. Twenty million have been sold without
one notable published case study of harm to patients. There is a study showing beneficial parasite
botfly extraction using the Extractor.16
Few carry or need a blood pressure cuff or sphygmomanometer, but a stethoscope is far more
useful for an EMS provider. Although heavier, with admittedly better sound, the WMO
backcountry 4 oz is better than a bare ear against the chest (Figure 7.21). The palpation BP
methodology saves the weight of 3-lb blood pressure cuff. Said cuff rarely saves the patient
where other equipment might. Of course when a vehicle is available, a 2-lb scope and 3-lb cuff is
not an issue and does permit more precise and accurate blood pressure measurement.
Common surgical tools, useful in many ways, are scalpel handles with three each #10 and
#11 foil sealed blades and Kelly hemostats.

Survival Equipment and the 10 Essentials

EMS provider’s personal survival equipment for your unexpected night or being unexpectedly
stuck out longer is essential to prevent from becoming an additional patient or worse. Note that a
more complete discussion of survival in EMS operations is found in Chapter 12.
There are 10 categories of these essentials you should practice with on a nice day in your
backyard before entrusting your life to them, in a far-from-help unexpected night out. The 10
were probably originated by the Seattle-based organization, The Mountaineers, in the 1930s and
are subject to change depending upon your operational environment, such as ocean or desert. The
Mountaineers added their list of 10 essentials to the third edition of their publication
Mountaineering: The Freedom of the Hills in 1974.17 That list is published here, with the
exception of “signal.” There are a few different lists of 10 today, but we feel this is the most
effective list for WEMS operations. The oldest Boy Scout books dwelt more on the skills than
the “tools.” The following text describes the 10 essentials. As a guy I know says, “Any tool will
do if you can do.”

Ten Essentials

1. Extra food should be carried, such as power bars including other high-calorie items you
will not be likely to rob from your kit to eat because they taste good. One physician in the
past has humorously suggested dog food, since you will not eat it until a true emergency
arises!
2. Extra water should be carried, planning for 2 to 3 days of emergency rations consisting of
a quart per 100 lb body as survival minimum, as well as ways to treat nonpotable water
found on the way. Knowledge of water treatment has changed over the years from halogen
commonly used in WWII, to iodine, which was abandoned in the 1990s by the World
Health Organization due to its ineffectiveness with protozoa (crypto and giardia) and
iodine-induced problems, to today’s only EPA-tested and -approved chlorine dioxide, 90%
of which is sold under the name of Micropur MP1 by Katadyn. The major water treatment
outdoor companies are Katadyn and MSR, both with many devices, yet only Katadyn has an
EPA-tested and -approved “purifier” called My Bottle. There are several hollow fiber filters
on the market that under good conditions may provide safe drinking water, but only the new
Katadyn BeFree filter has an easy testing system with visual inspection to check safe
function critical with any hollow fiber filter as there is no free lunch. The BeFree has a
solid, clear look, and soft feel unlike any other hollow fiber filter. All filters require careful
use to prevent accidental cross-contamination. Having BZK wipes handy to keep outlets,
bite blocks, and other cross-contaminable areas clean is a good idea (Figure 7.22).
3. Shelter, like many of these topics, is broad ranging. Lower ends include unusable shirt-
pocket-size foil sheets (as noted earlier, great for shredding in high wind to confuse enemy
radar), to a Gore-Tex two-person bivy sack or tent. Within that spectrum, one can find large
road-side heavy trash bags to the British hard-vacuum-packed “Blizzard bag” with triple-
layer insulated cells made of box construction.Perhaps the Space brand two-directional
reinforcing fibers “Emergency All-Weather Blanket” that will hold 200 lb before tearing is
a good middle choice as well as a strong nylon tarp. Like many of the 10 essentials, a mid-
choice can be a starting point for you or your team, to be upgraded later. Do not necessarily
pick the cheapest because your life may depend on your choice (see Figure 7.20).
FIGURE 7.22. Katadyn BeFree maintainable water hollow fiber filter. (Courtesy of Carl Weil and
http://wildernessmedicine.com, © 2016.)

4. Extra clothing is seasonal and both location and trip length dependent. Remember to factor
in how many you are responsible for. In the winter, wool and synthetics are often the norm,
including mittens versus gloves and balaclavas versus ball caps. Cotton in the summer and
in dry climates as found in western United States offers opportunity for evaporative cooling.
Desert ear and neck covers can be added with a white bandana to the common ball caps.
Even in the summer, desert nights may be cool, needing extra insulative clothing besides the
long-sleeve sun protection factor (SPF) fabric for moisture containment and sun protection.
The desert night may be more comfortable with jacket or pullover, socks, and mittens.
Further discussion of clothing for specific hot and cold environments can be found in
Chapters 13 and 14, respectively.
5. Fire options include metal matches or flint rods with a magnesium bar, which are my
favorite. The pocket lighter from the disposable to the well-made are top tools, as well as
life boat matches and won’t-blow-out birthday candles. It is better to practice fire building
on a nice day and then practice on a rainy day at home before that disastrous rainy EMS
operation. Few today use real flint, steel, and char cloth or fire drill as done in my youth.
Today some will polish an aluminum pop can with chocolate and use the sun to make a
focused heat point for fire. Stoves can provide a hot beverage, which can help morale and
hypothermia with a hot cup of cocoa or liquid Jell-O and bring water to a boil for safe
hydration. Knowing what fuel will be available sometimes causes concerns over which
stove to carry. No stove with fuel is smaller than the old Svea 123 still made today and
burns all liquid fuels. The new Optimus Polaris Optifuel multifuel uses all liquid fuels from
auto to jet fuel. It is a pocket stove just slightly larger than the Svea and will uniquely use
propane–butane mix canisters in both liquid or gas modes (Figure 7.23).
FIGURE 7.23. Optimus Optifuel small multifuel stove. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)

6. Lights now are mostly light-emitting diodes (LEDs) whether in handheld form, headlamp
form, or a small squeeze light form. Lightweight, small size, longer battery life, durability,
and low cost are the reasons. I suggest a small one without the switch that could
accidentally be left on for pocket or backup to your choice of headlamp. My belt pouch
carried LED light is my most used item and a great safety aid. US-made reliable brands are
Princeton Tec and Petzl.
7. Map and compass have advantages for there are no electronics to go bad or battery to
change. Compasses are more useful when combined with a map. Maps were updated at
seemingly random times but today they are on a 3-year cycle.18 A few compasses are
manufactured, with some models easier to use (various sighted models) and more reliable
(liquid filled and jeweled) (Figure 7.24). They vary as to the number of luminescent hours
they are rated for by price. The GPS has replaced map and compass for many, as the cell
phone has replaced the analogue watch, which can also act as a compass with the sun.
FIGURE 7.24. Compasses from Silva, Brunton, WMO, Suunto. (Courtesy of Carl Weil and http://wildernessmedicine.com, ©
2016.)

8. Signal devices range from the humble whistle (good for 50 to 100 yards) to the electronic:
DeLorme products (now owned by Garmin), SPOT satellite messengers, Emergency
Position Indicating Radio Beacons, Personal Locator Beacons, or satellite phones. In
between, we have plastic (or for better distance glass) mirrors, cell phone, and radios,
ranging from small handheld family talk-about radios to ham radios. Various flashing
signal-light LEDs usable also to see in the dark are available. Flares may be helpful but are
limited use and can start fires, yet dye packets may be seen on calm waters from the air.
Some of these signaling devices are discussed in more detail in Chapter 25.
9. Medical kit is the primary topic that this chapter addresses, so the discussion here will be
brief. A few general thoughts are to review your kit after each trip to replace what was used
or is now expired or damaged. Double bag all ointments and liquids. Use Aloksak bags or
heavy freezer-zippered bags. To find things easier, use black marker to label the bags. Have
a backup kit on larger trips. Be careful when buying kits on the basis of number of contents
as large numbers are often merely more Band-Aids. Include the frequently used items and
the critical though seldom-used items. Add a waterproof wilderness medicine field guide
(see Figure 7.29). Consider carrying waterproof paper with grease pen or pencil to allow
recording even in the wet weather, which causes ink pens to run, smudge, and blur.
Wrapping SAM-style splints and emergency blankets around the kit contents helps protect
them (Figure 7.25). My backup EMS/med/survival kit is worn daily on my belt and
contains two aspirin, BZK wipe, magnifying lens, tweezers, two safety pins,
cardiopulmonary resuscitation (CPR) shield, compass, LED light, whistle,
flint/magnesium/striker, 1-inch Band-Aid, three nitrile gloves, and four MP1 tabs.
FIGURE 7.25. WMO Harper belt pack with SAMs wrapped around fragile items. (Courtesy of Carl Weil and
http://wildernessmedicine.com, © 2016.)

FIGURE 7.26. Swiss Locking knife. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)

10. Knife (or other blade) may be contained in a multitool or be a medium 4-inch full-tang-
blade belt knife. The full tang means the steel runs from knife point to far end of handle
giving it maximum strength for harsh survival use. The belt knife is considered by many far
superior to any folding knife, which by definition could fold up on one’s hand even if it is a
locking version. However, if a folding style is used, a locking version is far preferred. The
 common Swiss Army style (Figure 7.26) even comes in a locking, safer using version.
Photo shows a selection of four belt knives. The handles should be molded rubber-like
material for great grip. The blade steel should run to the end of the handle called a full tang
(for max strength) and have a rounded blade end for skinning game if needed. The smaller
belt knives like the SOG Field Pup are more apt to be carried, and hence very importantly
useful compared with the large machete or Bowie style often left at home or in the truck.
Hence, a smaller knife will be carried with you when it is critical. SOG Field Pup, Gerber
StrongArm, Buck Omni Hunter, and Schrade Frontier with metal flint match in sheath are
shown as good representative examples of modestly priced (under $80) and well-made
useful choices (Figure 7.27). The Randall knife your father carried in WWII is probably
kept in the bottom drawer or, like mine, on the wall, but rarely carried, for fear of loss in the
field. Although wire saw are small and better than nothing, a hand-operated tool of chain-
saw-blade-linked pieces such as Ultimate Survival Technologies are far more durable and
faster cutting. Axes in average or unskilled hands lead to accidents and should be
increasingly discouraged in the backcountry without special training (Figure 7.28).19

FIGURE 7.27. SOG, Schrade, Gerber, Buck. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)
FIGURE 7.28. Chain saw. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)

NONESSENTIAL ESSENTIALS
Nonessential Essentials is a category WMO invented, reflecting the individual’s true needs for
their situation. This also allows for the variations in 10 essential lists in this chapter. The WMO
Nonessential Essentials is included in Box 7.1 WMO Nonessential Essentials is included.
Carrying a true wilderness medicine field guide is a good idea for many, especially if
wilderness emergency medicine is not their primary job. It should be shirt-pocket sized,
waterproof, practical, and have lots of reminder drawings. There are good ones that vary with
different ideas from some of the outdoor wilderness medicine schools. Field guides from
numerous wilderness medicine schools were requested for this chapter. The four field guides in
the photo were received from WMO, NOLS Wilderness Medicine, WMTC, and Stonehearth
Open Learning Opportunities (SOLO). The first three are on durable, outdoor-friendly,
waterproof material. All are helpful and modestly priced. Each reflects some of its originating
school’s philosophy and noteworthy practices (Figure 7.29).

Improvisation
There will be instances in which the “right” tool for the job just is not available. In these
situations, one must make do with the resources at hand, often outside the equipment’s intended
purpose or use. I have mentioned some improvisations elsewhere in this chapter and will discuss
improvisation in more depth now. Sometimes the item is thought of for only one purpose, yet
others can be brought into play. Here are examples from WMO’s play book.
Box 7.1 WMO Starter List of Nonessential Essentials
1. For protection from the most common outdoor damage to the largest body organ, skin cancers, we recommend
sunscreen with a minimum of SPF 30 along with lip balm of similar protection for each person.
2. Sunglasses or goggles should also be carried.
3. Have a positive attitude, travel with a partner, and check the weather forecast.
4. Duct tape/gorilla tape, soft iron wire/baling wire 10 ft, heavy plastic ties
5. Two, minimum 1-quart water bottles or bladders
6. Personal medications
7. Cook kit with at least or maybe a tritium cup or small pot
8. Clothes appropriate to local area with medium-weight leather gloves
9. Electronic signal units: EPIRB/cell phone/Garmin/SPOT
10. Solar cell to recharge batteries, backup LED head lamp
11. Foam pads for insulation and padding for patient packaging and transport
12. 8 × 10 ft light durable tarp, p cord/550 cord—50 ft
13. 80 ft × 8 mm rope and/or 22 to 30 ft of 1-inch tubular webbing
14. Pocket saw from real chain saw links, multitool—needle nose
15. Repair gear/sewing kit, dental floss—wide waxed not Gore-Tex, safety pins
16. Survival firearms (22/20 ga over and under, 357 revolver 4-inch minimum [superior training, local law knowledge, and
concealed permit strongly advised])
17. 50 rounds ammo for each fire arm plus larger-caliber rifle in Grizzly or Kodiak country
18. Food bag with tree line, bear canister, and bear spray
FIGURE 7.29. WMO, WMTC, NOLS, SOLO field guides. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)
FIGURE 7.30. WMO triangle carry. Make a woven set ring out of one large or two small triangle bandages or webbing for
patient to sit on, while rescuers hold the patient with patient’s hands over rescuers’ shoulders.

The humble safety pin became a special tool in the hands of a Littleton, Colorado physician
who inserted it in the hole into which the germ-filled tick has buried its head. The pin is pulled
back against the tick which quickly pops out without time to leave more poison in the patient.
Here is one of mine using a large WMO triangle. Roll it up lengthwise into a firm cravat
weaving it into a lose 8-inch circle with the ends overlapping. Two rescuers put their opposite
hands into the 30 circle with thumbs on outside. The patient sits on their ring hand and the cloth
ring. The carry is done with each of the patient’s hands held as a safety if they pass out during
carry (Figure 7.30).
The common 1-inch tubular webbing becomes a 6- or 4-man litter, a harness, one- or two-
person drag. The drawings show 20 ft of 1-inch tubular webbing tied at its ends together with a
water knot. The oval is laid out on ground 3 ft wide. The middle is pulled inward from each of
the long sides shaping 3 loops. If only 4 carrying rescuers are available, the loop on one end is
folded over the center loop making 2 loops to be carried. This is improved if a rectangular-folded
blanket, tarp, or tent with or without a foam sleeping pad is placed on top of the webbing under
the patient (Figure 7.31A, B).
FIGURE 7.31. A, Six-person WMO 20-ft webbing carry. B, Four-person WMO 20-ft webbing carry.
FIGURE 7.32. SOLO sling swath. (Courtesy of Lee Frizzell and http://soloschools.com/, © 2016.)

An arm sling and swath is nicely improvised from a jacket as taught by SOLO instructors,
demonstrated in Figure 7.32.
A knee splint permitting walking knee stabilization can be made from sleeping foam roll cut
pieces. The technique, as taught by NOLS instructors, is shown in Figure 7.33.
FIGURE 7.33. NOLS knee stabilization. (Courtesy of Tod Schimelpfenig and https://www.nols.edu/en/courses/wilderness-
medicine, © 2016.)

An ankle walking stabilization improvisation similar to an ActiveAnkle© can be created

from duct tape and a SAM splint, as shown in Figure 7.17.
The small bright AAA Pelican Mitylite can be fitted with a variety of mini tools. Voila, we
have a miniature EENT (Ears, Eyes, Nose, and Throat) kit that will examine and clean a wound;
check for abrasions to the eye surface enhanced by fluorescein ophthalmic strips and a cobalt
blue lenses; remove ferrous metal objects from the eye with a fiber-lit, smoothly protected, small
magnet, as well as nonferrous metal with a soft, fine nylon fiber loop; check the state of the
eardrum with 1-oz. 3-power magnification otoscope head to slip on the Mitylite; or check the
back of the pharyngeal space with a 90-degree light bender. These are just some of the cool add-
ons to the Mitylite from CFM Technologies that fit into the pocket-size corpsman EENT case
(see Figure 7.8).
In 2013, I along with other authors published “Retrieval of Additional Epinephrine from
Auto-Injectors,” demonstrating a technique to obtain multiple four additional doses from a
traditional auto-injector.20 This was the most read article in that medical journal for many years.
The practice described there should not be standard operating procedure and should be confined
to emergency situations only.
Remember that improvisational interventions are for emergent situations that usually could
not be preplanned for. They are not to save money or space. Remember, as with the emergency
doses of epinephrine from any of today’s many auto-injector, there is risk to the operator
especially if they are not tool and knife experienced. DO NOT perform improvisational
interventions if you are not well practiced in them. Get competent training because the patient
can also be hurt if the improvisational technique is poorly or incompetently done. Here is a dual-
injury example. Imagine, you use an old tarp or blanket, making a litter and pick the patient up
with some rescuers looking down or not listening. This approach might injure rescuers’ backs,
and maybe drop the patient, who now has a concussion or also an injured back! You must have
all rescuers’ attention before all actions. All must have their bodies arched forward, heels and
hips in line with shoulders and have their chins up, looking up, to minimize rescuer back injuries
per current EMS ergonomic recommendations. The patient must be test lifted only 6 inches to
make sure the system holds solidly, yet does not hurt the patient if the litter fails during the test.
If you have not been thoroughly trained in these critical skills, do not do them!
Because parachute cord and its parts are used for many improvs, you may ask what it is. The
sheath of MIL-SPEC MIL-C-5040 Type III parachute cord is braided from 32 strands, whereas
the core is made of 7 to 9 three-ply yarn strands. Civilian versions are often far less. Less of any
aspect drops the strength from the 550-lb breaking strength to as low as 50 lb. There are many
uses of parachute cord, also known as P cord or 550 cord. A suggestion is that you buy the real
parachute cord rather than light unknown-strength twine. The black parachute cord is said to be
stronger due to lack of bleaching.

Evacuation Equipment
Wilderness EMS evacuation tools range in cost from high-tech multimillion-dollar vehicles such
as a helicopter to patient movement tools such as Stokes litter, Reeves, Junkin or Thomas Basket,
Skedco plastic roll or big wheels, to name a few top products. While rescue teams will have
these expensive devices, few small recreational parties who do a large percentage of rescues will
have them, too. Everyone and any one can carry or has one of these: 22+ ft of 1-inch tubular
webbing, a strong blanket or tarp, or a climbing rope. You can improvise a great carry solution in
short time with simple items like these. Twenty feet of 1-inch tubular webbing tied at its ends is
laid out on ground 3-ft wide in a long oval. The middle is pulled inward from each of the long
sides shaping 3 loops. If only 4 carrying rescuers are available, the loop on one end is folded
over the center loop making two loops to be carried. This is improved if a rectangular-folded
blanket, tarp, or tent with or without a foam sleeping pad is placed on top of the webbing under
the patient (see Figure 7.31A and B).
If planning to improvise, the reader should take a course from an established school that can
teach the reader more of these effective improvisations.
Slings can be made from a pair of basic triangles or improvised with a variety of clothing;
however, they must be secure to prevent further bouncing injury and wide enough not to cause
pain or circulation problems as with poorly made slings from boot laces.21
Today most packs have an internal frame. Yet several companies still build and sell external
frame packs that, with the addition of hose clamps or wire ties, can be made into an improvised,
effective, strong stretcher (it does require additional padding). Three frame packs can be hose
clamped together to make a reasonable stretcher with foam pads or other materials positioned to
prevent pressure points for the patient.
There are different designs for a rope litter. Some are faster to make. Most are laborious. All
take practice to be done well. Shown here is a WMO design (Figure 7.34).
Many WEMS operations involve some type of mechanized vehicular transport. This type of
equipment is well covered in Chapter 28.
However, other WEMS operations may move patients and providers primarily via muscle-
powered vehicles, including horseback, mountain bikes, or paddling canoes or rafts. There are a
few specialized pieces of prevention safety equipment still to think about with the activity you
are engaged in. To start this type of gear list, here are a few starters:

Skiing: consider helmets, avalanche devices such as Avalung, shovels, probes, beacons, and
Back Country Access (BCA)flotation packs. These pieces of equipment are discussed more
extensively in Chapter 31.
SCUBA diving: pony tank system, Spare Air, redundant regulators, See-Me Float, See-Me
Strobe, electronic locators, and dive knifes. These pieces of equipment are discussed more
extensively in Chapter 17.
Bicycling: more tools, spare tube, extra chain, or link repair set and lights.
Horse trips: helmet, brake away stirrups, spare rein, hammer, nails, shoe, easy boot, latigo,
and horse med kit.

Evacuations when self-performed will usually be made under human power. Details and
training on helicopters, ground support, and search and rescue (SAR) groups are described in
Chapters 28 and 30. As with EMS operations, search and rescue operations and evacuations are
usually activated through a public safety answering point (PSAP; 911 in the United States).
Remember that, in terms of equipment for WEMS responders answering deployments from that
PSAP, all the safety gear in the world will not keep you safe if you do not know how to best use
it and are not aware of the hazards around you.
Regional emergency equipment is sometimes cached where it is available to the informed
(usually locals) for evacuations. In forested country, a common cache is forest service fire-
fighting gear, sometimes with a small first-aid kit. There are other notable resources, such as
backboards hanging on trees along the heavily used recreational waters of the Arkansas River in
Colorado (to be used for extrication rather than immobilization). The same is true on many of the
heavily rafted Canadian rivers. A third example would be Pikes Peak, a long climb of 2,289 m
(7,510 ft) vertical gain done by many, with five locations of oxygen tanks available to be used by
the informed. Consider talking to experienced locals before backcountry trips in an area to better
be aware of possible resources.
A reminder to the well-meaning, caring rescuer: heed the growing EMS conviction that, in
fact, “the scene is never safe.”22 This is particularly true in WEMS operations. To preserve your
life you must quickly determine if you can cope with the hazards involved in caring for your
patient. You must be safe and go home tonight to be able to care for tomorrow’s patient.
IMPLICATIONS FOR PRACTICE LEVELS
Most of the equipment discussed in this chapter is available to all scopes of practice. Those that
generally require physician oversight is marked with an asterisk, and specific practice level
discussions are included in the topical discussions. As an example, suturing is a complex skill
with many different styles, techniques, different thread materials, and different needle points and
sizes. Even many physicians who learned suturing in medical school no longer keep the skill up,
so it may be perishable. The rank amateur often wants to suture, sometimes with ugly results. A
stapler* may be a better choice, as discussed in the wound closer section above. This serves as
one example of equipment discussed in this chapter that have scope-specific use. However, in
aggregate, most WEMS equipment is available to most providers.
FIGURE 7.34. WMO climbing rope stretcher. (A) Make coil of rope roughly the size of the patient. (B) Cross loops every 6
inches with 6+ inches of loop ends crossing coil. (C) Secure rope crossings with clove hitches. (Courtesy of Carl Weil and Quick
Reference Backcountry Medical Care. 4th ed. Elizabeth, CO: Wilderness Medicine Outfitters; 2017. Available at:
http://wildernessmedicine.com.)

SUMMARY
Your best medical and survival kits are the ones with you now, which reflects your preparation,
training, thinking, and awareness. How far away is your kit right now? Do you at least have a
CPR shield and nitrile gloves within your reach now? Note photo of author’s current belt
survival, PPE, and med kit worn daily for 25+ years (Figures 7.35 and 7.36).
FIGURE 7.35. Author wearing WMO belt pouch and multitool. (Courtesy of Carl Weil and http://wildernessmedicine.com, ©
2016.)

FIGURE 7.36. Close-up view of belt pouch with contents. (Courtesy of Carl Weil and http://wildernessmedicine.com, © 2016.)
References
1. Brick T. Proper prior planning prevents pitifully poor performance. U.S. Air Force Commentaries. Available at:
http://www.af.mil/News/Commentaries/Display/tabid/271/Article/142169/proper-prior-planning-prevents-pitifully-poor-
performance.aspx. Accessed January 12, 2017.
2. Civilian Cric Pack. H&H Medical Corporation website. 2017. Available at: http://buyhandh.com/collections/kits-and-
packs/products/civilian-cric-pack. Accessed July 13, 2017.
3. Mayo clinic study 2011-2014 by Zietlow, Zietlow, Morris, Berns, Jenkins- Journal of Special Operations Medicine Volume
15, Edition 2/Summer 2015.
4. Lyles WE, Kragh JF, Aden JK, Dubick MA. Testing tourniquet use in a manikin model: two improvised techniques. J Spec
Oper Med. 2015;15(4):21-26.
5. Ruterbusch VL, Swiergosz MJ, Mongtongery LD, et al. ONR/MARCORSYSCOM evaluation of self-applied tourniquets
for combat applications. Panama City, FL: Navy Experimental Diving Unit; 2015. Available at: http://oai.dtic.mil/oai/oai?
verb=getRecord&metadataPrefix=html&identifier=ADA442842. Accessed November 4, 2016.
6. Hiskey D. Super Glue was invented by accident, twice. Today I Found Out: Feed Your Brain. Available at:
http://www.todayifoundout.com/index.php/2011/08/super-glue-was-invented-by-accident-twice/. Accessed November 4,
2016.
7. Forgey W. Wilderness Medicine: Beyond First Aid. 6th ed. Guilford, CT: Falcon Guides; 2012:108.
8. Dory R, Cox D, Endler B. Test and evaluation of compression bandages using a human tissue equivalent mannequin model.
Research poster sponsored by the Naval Medical Research Unit; 2014.
9. US Patent Office. Chest wound seal for preventing pneumothorax and including means for relieving a tension
pheumothorax [sic]: US 7504549 B2. Available at: http://www.google.com/patents/US7504549. Accessed November 4,
2016.
10. Haida Medical. What’s surgical staplers? [sic]. Available at: http://www.medicalstapler.com/Surgical-stapler-
knowledge.html. Accessed November 4, 2016.
11. Wilderness Medicine Outfitters Distance Learning website. Available at: http://learn.wildernessmedicine.com. Accessed
July 13, 2017.
12. Weichenthal L, Spano S, Horan B, Miss J. Improvised traction splints: a wilderness medicine tool or hindrance? Wilderness
Environ Med. 2012;23(1):61-64.
13. Nicolazzo P. The Wilderness Medicine Handbook. 3rd ed. Winthrop, WA: Wilderness Medicine Training Center; 2014.
14. U.S. Food & Drug Administration. Current Good Manufacturing Practice for Finished Pharmaceuticals: Packaging and
Labeling Control. CFR – Code of Federal Regulations Title 21: 21CFR211.137. Available at:
https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr=211.137. Accessed November 4, 2016.
15. Field Amputations. General Session. Wilderness Medical Society Wilderness Medicine Conference and 30th Anniversary
Meeting. July 12–17, 2013. Breckenridge, CO.
16. West JK. Simple and effective field extraction of human botfly, Dermatobia hominis, using a venom extractor. Wilderness
Environ Med. 2013;24(1):17-22.
17. The Mountaineers. The 10 Essentials: Explained. The Mountaineers Blog, May 5, 2014. Available at:
https://www.mountaineers.org/blog/the-ten-essentials-explained. Accessed November 4, 2016.
18. Moore L. US Topo—A new national map series, 2012 update. Directions Magazine. January 14, 2013. Available at:
http://www.directionsmag.com/entry/us-topoa-new-national-map-series-2012-update/300690. Accessed November 4, 2016.
19. Fundamentals of Camping. How to use an axe. Available at: http://www.angelfire.com/ia3/camping/axe.htm. Accessed
November 4, 2016.
20. Hawkins SC, Weil C, Baty F, Fitzpatrick D, Rowell B. Retrieval of additional epinephrine from auto-injectors. Wilderness
Environ Med. 2013;24(4):434-444.
21. Emergency Outdoors. Emergency First Aid tip: Improvised sling. Emergency Outdoors, June 13, 2012. Available at:
http://blog.emergencyoutdoors.com/emergency-first-aid-tips-improvised-sling/. Accessed November 4, 2016.
22. Whitehead S. The Art of EMS: Rescue task forces and the scene safety dilemma. EMS1.com, April 20, 2016. Available at:
http://www.ems1.com/ems-education/articles/83322048-Rescue-task-forces-and-the-scene-safety-dilemma/. Accessed
November 4, 2016.

*A US quarter coin is shown in Figures 7.3, 7.9, 7.10, 7.22, and 7.28 to show 1-size.
INTRODUCTION
This chapter discusses research and evidence-based medicine (EBM) in the context of wilderness
emergency medical services (WEMS). It addresses many questions, including these: What is
EBM? How does research contribute to EBM? How is research conducted? How does one find
and interpret research? How is research applied to practice? How can one become involved with
research?
Imagine you are backcountry skiing when a friend is hit by a small avalanche and pushed 50
ft through trees and rocks. She is partially buried, with her lower body under the snow. You
quickly dig her out to find that she has sustained a “boot top” open fracture of the tibia/fibula on
one leg because her ski failed to release, and a closed femur fracture on the other leg. There are
thankfully no other injuries and she remains alert and oriented but is in extreme pain. It is about a
20-minute ski down to the highway, and a 90-minute drive from there to the nearest small town.
How will you stabilize and evacuate this skier? Do you know that your strategy is correct?
What evidence are you using to inform your decisions? How confident are you in the evidence,
your interpretation of it, and its application in this wilderness setting?

EVIDENCE-BASED MEDICINE AND CHARACTERISTICS

OF RESEARCH

What Is Evidence-Based Medicine?

EBM has been described as the “conscientious, explicit, and judicious use of current best
evidence in making decisions.”1 Imbedded within this definition is the idea that we combine the
best available evidence with our own experience to make evidence-based decisions. We don’t
only act when we have clear, convincing evidence. Rather, we combine “current best evidence”
with our training and experience, taking account of the situation at hand to make sound treatment
decisions aimed at optimizing patient care. Hence the name EBM—the ultimate practice result is
“based” on evidence, not applied from evidence alone.2 See the WEMS: Introduction chapter for
further discussion of EBM in wilderness EMS.
What does “current best evidence” mean? Sometimes the current best evidence includes
results from multiple high-quality clinical trials. Sometimes, there have been no clinical trials
and decisions must be made based on quality improvement data, or based solely on experience.
Most times, there is some mix of quality improvement, lower quality studies, and (less often) a
few small, medium quality studies that all contribute to the current best evidence. There are areas
of medicine that have a great deal of evidence, but many more areas that do not. WEMS is
decidedly part of that second group.
Research plays an important role in EBM. Relying solely on our experience may lead us to
make erroneous conclusions on the effectiveness of an intervention. This may occur because we
may not see enough patients that have a certain condition or injury, it may occur because the
effect we think we are observing may be influenced or obscured by other effects, and/or because
we don’t have access to accurate outcome information for patients and so never really know for
certain what happened to them.
For example, perhaps a WEMS responder has seen two previous patients with an open
tibia/fibula fracture. In one case intravenous (IV) antibiotics were administered shortly after
injury, but despite this the responder heard from someone at the hospital that the patient
developed an infection. In the second case IV antibiotics were administered 10 hours after injury,
but the responder heard from a colleague that the patient did not develop an infection. Their
experience may suggest that time to IV antibiotic administration is not important.
Research, however, may follow a greater number of patients to their outcome, account (in the
analysis or design of the study) for differences in other factors that cause infections, and collect
more accurate and precise information on the outcomes of the patients involved. Research may
therefore reach a more detailed and thorough conclusion than the experience of a single provider.
The knowledge gained from research can then be translated into personal action (eg, a change in
treatment provided by a single provider) and/or system action (eg, a change in protocols,
standing orders, or education for a system of providers).
Although not incorporating the latest research into our own care, or that of the system in
which we operate, may result in providing less-than-optimal patient care, the alternative of not
providing an intervention altogether because of a lack of evidence is also not ideal for patients.
Some clinicians and systems may be tempted to justify not providing an intervention because of
a lack of research, but that approach is problematic because it may take years for one research
study to be conducted, and even then, that study may lead to more questions than answers and
may not be entirely applicable to the WEMS setting. Therefore, regardless of whether we are
individual clinicians or working as part of an organized WEMS system, we need to strike a
balance. We may use current best evidence to guide our practice, which may include research
studies when available, and other times it may be based solely on our own judgment and
experience or that of others when research is not available.

What Are the Challenges in Applying Evidence-Based Medicine Principles to

Wilderness EMS?
In theory, applying EBM principles may seem straightforward—we search for “current best
evidence,” we interpret it, and then we apply it to our practice or the practice of our WEMS
system. In reality, it is a lot harder, and this may be particularly so for those working in WEMS
systems.
For example, in searching for evidence we may encounter a lack of research on the patients
and scenarios encountered in the WEMS environment. Instead research may need to be
“borrowed” from other settings, such as traditional EMS, military medicine, or in-hospital care.
Interpreting evidence, especially research, can involve navigating seemingly difficult concepts
and terms. Furthermore, applying EBM to our practice can be influenced by many factors.
Physicians, for example, who routinely apply EBM principles, might be more comfortable
applying evidence to their practice, compared with a wilderness first aider. Responders in an
organized EMS system may not be empowered to deviate from existing protocols or policy
despite their knowledge of the evidence, but they can advocate for changes to system protocols
and procedures.

How Does Research Contribute to Evidence-Based Medicine?

Although there are numerous definitions for research—and no single universally accepted
definition—it is in principle an activity designed to extend our current knowledge in a detailed
and thorough manner.
We have mentioned that current best evidence should be used in EBM. By “best” we mean
that the evidence should effectively address the area of interest and limit alternative explanations
for the conclusions. For example, we may be trying to find evidence to answer the below
question:
In adults injured in a wilderness setting, does the application of a traction splint, compared
to a nontraction splint, relieve pain and decrease complications from a femur fracture?
The “best” evidence in this case would be the outcome of femur fracture patients. Our
highest quality and most likely source for finding such evidence is a research study that has
followed a suitably large number of patients who suffered a femur fracture in the wilderness
setting to their outcome (to determine pain and complications). This study would extend our
current knowledge of the treatment of femur fractures in the wilderness setting by providing
detailed information on the outcomes of pain and complications arising from two different
treatment approaches. If the study was designed and executed correctly, then this information
would be systematic and thorough.
The described research study would provide important treatment information that experience
alone may not provide. Research is a powerful tool to better understand not just treatment, but
also patient preferences, cost, and many other aspects relating to WEMS care.

What Are the Types of Research?

If we think of research broadly, it may be divided into four pillars. These include the following:

1. Biomedical,
2. Clinical,
3. Health Services, and
4. Population Health.3

Let’s again use our situation of a backcountry skier in a remote location with an open
tibia/fibula and closed femur fractures. Let’s imagine for a moment that we are assessing this
patient and given her injuries, her fast pulse, pale and sweaty skin, and deteriorating level of
consciousness, conclude that she is in shock. If we wanted to improve our treatment of patients
in this scenario using EBM, we may want to understand from research the principles and best
treatment for hemorrhagic hypovolemic shock.
We may start by understanding research from the first pillar (biomedical), which would
describe the impact that hemorrhagic hypovolemia has on the molecular, cellular, organ system,
and whole body levels. This may include the use of animal models.
Next we would want to understand clinical treatments that may help improve outcome.
Research from the clinical pillar would provide information on the diagnosis and treatment of
fractures. The goal of this pillar is to explore interventions to treat a fracture that optimize health
and quality of life.
Next we would use research from the health services pillar to understand these interventions
in the real world, such as WEMS systems. Through changes to policy and practice, this pillar
optimizes the effectiveness of an intervention (how well does it work in practice?) and efficiency
(is it worth doing?). This may include how patients access WEMS, the WEMS system itself,
training, equipment, WEMS funding, etc. The health services pillar is particularly important for
WEMS providers and systems because “cutting-edge” clinical treatments, which are generally
developed in an ideal setting such as a hospital, may be neither possible nor feasible (because of
environmental factors, cost, training, etc.) in a WEMS setting.
Finally, from the population health pillar we may want to understand the importance of
wilderness to population health, and the social and educational factors that influence wilderness
pursuits and WEMS incidents.

Why Is Health Services Research So Important to Wilderness EMS?

As the previous example illustrates, information from all pillars can inform a WEMS situation,
but for WEMS systems, research describing the health services pillar may be the most directly
relevant. This pillar primarily describes research that aims to assess effectiveness, which seeks to
assess interventions in the actual setting that they are applied, to determine if an intervention
works in practice. It also seeks to assess efficiency, which is the effect of an intervention in
relation to the resources required to apply it, to determine if it is worth it.4 In other words, this
pillar supports changes to practice that promote access to WEMS systems, quality of WEMS
system care, and the ensuing costs of providing this care, with the overall goal of improving the
health of patients that access a WEMS system.5

What Is Rigor in Research?

You may have heard the phrase “a rigorous research study,” but what does this actually mean?
Although there are many definitions of rigor as a word, most contain the notion that something is
exact or accurate. In research, there are many definitions of rigor, with the term applied
differently depending on what research approach is taken (more on this later). For our purposes
we will suggest that rigor is the degree of evidence provided to support the stated conclusions of
a study. So more rigorous studies provide more support for the stated conclusions, therefore
minimizing alternative explanations for the study conclusions. It is important to realize that rigor
can apply not only to the approach taken to study a research question, but also the quality of how
this approach was applied in the real world (eg, Were certain patients systematically excluded
from the study? Were the researchers inaccurate in their collection of information?). For
simplicity, let’s focus on the approach taken to study a research question first, and illustrate with
an example.
Let’s say we want to design a study that assesses the impact of a traction splint on the level
of pain in patients with a femur fracture to test the theory that patients that receive a traction
splint have less pain than those that don’t. The most rigorous way to study this would be to
measure pain on a patient that received a traction splint, then go back in time to the exact
moment of injury, and provide the exact same treatment, but this time not apply a traction splint.
We could then look at the difference in pain scores between when the patient received and did
not receive a traction splint. In other words, ideally, the only thing that would change between
the situations would be the traction splint; everything else (eg, the patient, their injury, other
treatments, time to access the patient, mode of transport) would be the same. Perhaps this could
be repeated on many patients, and we could conclude with a great deal of confidence the impact
of a traction splint on pain.
The approach taken to study this research question would be considered extremely rigorous
because there would be very few alternative explanations as to why the patient’s pain level
differed between the two scenarios, after all the only thing that changed was the application of a
traction splint. Although extremely rigorous, this study design would also be impossible, unless
we invent time travel. So researchers will often try other approaches to get close to the same
information. For example, they may randomly assign one patient to receive a traction splint, and
another to not receive one. Unlike the earlier “time machine” approach, where one patient in two
exactly similar situations received and did not receive a traction splint, there are now two
patients and two different situations. Therefore, any differences between the characteristics of
these patients and/or the treatment they received may explain differences we observe on level of
pain (ie, it is not just the application of a traction splint that may explain differences in pain).
The approach to this study would be considered less rigorous than the “time machine”
approach, but obviously more feasible.
There are many other approaches to research, and we will learn in the following sections
why some approaches are more rigorous than others. We will also learn how the quality with
which an approach is implemented in the real world can also impact rigor.

Why Is Rigor in Research Important?

Based on our previous example, and trying to apply EBM to our treatment of femur fractures,
what research approach would give us the best information to inform our care? We would prefer
the “time machine” approach because there would be less room for alternative explanations for
the conclusions and therefore less chance of reaching a wrong conclusion. Because the “time
machine” approach is impossible, we have to settle for the alternative approach of randomly
selecting different patients to receive or not to receive a traction splint. This example, however,
illustrates that as users of research we want the most rigorous research approach possible,
because it reduces the chance of making incorrect conclusions. Obviously, we don’t need to say
that making incorrect conclusions from research and then applying this to practice can have
negative consequences for our patients and for our WEMS systems, in terms of both patient care
and cost to the system.
If rigor is so important, and the avoidance of incorrect conclusions so critical, why aren’t all
research studies as rigorous as possible? Rigorous studies are often expensive studies. In other
words, the more rigorous a study, often the more resources it requires. This raises issues of
practicality and feasibility—the impossibility of time travel is not the only impediment to
rigorous research. As we will learn later in the chapter, the design of a research study has
important implications for the resources it requires, and there is a balance between rigor and
feasibility.

What Are the Steps in Conducting a Research Study?

Designing a research study is a process that has distinct steps (Figure 8.1). In general, research
will start with an idea that leads to the development of a research question. A set of procedures
will then be used to answer the research question (the research methods). Data are then collected
and analyzed (the results), and conclusions are drawn. Action is then taken on the results and
conclusions. In the case of health services research, it is hoped that the results and conclusions of
the study will positively impact access, quality, or cost of care.

From Idea to Research Question

Research always starts with an idea. The idea could be based on observations, other research, or
a known gap in the knowledge base in a certain area. It could be a new idea, or testing an
existing theory in a novel way or in a new population. The challenge in research is often how to
translate an idea into a feasible research question.
The starting point in going from idea to research question(s) is to determine the problem or
overall purpose of the proposed study. Let’s return to the example of femur fractures, traction,
and pain we introduced in the previous section. The problem in that example is that we have
patients in pain from a femur fracture, and we think that applying traction on the injury would
reduce pain. The challenge is whether we can practically maintain this traction for a prolonged
extrication as is common in WEMS situations, whether it is worth the time and effort of applying
traction in terms of a significant reduction in the patient’s pain, and whether there are important
side effects.
FIGURE 8.1. The research process.

A critical activity in going from idea to research question is a literature search, to find other
research on a similar topic. The literature search helps frame the question and identify “gaps in
knowledge.” In this case, we may look for research on the treatment of femur fractures that has
been conducted in the WEMS setting, but may only find research that indirectly answers the
question (eg, a femur fracture study from the hospital setting, general pain control in austere
environments). This literature, however, is still useful for describing the gaps in knowledge in
this area, and may also help to develop the procedures that will be used to answer the research
question (eg, what types of commercial traction splints may be available, what type of pain scale
to use).
Before we specify a research question, let’s introduce a memory aid that may help us create a
complete research question: PICO. PICO refers to important information that should be
contained in most research questions: Population (who you intend to study), Intervention (the
treatment, intervention, or other factor you want to study), Comparison (a baseline or control
treatment or group), and Outcome (the thing you think might be affected).
So for our research idea, our research question could be this:
In adults who sustain a femur fracture in the wilderness setting (Population), does
application of a traction splint (Intervention), compared to no traction splint (Comparison),
decrease pain (Outcome)?
Note that we mentioned earlier that PICO should be used in most research questions, but not
all research questions. For certain research approaches, such as qualitative research, PICO is not
appropriate (more on this later).

From Research Question to Methods

Now that we have specified our research question, we have to plan out how we may approach the
research question in order to answer it. Research methods are the procedures that researchers
employ to answer a research question. The research question will dictate what methods should be
used; in other words, certain types of research methods are best used to answer certain types of
research questions.
The three broad approaches to research are quantitative, qualitative, and mixed methods.
Each broad approach uses specific methods, or in the case of mixed methods a complementary
combination of quantitative and qualitative.
Quantitative methods in general focus on describing phenomena or differences numerically.
Using our earlier example, we may compare pain scores between those that received a traction
splint and those that did not. Quantitative methods are the most commonly used approach in
medical sciences, and although useful for describing “what,” it does not often explain “why.”
That is where a qualitative approach may be best. Qualitative methods generally focus on
exploring phenomena in-depth. Using our earlier example, we may want to assess not just a
patient’s numerical pain score, but how a traction splint made them feel. The difficulty of
adequately measuring suffering via a single numerical value, as well as the characteristics of
catastrophizing and other pain modifiers, has been discussed elsewhere, and has great relevance
to the field of WEMS.6 We may also want to explore barriers to the use of a traction splint in the
WEMS setting from a provider’s perspective. Both of these research questions might be better
answered using qualitative methods.
Finally, a mixed-methods approach may use both quantitative and qualitative methods to
more comprehensively answer a research question. Using our example, to fully understand the
implications of using a traction splint in the WEMS environment, the best study may first assess
whether there was a quantitative difference in pain scores between those that received a traction
splint and those that did not, then explore why this difference may or may not have occurred
from the patients’ and providers’ perspectives. We will go into detail on all three of these
approaches later in the chapter.

From Methods to Results

One of the most exciting parts of research is when the research question and methods have been
planned and data can be collected and analyzed. But we are not quite ready to start enrolling
patients and collecting data just yet. First we have to submit our study proposal to be reviewed
by an Institutional Review Board (IRB).
An IRB is a committee that reviews the ethics of conducting research using human
participants. IRBs (sometimes referred to as Research Ethics Boards outside of the United States)
review the proposed study methods to ensure that research participants are being respected and
protected. They ensure the participants are freely consenting to be involved with the research,
will not be harmed physically or psychologically, and will not have their personal information
used or disclosed without their consent.
Once IRB approval is in place, then personnel can be trained in inclusion and exclusion
criteria, consenting patients to be part of the study, delivering the intervention, and collecting the
data. This step can be quite onerous if up to this point the study team has not included members
of the system in which the study will take place. For WEMS systems, this will be particularly
important given the challenges inherent in providing routine care in these environments, let alone
conducting research. It cannot be overstated how important it is to pilot test study procedures to
ensure that they work before attempting to recruit participants to the study.
 When data collection is complete, the next step is to analyze the results of the study.
Quantitative studies will prespecify how they are going to analyze the data prior to data
collection (called a priori analysis), so that the knowledge of the data does not influence how the
data are analyzed. In our femur fracture study, we may specify prior to data collection that a
difference of 5 on a 10-point numeric rating scale for pain is clinically significant. Therefore, an
average reduction of at least 5 points would suggest that traction is effective in reducing pain.
Qualitative studies, on the other hand, will often specify the design of their study ahead of
time, but allow for flexibility and responsiveness in the analysis to fully explore the data. In our
example, we may find that some providers were less prone to bring a traction splint if the patient
was a far distance from the trailhead owing to weight. This initial finding may lead us to explore
this aspect of the analysis further, perhaps even purposely recruiting more providers that
expressed reservations about using a traction splint to ensure their thoughts were explored.
We will be studying in greater detail quantitative, qualitative, and mixed-methods
approaches later in the chapter.

From Results to Conclusions

Once the results and analysis are complete, the researchers will often conclude with a statement
that succinctly answers their research question. If we took a quantitative approach to the femur
study question, we may conclude that traction splints are superior to routine splinting in reducing
pain. Or perhaps if we took a qualitative approach we may conclude that although providers
thought that traction splints were effective in reducing pain for their patients, the logistic
challenges of applying a commercially available splint designed for use in traditional EMS
systems in the WEMS setting hindered use. It is important that regardless of the methods used,
the researchers do not over- or understate their conclusions. Often a section outlining limitations
of the research methods accompanies the conclusion to ensure that the reader is aware of the
shortcomings of the research approach or the application of this approach in the real world.

From Conclusions to Action

Once a study is complete, and often published, the results should be translated into action. This is
sometimes called knowledge translation (KT). Action could mean that it changes personal
practice, or in the case of those that work for a WEMS system that has standing protocols or
procedures, perhaps results in a change to these policies. It is very important that users of
research take into account how well the researchers answered their research question (in other
words the rigor) before translating it into practice. As we have previously mentioned, rigor
incorporates the ideas of using the best research methods (in balance with feasibility) to answer
the research question, and applying these methods correctly. Another important aspect of
applying research into practice is the idea that the setting of the study is sufficiently similar to
your own setting to apply the research findings (we will cover this in more detail later in the
chapter).
Finally, in some instances there may be conflicting conclusions from multiple studies. An
important component of KT is getting the evidence straight, which means summarizing all
known studies on a topic with due consideration to the rigor of these studies, and in combination
with your own experience, translate the findings into practice.7

What Are the Basic Principles of Quantitative Research?

As mentioned previously, quantitative methods focus on describing with numbers. These
descriptions are based on observation and measurement, and broadly employ two approaches,
experimental and nonexperimental.
An experimental approach means the intervention that is the focus of the study is under the
“control” of the researcher. Using our femur and traction splint example, an experimental study
design may involve the researcher creating a process to randomly allocate who receives a
traction splint and who receives a traditional splint in order to compare the two groups. In other
words, the type of splint that a patient receives is under the “control” of the researcher.
By contrast, a nonexperimental approach would mean that the intervention is not under the
“control” of the researcher. An example would be if certain WEMS system patients received a
traction splint, and others did not (perhaps because the splint could not be transported to the
scene or a variety of other reasons). In this case the intervention would not be under control of
the researcher, but the researcher would still be able to observe and measure the outcome of
patients who did and did not receive traction.

Randomized Controlled Trials

A randomized controlled trial (RCT) is considered by many quantitative researchers to be the
gold standard design for studies of therapies or interventions. If we recall the section on rigor,
randomly allocating an intervention to two or more groups of individuals is the closest thing we
can get to the “time machine” approach.
In the “time machine” approach, we could put the traction splint on a patient, assess their
pain, then travel back in time and put on a traditional splint. Remember, the reason this is so
powerful is because everything about the patient is the same, and the only thing that differs is the
splint. Therefore, any differences we see in outcome must be attributable to the splint. This is a
concept called causality; the traction splint is causing a change in pain level. (Causality is
important to differentiate from “correlation”—we will cover this later in the chapter.)
An RCT is an extension of this idea, except that two (or more) groups are created, one that
gets the intervention and the other that does not. The key feature is that allocation of who gets
what intervention is done randomly—in other words by chance. The reason why we want to do
this randomly is that in theory the only systematic difference between the two groups should be
the intervention (similar to the “time machine” example). All other known (or unknown) factors
that may influence the outcome should be nearly the same. So if we apply this to our example of
a traction splint, we could create a research study where one group of patients randomly receives
a traction splint and the other group does not. These groups should theoretically only differ by
the type of splint they received. This type of study design is an example of an experimental study
design, because the researcher is controlling who gets the intervention and who does not.
So why would we not allow responders to decide who gets a traction splint and who does
not? Why is it better to randomly decide? The reason is that we all have biases. It may be that
responders believe that traction reduces pain, and so they may place a traction splint on those
patients who appear to be genuinely in a lot of pain over those that appear to have less pain. This
may result in the postsplinting pain scores between the two groups being similar, not because the
traction splint is not effective, but because patients in the traction splint group had a higher pain
score to start off with. You can see that bias is an important factor, but can often be addressed in
the design or analysis phases of a research study (more on this later).
We now know why we need to randomize patients, but is randomization enough to prevent
bias? Not entirely, we also ideally need to “blind” patients, providers, and outcome assessors on
what intervention they are receiving. This is to prevent changes in data collection, assessment,
treatment, or perception of treatment based on knowledge of the intervention. In some RCTs this
is possible, like a drug trial where two drugs can be made to look identical. For trials involving a
traction splint, this is obviously impossible. In trials where it is not possible to blind the
intervention (called unblinded or open trials), it is important to record other factors that may
influence the outcome to make sure these other factors are not influencing the perceived or real
effect of the intervention. For example, with our traction splint study, we may want to record
presplinting pain scores to ensure that the group that received traction splints had the same initial
score as those that did not.
One may come across numerous terminologies to describe who was blinded in a study. Some
may suggest that a “single blind” study is when the patients involved in the study do not know
what intervention they are being given, but the researchers do. A study may be “double-blind”
when both the patients and the researchers who are following the patients do not know what
intervention has been provided, although there is no universal agreement on these terms. It is
important to note that there is often inconsistency of the meaning of “single blind” and “double
blind,” and caution in your interpretation is needed.8,9 Although these terms are still used, a more
modern approach describes who was blinded instead of using this terminology, making it easier
for the reader to interpret.8

Observational Studies
Thus far, we have learned about how randomly assigning groups of patients to receive an
intervention (an RCT) is the most rigorous approach we can use, without using a “time
machine.” It is rigorous because we can infer causality between an intervention and an outcome
(eg, traction and pain). It is important to realize though that there are many situations where
using an RCT approach is either not feasible or is unethical.
An RCT is expensive and takes a tremendous amount of time and resources to implement.
Imagine if we were to implement a study that randomly assigned WEMS patients to receive
traction or no traction. First, we would likely need many different systems to participate in the
study so that we could enroll enough patients to achieve an appropriate sample size (more on this
later). Second, we would have to train enough WEMS providers on the study methods so that
they could identify patients that meet inclusion criteria for the study, consent the patient to be
part of the study, and then apply the intervention. Third, we would have to create a random
allocation process, so that patients could be randomly assigned to a group. This would involve
working with operations managers of the WEMS systems to ensure that crews had the right
equipment on hand on the scene (ie, both types of splints), and that they were not aware of what
intervention they were providing until after they consented the patient to participate (to reduce
bias). In addition to this, we would need to have an extensive research team that may include
epidemiologists, biostatisticians, clinicians, WEMS operations managers and responders, and
perhaps other specialized academics, such as health economists, geographical information
system (GIS) specialists, etc.
In addition to feasibility, there is also an ethical responsibility to not conduct an RCT if the
alternative intervention is not thought to be clinically equivalent. For example, would it be
ethical to conduct an RCT where one group of patients gets direct pressure for a severely
bleeding wound, and another group gets no treatment to directly control bleeding? Definitely not,
as direct pressure is the gold standard for controlling bleeding, and doing nothing would be
unethical! This is a clear example of an unethical RCT, but sometimes it is not that clear. What
about traction on a femur fracture? Would it be ethical to carry out an RCT where some patients
received traction and others did not? That may depend on the balance of existing evidence
around the benefit and harm of the intervention. Some RCTs are required to have a data
monitoring committee, that ensures participants are not being harmed, or to establish futility (ie,
when the trial reaches a point that it cannot hope to achieve its objectives no matter if all future
patients had a certain outcome).
In situations where an RCT is neither feasible nor ethical an observational study design may
be the answer. Previously we introduced the concept of experimental and nonexperimental
designs. We are now moving from the idea of the researcher controlling who gets an intervention
(experimental design) into the realm of the researcher not controlling who gets an intervention
(nonexperimental design).
Observational studies are studies where the researcher observes the outcome of patients who
may or may not have received a particular intervention. It can also include situations where there
is no intervention, but perhaps an exposure. An example may be the exposure to backcountry
cabins in areas known to have rodents that carry Hantavirus and the development of Hantavirus
pulmonary syndrome. Observational study methods can be further categorized into cohort studies
and case–control studies.
Cohort studies are studies that identify patients on the basis of their intervention or exposure.
These patients are then followed for a period of time until they develop (or not) an outcome of
interest. Using our example of traction and pain control, we could develop a study where many
different WEMS agencies report patients that have a femur fracture. Some of these patients may
have received traction, and others may not have for a variety of logistical (eg, traction splint not
on-scene), clinical (eg, other injuries contraindicated its use), or quality (eg, provider failed to
apply traction splint) reasons. The researcher could train the various organizations to assess pain
using a standardized pain score before and after application of a splint (regardless of splint type)
and from these data compare the difference in pain score between those that received a traction
splint and those that did not.
Case–control studies work in the other direction; they start with an outcome and then look
backward in time to see if there is an association with an intervention or exposure. For example,
the researcher could develop their study by creating two groups of patients, those that had a
“large” change in pain score, and those that had a “small” change in pain score. They could then
look backward in time to determine what type of splint each of those patients had. From these
data the researcher could compare the number of patients that received traction between these
two groups.
Although we have used the same clinical question to illustrate the difference in approaches
between cohort and case–control studies, often the purpose of the study and research question
will dictate what approach is taken. In general, case–control studies are used to identify patients
that have a rare outcome. If a cohort study was used for a rare outcome, a large number of
patients would likely have to be recruited to the study to get a small number of patients that had
the outcome of interest, making the case–control design more efficient. Conversely, if the
exposure or intervention was rare, it may be more efficient to use a cohort design.
Let’s take a moment to further consider study design choices. At this point you may be
thinking that if RCTs are sometimes unfeasible or unethical, then why don’t we always use
observational study designs? The answer to this relates back to the concepts of rigor and
causality that we introduced earlier in the chapter. The most rigorous study design that can be
practically applied in the real world is the RCT, because this design has the ability to establish
causality between an intervention and an outcome. Observational study designs, however, are
more challenged to establish causality between an intervention and outcome because they don’t
use random allocation of an intervention. Observational study designs report associations
(sometimes referred to as correlations), but these may not always be causal. An often cited
example is the association between the sale of ice cream and the rate of murder. Now no one
would likely be able to sell the idea that ice cream consumption causes murder, but nonetheless
the two are associated. The reason is likely that hot weather may cause both increases in ice
cream sales and murder. Using our example of a femur fracture study, we may see a strong
association between the use of a traction splint and reduction in pain and be tempted to conclude
that the use of a traction splint causes a reduction in pain. We must be careful, however, to
ensure that other factors were not influencing this association. For example, it may be that in the
WEMS system from which the data were collected the “traction splint kit” is carried with the
“pain control kit,” so patients that get traction also get narcotic pain control (and vice versa—
those who don’t get traction don’t get narcotic pain control). So the actual cause of the pain
reduction may be the combined effect of traction and narcotic pain control, not traction by itself.
It is therefore important to not routinely interpret associations as causations, because association
does not always imply causation, but investigating association is the first step in evaluating
causal relationships. From there, careful consideration of criteria such as biologic plausibility,
strength of the association, and consistency of the findings in different studies may lead one to
eventually conclude causation.

Case Reports and Case Series

This approach is the most basic type of nonexperimental approach because it describes a patient
or patients that have received similar interventions or exposures, or experienced similar
outcomes. A case report is one patient, and a case series is an extension of the case report
containing more than one patient. Unlike cohort and case–control studies though, this type of
study has no comparison group. This is what limits this approach in drawing conclusions
comparing the outcome of patients with different interventions or exposures, or comparing the
intervention or exposure of patients with a different outcome. It is still very useful though
because it can enable planning for resources. For example, a case series of all backcountry
skiing–related incidents could assist WEMS systems to appropriately plan for how many of these
cases exposed WEMS personnel to avalanche danger, involved prolonged extrication from
remote settings, and what equipment and personnel resources were required. They can also be
very useful for generating new hypotheses that can be tested with a cohort, case–control, or RCT
design.

Systematic Review and Meta-analysis

Thus far, we have discussed studies that answer a research question by collecting data through
observations or directly engaging participants (sometimes called original research). There are
types of studies, however, that answer research questions by using the results from other studies.
These types of studies are broadly called literature reviews.
You may recall from the beginning of this chapter the basic approach to EBM was to search
for “current best evidence,” interpret it, and then apply it to personal practice or the practice of a
WEMS system. In the process of interpreting the evidence, we need to get the evidence straight;
in other words, come to a conclusion on what the research evidence is actually suggesting. If we
have one or two studies on a topic, this may be a reasonable undertaking, but what if we have 10
or more studies, with many having conflicting conclusions? You can see that it can get pretty
complicated. That is where a literature review comes in.
Traditional literature reviews (sometimes called narrative reviews, critical reviews, or
commentaries) suffered from a lack of transparency with regard to how research studies were
included and interpreted. Like all research, the methods in a literature review should be
transparent and other researchers should be able to replicate the methods to confirm findings. To
address this shortcoming in traditional literature reviews, a type of literature review called the
systematic review was developed.
A systematic review differs from a traditional literature review in that it has a defined study
protocol. That is to say, the researchers have a plan that they have developed prior to starting the
study that defines how research studies will be located, reviewed, and included. Similar to other
study types previously mentioned, the research question will often dictate the precise methods
used. For example, a systematic review on the use of traction in the WEMS environment may
yield a different strategy to search for relevant studies compared to a systematic review on the
use of traction in the health care setting.
There are generally eight steps to completing a systematic review:

1. Create the research question (using PICO)

2. Define the criteria for study inclusion/exclusion
3. Develop the study search strategy
4. Select studies for inclusion
5. Extract data from the studies
6. Assess the quality of included studies
7. Analyze and interpret results
8. Make conclusions, recommendations, and undertake KT activities

Sometimes researchers may combine the results of individual studies together to provide one
single estimate of the effect of an intervention or exposure. This approach is called a meta-
analysis and is usually employed with RCTs, but can also be used with observational studies.10,11
Meta-analysis is quite powerful in informing care because it takes the results of the individual
studies in a systematic review and derives a single conclusion based on the combined data.
Meta-analysis is a subset of systematic reviews, so there are many systematic reviews that do
not contain a meta-analysis, because it is not always appropriate or desirable to combine results
of multiple independent studies. When considering whether to conduct a meta-analysis,
researchers will consider how appropriate it would be to combine (or pool) the results of
included studies.

Types of Quantitative Data

As we have previously learned, quantitative studies use numbers to describe observations. Data
related to these numbers come in a variety of formats. When study participants are placed into
distinct categories, these data are called categorical. There are two types of categorical data, the
first are called nominal data, where there is no order to the categories. Using the traction study
example, data could be collected on activity at the time of injury, where participants in the study
could be categorized as skiing, climbing, caving, hiking, and other. The second type of
categorical data is ordered and is called ordinal data. Again using the traction study example,
participants could be categorized as having severe, moderate, or mild pain. In either case, these
categorical approaches are considered quantitative because we count the number of participants
in each category.
Many quantitative studies will go beyond categorical data to use numerical data, which can
be divided into discrete or continuous data. Discrete data are used to measure counts or numbers
of events, where the variable can only take on a whole number value. An example may be the
number of femur fractures a WEMS system responds to in a year. Continuous data, in contrast,
don’t have a theoretical limitation on the value they can take other than the physical means by
which the data are measured. For example, we could record the age of patients who sustained a
femur fracture. Depending on the method used to record time, the reading could take on the
value of a whole number (eg, 44 years) or any number between whole numbers (eg, 44.525
years).

Describing Quantitative Data

All quantitative studies will use numbers to describe participants in some manner. In the case of
categorical data, results are often expressed in counts and percentages. Numerical data, however,
are reported differently to categorical data in that a measure of central tendency and a measure of
the spread of the data are used.
Measures of central tendency report on the “middle” of the dataset, that is to say a single
quantity that sufficiently represents the typical value from the data. The two most common ways
to do this are the mean and median. The mean is calculated by adding up all the values of a
dataset and then dividing by the number of values. For example, if we wanted to calculate the
average age of a patient that sustained a femur fracture, we could add all the ages for each femur
fracture event and divide by the number of femur fracture events in a time period (let’s say a
year). This would give a value that would represent the typical age of a patient who sustained a
femur fracture (the mean). The mean is sometimes referred to as the average, although the term
average has also been applied to the median, so this practice is discouraged.
The median is calculated by ordering all ages from lowest to highest, and taking the value
that is at the middle (ie, equal number of values above and below it). This value is also referred
to as the 50th percentile, because it has 50% of values lying below it and 50% of values above it.
So if there were 5 femur fracture patients, and their ages were 14, 22, 30, 45, and 60, the median
(or 50th percentile) would be 30. If there is an even number of patients, then the mean of the two
middle observations is used as the median.
Each of these measures has its own advantages and disadvantages. The mean has a number
of good mathematical properties that make it particularly useful for statistics. Unfortunately, it is
heavily influenced by extreme values in the dataset. In the case of age, if the majority of femur
fracture patients managed by WEMS were between the ages of 20 and 40 years, but there was
one patient who was in their late 70s, the observed mean age may get distorted by this one
“extreme” value. The median, on the other hand, does not have the same desirable mathematical
properties, but is not affected by outlying values. One may see the mean reported when there are
no outlying values affecting it, or the median when there are outlying values.
A measure of central tendency is a good starting point to understand the data, but it is also
important to have an appreciation of how the data are distributed around the measure of central
tendency. In other words, are the data all close to the mean or median, or are they spread out.
When a mean is reported, the standard deviation is usually reported to describe the spread of the
data. The standard deviation can be thought of as an average of how each individual observation
differs from the mean. However, the standard deviation should not be used when there are
extreme values. Instead, in these cases, the median is usually reported with an interquartile range
describing the spread of the data.
The interquartile range is the difference between the 25th and 75th percentiles and provides a
numerical estimate of the distance spanned by the central 50% of the dataset. In case it wasn’t
intuitive, the 25th percentile is the point where there is 25% of data below it and 75% above it
and the 75th percentile is the point where there is 75% of data below it and 25% above it. Recall
that the median is the 50th percentile.

What Are the Basic Principles of Qualitative Research?

As we have previously described, a qualitative approach seeks to understand participants’
perspectives on phenomena—often the “why.” Although specific approaches may differ
depending on the methods used, in general qualitative researchers will create meaning of
participants’ perspectives from observations, written words, conversations, interviews, and group
discussions.

Qualitative Study Designs

We previously introduced an example of a qualitative approach to the femur fracture study and
how it could be used to explore barriers in applying a commercially available femur traction
splint. We could approach this research question using a variety of qualitative methods12:

Description: The researchers summarize information provided by participants.

Ethnography: The researcher studies a culture to understand the perspectives of people who
live in that culture.
Phenomenology: The researcher studies the meaning of a lived experience.
Grounded theory: The researcher creates a theory that can be further explored.

Using a descriptive qualitative approach, a researcher could report on the benefits and
challenges associated with using a traction splint in the WEMS environment, perhaps from data
collected in an online survey using free text boxes. Using ethnography a researcher could
explore the experience of WEMS responders as it relates to traction splints by observing their
interaction with the equipment and their patients during actual responses. Another approach may
be to use phenomenology to explore the perspectives of WEMS responders that participated in a
study of commercially available femur traction splints. In this case the researcher may opt to
hold a focus group, where a series of open-ended questions are asked. The questions may
stimulate discussion about the study and commercially available femur fracture splints. Finally, a
researcher using grounded theory could create a theory around factors that influence the
purchase of WEMS equipment, including traction splints, such as cost, training requirements,
weight and size, and benefit. In this case, they may wish to conduct telephone interviews of
WEMS operational managers, medical directors, and responders from a variety of agencies.

Highlighting Quantitative and Qualitative Approaches

Quantitative and qualitative methods should not be seen as opposing approaches, but rather
complementary ones, that allow for a more thorough understanding of a phenomenon.
Quantitative researchers will focus on objective measures that focus on describing and
quantifying, often attempting to establish a causal relationship between an exposure or
intervention and an outcome. Quantitative researchers will attempt to account for factors that
cause an alternative explanation for the conclusions and will often have specific sample sizes that
are required to reach a certain level of statistical certainty, which may require hundreds or even
thousands of participants. Depending on the study design and purpose, the sample size may be
based on the desired precision of the sample estimates or the ability to rule out the play of chance
on differences in outcome between two groups (more on this later in the chapter).
Qualitative approaches, by contrast, will often use subjective interpretations of experience to
thoroughly explore a topic. Qualitative research is not attempting to establish causality between
an intervention/exposure and an outcome, hence the PICO format for a research question is not
appropriate. Qualitative approaches tend to focus on in-depth understanding of a much smaller
sample compared with quantitative approaches. Often the sample in qualitative research is
“purposively” recruited, which is to say that certain individuals are included in the sample
because they have characteristics of interest. For example, if one were studying barriers to
applying traction in the WEMS setting using a commercially available device, there may be one
responder who has vocally opposed the device, because they may have had a negative
experience. This may be someone that would provide a perspective that would “balance out”
other participants and it may be desirable to include them in the sample. Alternatively, a
qualitative sample may simply be a convenience sample of individuals that the researcher has
ready access to (eg, an injured WEMS responder as they are not on active duty). Unlike
quantitative approaches that attempt to control or eliminate the bias that researchers may bring to
a study (recall our discussion of randomization and blinding), qualitative researchers embrace
this bias, exploring how their own perceptions and experiences may shape and influence the
research. Data are often analyzed concurrently with data collection, and new ideas and directions
are incorporated into the research as the study progresses. There are no sample sizes per se in
qualitative research, but rather data are collected until no new themes or information are being
identified, which is a construct called “saturation.” This may occur with 10 to 20 participants, but
it is difficult to predict and also can depend on the researcher and the purpose of the research.

What Is Mixed-Methods Research?

The complementary nature of both quantitative and qualitative approaches can provide the most
holistic exploration of a topic. It is for this reason that researchers may employ a mixed-methods
approach. Although thus far we have predominantly discussed quantitative and qualitative as the
two major approaches to research, now we will discuss what many consider the third, mixed
methods.13
The approach used for mixed methods depends on the research question and what is known
about the topic. For example, if you were attempting to understand the importance of traction in
WEMS systems, you may start by talking to a medical director and an operational manager.
They may then recommend that you talk to a WEMS responder, who may in turn lead you to
another responder. This early work may lead you to naturally flow into a qualitative approach to
develop a sense of the topic from a small purposely selected sample. This qualitative work may
then inform a largely quantitative survey that can be distributed to a much broader sample
containing questions that are relevant to the topic and gleaned from the initial qualitative
approach. The quantitative data from the survey can then be analyzed and combined with the
results of the qualitative analysis.
Alternatively, the opposite approach could have been taken where a quantitative survey
could have been sent to a broad sample to gain a basic understanding and quantification of
phenomena. Areas of interest or controversy could then be explored in-depth by using qualitative
approaches, perhaps by individual interviews or focus groups.
In practice, what may be found are some mixed-methods studies that appear to equally apply
both quantitative and qualitative methods, and other studies that appear to be a predominantly
quantitative or qualitative study but with some mixing of approaches as required.13 As with all
research, the purpose of the study and the specific research questions should guide the chosen
methods.

Surveys
Surveys can be a powerful tool to gain an understanding of phenomena from the perspective of a
targeted group of people. We have already introduced the example of engaging WEMS
responders with a survey to understand the importance of traction in WEMS systems by
combining separate quantitative and qualitative data collection and analysis techniques. Surveys
can incorporate combined approaches, where both the quantitative and qualitative data are
collected simultaneously. For example, a survey could ask WEMS responders to rate the
effectiveness of traction for pain control on a scale from 1 to 5. There may also include a free
text box to allow respondents to elaborate on their quantitative answer. Both quantitative and
qualitative techniques would be used to analyze the data.
Surveys can be challenging to create, because the survey questionnaire must collect valid (ie,
the questionnaire is actually measuring what the researchers think it is measuring) and reliable
(ie, the measurement is consistent across all participants) data. Surveys must also obtain a
reasonable response rate to minimize the error that can occur when interpreting data about a
population of people from a survey sample (more on this later).

How Do You Interpret Research?

Critical appraisal is the process of making sense of a research study in terms of practice. Practice
may include individual practice, or more broadly the practice of a system. Although there are
many specific approaches to critical appraisal, in general, the goals are to assess what the
researchers did, how they did it, whether one can trust the conclusions of the study, and
ultimately whether the conclusions are appropriate to apply to practice. It is important for anyone
using research to not merely skim the introduction and then read the conclusions, because
important details can be missed.
Critical appraisal is an essential step in the process of EBM; it is also a very difficult step
given the differences in research approaches and the array of specific methods that can be
applied. Although the design of the study is one aspect of trusting a research conclusion, so also
is the quality of how the design was implemented. Poorly conducted studies may limit the ability
to apply the conclusions into practice, even if the design was appropriate.
Although there are similar attributes to critically appraise evidence, regardless of the
approach taken (quantitative, qualitative, and mixed methods), certain designs within each
approach may require specific criteria for assessment. Although it is beyond the scope of this
chapter to outline every criterion for every type of research, we will focus on some important
areas of assessment for the types of studies that you may most frequently encounter. Where they
differ, we have separated out quantitative and qualitative approaches.
We would propose that for WEMS systems, critical appraisal of existing research is an
important skill for medical directors, managers, and responders of all training levels. A
collaborative approach to interpreting the research literature and a focus on how to apply
findings in the local context will contribute to maintaining high standards, and root a WEMS
system’s practices in a contemporary, intentional EBM framework. WEMS systems that provide
an opportunity for their responders to be engaged in this process not only contribute to the
development of WEMS as a profession, but also ensure that their protocols and policies have
undergone extensive scrutiny by all members of the WEMS team. Uptake and adherence to
protocols and policies may be enhanced when all members of the organization understand the
evidence that underlies it and have had their opportunity to provide input.

What Did the Researchers Do?

The first place to start reading a research paper is not surprisingly the introduction or background
section. The researchers should introduce the topic of discussion, what important research has
been conducted in this area, the gaps that exist in the knowledge, and the purpose of the research.
Some authors may also include specific research questions at this point.
Remember that a good research question for quantitative research should include elements
outlined in the PICO mnemonic. For qualitative research, the research question may evolve as
the study is conducted, but the reader should still have a good idea of the purpose of the research.

How Did the Researchers Do It?

Building on the information from the introduction or background section, the methods will
describe how the researchers answered their research question. Is the study that you are
reviewing original research, or is it a study reporting other studies (traditional literature review or
systematic review and/or meta-analysis)?
If it is original research, did the researchers employ a quantitative, qualitative, or mixed-
methods approach and specifically what methods within these broad approaches were used?
For quantitative studies one can ask if there is a comparison group, and if the answer is yes
then the authors by definition did not use a case report or case series approach. Now ask whether
participants were randomly assigned to receive an intervention. If yes, then the researchers
conducted an RCT, if not then perhaps observational methods were used (cohort or case–
control).
It is important at this point of reading a research study to begin to decide if an appropriate
approach was taken to answer the research question(s). In the case of quantitative studies, it is
also important to consider if a more rigorous approach could have been taken.
For example, if one were reading a research study that asked if traction reduced the incidence
of hemorrhagic hypovolemic shock in femur fractures, one should be concerned about whether
the most appropriate approach was taken if qualitative interviews with patients are described. For
this research question, a quantitative approach would be a better option. It would also be
concerning if the researchers tried to address this question using a case series, because there
would be no comparison group.
We have learned that, for quantitative research, different approaches can have different
strengths to rule out alternative explanations for conclusions (recall the term rigor). It is generally
accepted that there is a “hierarchy of evidence” (Figure 8.2) based on the relative confidence one
can have in the results coming from each study design. A meta-analysis (combining the results of
many studies together, usually RCTs, into a single estimate of effect) is regarded as the study
design yielding the highest level of evidence, followed by single RCTs, observational studies,
case series and reports, and finally expert opinion. Notice that the resources and effort required to
conduct a study is generally inversely related to the rigor of the study design. The hierarchy
illustrates the balance between feasibility and rigor that researchers must balance when designing
a study—making it as rigorous as possible given the resources available to conduct the study.

FIGURE 8.2. The hierarchy of evidence. SR/MA, systematic review/meta-analysis.

Although it is tempting to think that in all cases a study further up the hierarchy of evidence
will universally provide better evidence than a study further down the list, this is not necessarily
the case because the quality of how a study was executed has an important impact on the quality
of the results. For example, a well-designed and executed cohort study may be more rigorous and
provide better evidence than a poorly designed and executed RCT.
You may notice the absence of qualitative studies in this hierarchy. This is because a
qualitative study design is not an appropriate design to elucidate the effectiveness of an
intervention or impact that an exposure may have on outcome. Some have suggested that instead
of a hierarchy, a more holistic approach may be to use a typography describing the most
appropriate methodology to use given the research question.14 An example of a typography that
may be applied in the WEMS setting is provided in Figure 8.3. The typography illustrates that
different research methods are better suited to answer different research questions, and
incorporates qualitative and survey research designs. The typography may therefore be a better
model to use when deciding if appropriate methods were used to answer a research question.

Can the Research Conclusions Be Trusted?

A broad goal of most quantitative research is to take a sample and generalize the results from that
sample to the population. For example, we may want to take a sample of patients with a femur
fracture from a variety of WEMS systems and generalize those results to all wilderness patients
(the population) that have a femur fracture.
Intuitively though, there may be some ways in which a research study is designed, executed,
and the data analyzed that may affect the accuracy of that estimate. For example, if we recruited
patients for a femur fracture study from WEMS systems that did not operate in temperatures
below 0°C (32°F), and then made conclusions about all wilderness patients, is there an issue?
What about if some WEMS systems assessed pain using a scale from 1 to 10, and others on a
scale from 1 to 5? What if some patients in the study had other painful injuries in addition to the
femur fracture? What if the femur fracture study only recruited three patients?
As we mentioned previously, there are issues related to the design, execution, and analysis of
quantitative research that may lead to alternative explanations for the conclusions, and thus
potentially erroneous conclusions. A study that has addressed these issues is said to be internally
valid. There are two broad categorizations of issues that affect internal validity; the first is bias,
and the second random error.
Biases, or systematic error, are factors that can affect the accuracy of the conclusions of a
study and render them incorrect. You may recall that we used this term previously to describe
why we prefer to randomly select patients to receive a traction splint. We illustrated that relying
on a WEMS provider to decide who gets traction may affect the accuracy of the conclusions of
the study and render them incorrect (eg, concluding that no difference in pain existed because
those that received a traction splint had a greater initial pain score). There are other types of bias
that are frequently encountered in quantitative research.
Previously we asked if there was an issue in making conclusions about all wilderness
patients if we had not included any patients who were injured and treated in environments less
than 0°C (32°F)? The answer to this is yes, but only if temperature may be in some way related
to the outcome. In the case of femur fractures and traction, it may be that patients who are
injured in the cold have less perception of pain than those injured in warm environments and
perhaps a higher incidence of developing complications like frostbite. This example illustrates an
issue known as selection bias, where patients that are included in the study sample are
systematically different to those that do not take part. The researchers should either try and
recruit patients from cold environments, or adjust their conclusions to reflect this limitation in
their recruitment. When reading a study, always ask if there are patients who may have
characteristics related to the outcome of the study that are missing from the sample included for
study.

FIGURE 8.3. A typography of evidence for health services research and wilderness emergency medical services systems.
Adapted from Petticrew M, Roberts H. Evidence, hierarchies, and typologies: horses for courses. J Epidemiol Community Health.
2003;57(7):527-529, with permission from BMJ Publishing Group Ltd.

We also asked if it was an issue if some systems used a 10-point pain scale, and others a 5-
point scale. If we analyzed these data together, and reported all results on a 10-point scale, we
would likely systematically underestimate the pain from the systems that used a 5-point scale
because the maximum pain their patients could ever feel is 5 out of 10. This is an issue called
information bias. The researchers should ensure that data collection is consistent across all study
sites, and that training in how to apply pain scales is also consistent (sometimes referred to as
reliability). In this example, pain scales should be applied the same way between each WEMS
responder that is collecting data (interobserver consistency) and between each use by individual
WEMS responders over time (intraobserver consistency). Several methods exist for measuring
observer agreement, the most widely used being the “kappa coefficient.”
In addition to personnel using a data collection tool correctly, the tool itself needs to collect
data in a valid and reliable way. Validity in this context means that the tool is accurately
measuring what it is supposed to measure, and reliability means that it is doing so under the
conditions and in the patient population under consideration. These concepts can be illustrated
with a new type of thermometer. We want to know if the thermometer’s measurements are valid,
and reliable so we compare them to some “reference standard” (an accepted measurement tool)
to see if the information they generate is equally valid and reliable or, if not, how much it
deviates from that reference standard and under what conditions. In our femur fracture example,
it would be important to ensure that the tool that is used to measure pain is valid and reliable, and
again that WEMS responders have been appropriately trained to use the tool.
Finally, what if patients had other painful injuries? It is not inconceivable that patients will
also have other painful injuries in addition to a femur fracture (like in our scenario where the
skier also had an open tibia/fibula fracture). In these patients, the other painful injuries may
independently be an additional source of pain. This is an issue called confounding. Researchers
should attempt to account for confounding either in the design and implementation of the study
(eg, patients with other painful injuries should be excluded) or in the analysis (eg, by accounting
for other painful injuries). Always ask if there are factors that are related to the intervention, and
may independently be a cause for the outcome. If yes, ask if this factor or factors have been
“controlled for” either in the study design through restricting who are enrolled, or in the analysis
by accounting for the confounder. This is particularly important in observational study designs,
where there may be uncontrolled confounders that may explain any observed differences
between study groups (intervention/no intervention or exposed/not exposed).
Up to now we have reviewed some specific sources of error that may render a conclusion
untrustworthy (ie, selection bias, information bias, and uncontrolled confounding). We now turn
our attention to variability that is not systematic but is attributable to chance alone.
Random error occurs in every study. When we measure anything in a study (eg, pain,
survival, satisfaction) it is only measured in a subset—a sample—of the people we are interested
in. Usually it is impractical or inefficient to try and measure the characteristic in the entire
population, even if the entire population was easily accessible. Instead, we draw a sample that is
intended to be representative of the population; however, because we are working with only a
sample and not the entire population, there is a chance that the results from the sample will not
be reflective of the true population characteristic. Statistics provides a way for us to account for
this chance.
One of the factors under our control that impact the statistical conclusions of a study is the
sample size. Above we asked if there was an issue if the femur fracture study only recruited three
patients. These three patients may, by chance alone, be a group where traction did not improve
pain control. Although this is unlikely, it is not implausible. However, if instead of 3 patients we
had a group of 10, 20, or even 100 patients, the likelihood of random error impacting the
conclusions is dramatically reduced.
Imagine if you wanted to find out whether WEMS providers apply traction to a femur
fracture in the wilderness setting. You create a survey and give it to a random sample of 10
members of an association of WEMS providers. Obviously, with only 10 surveys there may be a
large potential for differences between what the sample of 10 reports and what all WEMS
providers would report if surveyed. This theoretical difference is what is known as uncertainty,
and statistical procedures such as confidence intervals and P-values allow the researcher to
express this uncertainty numerically.
The uncertainty that exists due to sampling is expressed through confidence intervals.
Confidence intervals provide a range of values within which the population level estimate is
expected to lie with a specified level of confidence (usually 95%). From the example above, to
capture the plausible values for the true proportion of WEMS providers that apply traction to a
femur fracture, a confidence interval based only on 10 providers will need to be quite wide,
because the sample is small relative to how many WEMS responders there are in the whole
world. A confidence interval based on many more providers (eg, 200) will be much narrower for
the same level of confidence.
For example, let’s say in our example of 10 providers, 50% (5 out of 10) of that sample
group provide traction. Because this is a sample and the population level estimate is the one we
are trying to understand, we need to provide an estimate of where we believe the population level
estimate to be, based on the information we have from the sample. In this case, the 95%
confidence interval for the number of providers that administer traction for femur fractures
would be 18% to 82%. In other words, the true number of providers that administer traction for
femur fractures could be as low as 18% or as high as 82%.
You may see this written as follows: The number of respondents that reported applying
traction to femur fractures was 50% (95% CI 18%, 82%). This means that 50% of the sample
reported applying traction to femur patients, and we are reasonably confident (ie, 95% confident)
that if we surveyed all WEMS providers in the world the proportion that apply traction would be
between 18% and 82%. It is beyond the scope of this chapter to describe how to calculate
confidence intervals, but that knowledge is not needed to be able to interpret them.
Unlike bias, which can be much more complicated to remedy, a larger sample size usually
enables estimation to an acceptable level of imprecision. In our example, let’s say that instead of
10 surveys, 385 surveys were received. Let’s also say that 50% of respondents still administer
traction to their patients. Due to the larger sample size, our confidence interval will be narrower
than 18% to 82%; specifically it will be 45% to 55%. Therefore, we would conclude with 95%
confidence that the proportion of WEMS providers that apply traction to femur fractures was
between 45% and 55%. One can see that as the sample size increases, the precision of our
estimate increases, and this is reflected in a decrease in the width of the confidence interval.
The principle that is described above is manifest in all statistical tests and one will often see
confidence intervals given in situations where two or more groups are being compared (perhaps
in an RCT), or in the estimated risk of developing a disease or specific outcome from an
intervention or exposure. Understand that every value within a confidence interval is a plausible
estimate of the characteristic under study, not just the middle of the confidence interval. As you
learn more about research you’ll realize that in many cases the foundational theory presented in
this section is used before the research is conducted to estimate the size of the sample that would
be required to provide confidence intervals of a certain width. This exercise is known as sample
size estimation and is beyond the scope of this chapter.
Another measure of uncertainty that you may come across when the results of a quantitative
study are being reported is the P-value. P-values are most often used when assessing whether
chance can be ruled out in explaining the difference between two groups (eg, patients that
received traction and those that did not). P-values have their roots in statistical hypothesis
testing, which operates on the assumption of a null hypothesis—usually that there is no effect—
followed by some calculations that render the P-value. What the P-value provides is the
probability of obtaining the results that were observed in the sample (or something more
extreme) if the null hypothesis were true. If the P-value is small—say less than 1 in 20 or 0.05—
then by convention it is assumed that the null hypothesis must be false. In hypothesis testing it is
not usually the null hypothesis that is of interest to the researchers but rather some alternative
hypothesis.
For example, if we believe that traction is effective in reducing pain for femur fractures and
we wished to test this hypothesis by comparing pain in those who received traction versus those
that did not, the null hypothesis would be that there is no benefit for traction on pain following
femur fracture. The alternative hypothesis is then that there is a benefit to traction for reducing
pain. If we observe a difference of 10% between the numbers of patients that achieved adequate
pain control between the two groups, and if the statistical test renders a P-value that is less than
0.05 we would call the 10% difference “statistically significant.” We would conclude that it is
unlikely that we would have observed a 10% difference if there was no benefit to traction.
Conversely, if the P-value was greater than 0.05 we would have concluded that 10% was not a
large enough difference to conclude that the null hypothesis was not true and the results are
called “not statistically significant.” We would conclude that we did not demonstrate a benefit to
traction beyond what would have been expected by chance alone.
Up to this point we have discussed only quantitative studies, but qualitative studies have their
own specific set of criteria that should be reviewed prior to trusting research conclusions.15–17
Specific to qualitative studies, one should look to see that the researcher justified the specific
qualitative methods used (ie, descriptive, ethnography, phenomenology, or grounded theory)
relative to the purpose of their research.
Did the researcher provide information on their background and their relationship to
participants? Recall that qualitative researchers embrace how their own perceptions and
experiences may shape and influence the research. The reader, however, must be able to assess
how these perceptions and experiences of the researcher may have influenced the conclusions. In
addition, what about the researcher’s relationship with the participants? Was there a “power
relationship” present, such as the researcher being the participant’s employer, or perhaps
clinician? If so, how was this managed to ensure that participants felt comfortable and that they
could speak freely. It is important to ensure that the method to engage participants in the research
was appropriate and free from power relationships. For example, if a focus group was conducted,
were managers and medical directors included with responders, and if so would responders feel
comfortable speaking candidly, especially if their opinion differed from that of their employers?
How was sampling conducted? Was a convenience sample used, or a purposive sample?
Purposive samples may provide more holistic and in some cases valuable information, compared
to a convenience sample. For example, if operational managers and medical directors were the
only ones engaged in a research study because it was easier to schedule a time to meet compared
to responders (a convenience sample), the conclusions of the study would likely not be as
complete compared to an approach that targeted certain responders due to their characteristics (a
purposive sample).
How were the data analyzed? Researchers should provide a clear indication of the approach
taken. Did the researcher analyze the data alone, or did someone else independently analyze the
data? For some qualitative methods having another researcher independently analyze the data
may increase the opportunity to understand different views of the same data, providing a more
rigorous analysis.
Did the researchers reach data saturation? Recall that with quantitative studies there is a
specific sample size required to control for random error, but in qualitative studies the sample
size is often based on data saturation. Data saturation is when no new information is being
discovered; in other words, the researcher has a very comprehensive and complete view of the
research topic and enrolling more participants will not add to this view.
Were participants given the opportunity to provide feedback to the researchers and the
findings? It is important to allow participants the opportunity to ensure that the researchers truly
understood what they were trying to say. Was there consistency throughout the study in terms of
the data presented and the conclusions reached? A study conclusion that does not seem to be
supported by the data is problematic.
Although we have explored some issues related to trusting a quantitative or qualitative
conclusion, we have certainly not listed all issues. It is important with any study to consider how
the whole approach to the study was taken, and whether this makes sense from your own
experience and training. For example, were there any financial incentives for the study to find a
positive result? Did the researchers provide enough training to the personnel involved in the
study? Was any quality assurance done to ensure that the intervention was being applied
correctly? Basically you need to be looking for the proverbial “red flags” in every aspect of the
study, and determine if these “red flags” may have influenced the conclusions of the study, the
magnitude of this influence, and potentially the direction (overestimation or underestimation).

Can the Research Conclusions Be Applied to Practice?

In the previous sections we have focused on what the researcher did, how he or she did it, and
whether the research conclusions can be trusted. If we have carefully considered the details of
the research study, and have decided that the conclusions of the research can be trusted, it is now
important to consider whether you can apply the findings in your practice or your WEMS
system. In other words, generalize the findings from the study setting to your own.
Regardless of the type of study methods used, whether a study can be applied in your
particular setting should never be considered unless the conclusions can be trusted. It is
important to note, however, that although the conclusions of some studies cannot be fully trusted,
there may still be some useful information, and potential lessons that can be learned from the
study, especially if you are considering studying the same topic. It is always important to set the
issues identified with the study design into the bigger picture as it relates to the study and the
study topic.
For example, perhaps in a cohort study assessing traction in femur fracture patients, only five
patients were recruited to the study. Obviously this would not be a large enough sample size to
make a comparison between study groups, but there still may be important lessons in how many
femur fracture patients can be expected to be enrolled in a similar study, challenges with
applying traction in the WEMS environment, and other lessons or information that may be
important. Never reject a study immediately after finding an issue with the study design; always
look to see if there are other lessons that can be learned.
When generalizing results from a study consider patient characteristics (are patients in the
study similar to ones encountered locally), the response environment (wilderness or traditional
EMS, etc.), the training of personnel (are different professions responding, such as physicians
and paramedics? Is the training of these professions similar locally? etc.), the experience of
personnel (number of responses per year, number of years, type of response, etc.), the type of
equipment used (commercially available products vs “homemade” or improvised, etc.), and the
characteristics of the system (call volume, response time, mode of response, patient
characteristics, etc.). Assessing whether to generalize the results of a study requires content
expertise more than research expertise.
In addition to above, some studies may report “statistically significant” findings, but that
does not suggest that the findings are “clinically significant.” Unlike “statistical significance,”
where an observed difference is deemed to be more than is expected by chance alone, “clinical
significance” is determined entirely by clinical experience and asks the question of whether the
observed difference has any clinical relevance. Some studies may define, prior to data collection,
what they consider to be “clinically significant” findings; others may not and leave it up to the
reader.
Qualitative researchers tend to not use the term generalizability, but rather transferability.
Transferability of qualitative research requires careful consideration of the sociocultural context
in which the study was set.15 Qualitative researchers may attempt to increase the potential
transferability of their study by including a discussion on how the results of the study may be
transferred into different contexts, or the theoretical importance of the findings.

Some Final Thoughts on Critical Appraisal

Critical appraisal involves considering not only how shortcomings in the methods, or the
application of the methods into practice, influence the trustworthiness of the conclusions, but
also how it may impact the generalizability (quantitative research) or transferability (qualitative
research) of the findings into local settings. For example, you may be generalizing results from
an RCT to your local service, and find that the system and patient characteristics are quite
similar, except locally you and your colleagues have been using the intervention for many years.
In the study site, however, you note that responders began using the intervention specifically for
the research study. Although the training program was similar between your local site and the
study site, you know that experience applying the intervention in practice is critical for the
success of the intervention. You note that the authors shared your concerns about lack of
experience and in the limitations section provided an analysis where they plotted the differences
between the two study groups over time. Not surprisingly, they note greater effectiveness for the
intervention was found later in the study. In other words, as personnel got more experience with
the intervention, the effectiveness increased. Overall, however, the researchers failed to
statistically demonstrate that the intervention was effective beyond what would be expected by
chance. So what do you do? In this case, you may be right to not trust the conclusions because it
seems that the lack of experience may have hindered the correct application of the intervention
resulting in an underestimate of the true effectiveness. With this in mind, and setting the results
in the context of your local system that has considerably more experience applying this
intervention, this study may support the use of the intervention in your local context, even
though the research conclusion was that there was no “statistically significant” benefit.

Searching the Research Literature

We have previously mentioned that literature searching is an important activity in going from
idea to research question and in systematic reviews. It is also an important step in searching for
research to make an evidence-based decision about a clinical or operational question. A literature
search often involves attempting to identify the relevant studies that pertain to a review question.
In some circumstances, this review may also be extended to include references from nonresearch
sources as we will learn in the grey literature section.

Formulating a Review Question and Research Databases

A review question guides a literature search, whether for research or evidence-based decision-
making purposes. We have previously introduced the PICO mnemonic to help guide a research
question, but it can also be used to guide a review question. The previous research question about
femur fractures and the use of traction to reduce pain could also be applied as a review question
to guide a literature search. There are two general types of research databases, those that have
primary research and those that have synthesized research.
Primary research databases generally contain research articles that have been published in
peer-reviewed journals, although some include journals that are not peer-reviewed and books.
Peer-reviewed journals require each article to be reviewed and critiqued by experts who are not
part of the study team. This process is intended to serve as a gatekeeping mechanism to ensure
that the knowledge meets a certain standard and also helps improve the quality of the manuscript.
The most common medically focused primary research database is PubMed, which comprises
over 26 million articles from the fields of biomedicine and health. This database is freely
available on the internet.*
These databases are queried using carefully selected combinations of search terms. There are
two broad types of search terms used in searching research databases: keywords and controlled
vocabulary. Keywords are simply words that may be in one of the information fields for the
study (eg, title, abstract). Controlled vocabulary terms are specific terms used to index studies so
that they can be more readily identified. An example of a controlled vocabulary index is the
Medical Subject Heading (MeSH) terminology for PubMed. A combination of both keywords
and controlled vocabulary terms should be used to provide the best opportunity at retrieving all
relevant articles.
For example, if we took the research question in the PICO format introduced previously, and
used it as a review question, we could develop a search strategy to search PubMed as outlined in
Table 8.1. In PubMed, search terms are automatically mapped to MeSH terms and so it is
important to look at the search details box after entering search terms to determine how it was
mapped.18 Table 8.2 provides an example of how search terms are mapped to MeSH and
keywords in PubMed.

Table 8.1 Potential Search Terms Related to Different Aspects of the PICO Review
Question
PICO Aspect Search Terms
Population—Adults Adult
Population—Femur fracture Femoral Fracture
Population—Wilderness setting Wilderness, Wilderness Medicine, Wilderness Emergency
Medical Services
Intervention—Traction splint Traction, Traction Splints
Outcome—Pain Pain

Note: PICO question—In adults who sustain a femur fracture in the wilderness setting (Population), does application of a
traction splint (Intervention), compared with no traction splint (Comparison), decrease pain (Outcome)?
All “Search Terms” in this table are MeSH entries.

Table 8.2 Example of Search Details from PubMed

Terms Entered into the PubMed Search Box Resulting PubMed Search Details
Adult Femoral Fracture Wilderness Pain (“adult”[MeSH Terms] OR “adult”[All Fields]) AND (“femoral
fractures”[MeSH Terms] OR (“femoral”[All Fields] AND “fractures”[All
Fields]) OR “femoral fractures”[All Fields] OR (“femoral”[All Fields]
AND “fracture”[All Fields]) OR “femoral fracture”[All Fields]) AND
(“wilderness”[MeSH Terms] OR “wilderness”[All Fields]) AND
(“pain”[MeSH Terms] OR “pain”[All Fields])

Note: All Fields = Searches all fields in PubMed except Place of Publication, Transliterated Title, Create Date, Completion Date,
Entrez Date, MeSH Date, and Modification Date; MeSH = Medical Subject Heading. Source: PubMed Help.
http://www.ncbi.nlm.nih.gov/books/NBK3830/. Accessed July 2016.

Although individual search terms can be combined using common Boolean operators (AND,
OR, NOT, etc.), as outlined in Table 8.2, PubMed automatically combines the search terms for
you (other search engines might not do this automatically). There are also other more advanced
options for searching PubMed, and freely available tutorials for more information.
Synthesized research databases contain searches that have already been conducted and the
literature summarized in some way. Some databases, such as the Cochrane Database of
Systematic Reviews, provide high-quality systematic reviews of the literature and are freely
available on the internet for searching.† These databases often have smaller numbers of articles
compared to primary databases, which may mean that simpler search strategies may be used (eg,
just the term femoral fracture).

The Grey Literature

Up to this point we have talked about research that is accessed through traditional publications
such as journals. There is, however, a substantial body of evidence that is not published in
traditional journals—called “grey literature.” Grey literature may be comprised of a broad range
of documents in both print and electronic format from all levels of government, industry, and
even academics.18 Examples of grey literature include reports, conference proceedings, and
presentations. Searching for grey literature can be challenging given that there is no single
repository for grey literature sources, therefore internet search engines such as Google are often
used. Just as we have described for searching research databases, having a focused review
question and search strategy can reduce the number of items that need to be reviewed. In
addition, restricting the results to certain formats, such as .pdf documents, can also help focus the
search.
Because grey literature is not peer-reviewed and can be published by anyone, it is important
to determine who published the document, what biases they may have, and how these biases
have affected the content of the publication. The same critical appraisal needs to be applied to
grey literature as with peer-reviewed literature, but in many cases it is more challenging, because
without the peer review, important information may not be provided in grey documents.
In the context of our literature search on femur fractures, we may find very little research in
WEMS published in traditional research journals. Our next step may be to search the grey
literature to find unpublished reports or presentations from WEMS systems describing the
treatment of femur fractures in their services. This may also include presentations made at
conferences. Grey reports may be an important source of information for emerging fields such as
WEMS.

Scouring References
Once you have found research studies, articles, or other sources that meet the criteria outlined in
your review question, take a look at their reference lists. Are there other articles that they cite
that sound relevant? If yes, look for those articles in PubMed by entering the relevant
information into the search box (author name, article title, journal name, PubMed number, etc.)19
or by again searching the grey literature. This may identify important references that may have
been excluded from the original search by taking advantage of the searching done by the authors
of each of the papers identified by your search.

Getting the Articles

It is important to note that citations listed in a research database may not be freely accessible.
Although some “open-access” journals are free to access, many are not. Access to journals is
often granted to students of educational institutions, but also sometimes employees of health care
or EMS systems, or members of professional associations. At worst, you might have to purchase
access to an article, but most journals allow you to purchase just the article you need rather than
a full subscription.

What Is Knowledge Translation?

Recall that the basic steps in EBM are searching for evidence, interpreting evidence, and then
applying it into practice. Also recall that “action” is a part of the research cycle (Figure 8.1).
Thus far in the chapter we have focused on understanding research and its contribution to EBM,
and interpreting and finding research. Now we will focus on the last step, taking what is known
from research and aligning this knowledge with clinical care.
This last step is sometimes referred to as the knowledge-to-action (KTA) gap.20 By action
what is meant is that it is not only practitioners that should use knowledge gained from research
in their practice, but also managers, government policy makers, and the public.
You may come across many terms that are used to describe the KTA gap, such as KT,
knowledge transfer, and knowledge exchange.20 For our purposes we will use the term KT, but in
doing so emphasize that this term is broader than simply the KTA gap. True KT influences many
steps in the research process (recall Figure 8.1), including defining the research questions and
methods.21 Our focus now, however, will be on the KTA gap.

How Can Knowledge Be Applied to Individual Practice and Wilderness EMS Systems?
In traditional EMS systems, some have proposed that there are two broad steps in the KT
process: getting the evidence straight and getting the evidence used.7
We have already talked about getting the evidence straight, and as you have probably already
determined this may sometimes be challenging. This is especially the case when the existing
research may reach contradictory findings. To that end, there are many different methods that
can be used to come to a single conclusion on a body of evidence and rate how rigorous this
conclusion is. One of the most widely used systems is known as the Grading of
Recommendations Assessment, Development and Evaluation (GRADE). This approach involves
grading quality (or certainty) of evidence and the strength of recommendations.22
 The second step is getting the evidence used. Although for personal practice this may be
straightforward, it becomes more challenging when changing the practice of a system. The
potential benefit of a change of practice must be weighed against the cost of initial and ongoing
training, equipment, and logistics. For example, it may be found that traction is beneficial in
reducing pain for patients with a femur fracture, but what if a WEMS system only encounters
one femur fracture patient every 6 to 7 years?23 Is it worth equipping, training, and arranging for
traction equipment to be available for every call out? What if there was also a high turnover of
volunteers in the system, necessitating considerable training cost for new members? In addition,
once an intervention such as traction is implemented, there needs to be a system in place to
ensure that the intervention is being applied to the right patients, being applied correctly, and
given the low number of femur fracture patients, refresher training provided.

HOW TO GET ENGAGED IN RESEARCH

There are three broad levels of involvement that a WEMS practitioner can have with research.
The first level is the most fundamental and should involve all practitioners, where the WEMS
practitioner responds to a call and records data as specified by their system. Because all
organizational data may be used for research purposes at some point it is critical that WEMS
practitioners ensure their data are accurate and complete. WEMS practitioners may also be asked
to enroll patients into a study. Enrolling a patient may require having the patient sign an
informed consent form, or perhaps reading out a prepared script for the patient. Taking care to
ensure that these routine activities are done well is a significant contribution to the research
enterprise.
The second level of involvement is being a member of the research team and is an excellent
way to transition into a more formal research role. Many research teams will include WEMS
practitioners to provide a unique perspective that can help create a meaningful research question,
design appropriate methods, and provide understanding of the results of the study. Being a
member of a research team often requires a great deal of work, and this work is often not paid.
The amount of work is dependent on what role is being played on the study team, the size of the
study team, and the nature of the study. When deciding if you should be a member of a research
team, make sure that you have a clearly defined role and understand the expectations that
accompany that role.
The third level of involvement is as the principal investigator (PI) of a study. The PI is
ultimately in charge of the research project. All aspects of the research are their responsibility,
which includes the ethical framework such as consent and privacy, the development of methods,
the implementation of the protocol to collect data, and the interpretation of results and KT. For
those WEMS practitioners that are not medical directors, often the medical director must also
sign off on the study protocol, especially if there is a change of clinical practice or clinical
implications to the study. Sometimes these practitioners may colead the study with the medical
director or other researchers (who serve as co-PIs).

So You Have a Research Idea, What Next?

Nothing is more exciting than having a research idea. Like many areas of research, however,
there is no shortage of good ideas, but rather a shortage of resources that can take the idea and
make it become reality. If you have a research idea, begin by discussing it with colleagues to get
their opinion. Perhaps discuss it with your medical director and/or operational managers to
further develop the question. A mnemonic that may help develop a good question, in addition to
PICO, is FINER: the research question should be Feasible, Interesting, Novel, Ethical, and
Relevant. If the idea is still thought to be a good one, then you can assemble a research team.
Research teams should be large enough to include key individuals that bring relevant
knowledge and experience to the team, but not so large that nothing can get done due to endless
debate. The best research teams have a diversity of skills and experience. Although the exact
makeup of a research team will depend on the research question, and the knowledge and
experience of the members, they typically include at least a methodology expert and a content
expert. For example, a cohort study that is following femur fracture patients through their course
of treatment may have a research team that comprises someone with WEMS experience, an
epidemiologist (to address issues of bias in the study design and analysis), and a biostatistician
(to address statistical issues). Other specialized team members may be required such as a pain
expert, a GIS specialist, or a health economist. Finding collaborators on a research study can be
difficult, because most studies cannot afford to pay collaborators for their time. Universities and
other academic institutions may be a good place to start, as are conferences. Once the research
team is assembled, funding can be sought.

The Importance of Mentorship

The importance of mentorship cannot be overstated for both those conducting research and those
using research to guide their practice. Conducting research involving humans is complicated,
regardless of how seemingly simple the study design is. Finding and working with a mentor is
key to learning first-hand the dos and don’ts of conducting a study.
Mentorship is also important in learning how to use research to guide practice. EBM may
seem straightforward, but being able to confidently interpret and apply evidence in the WEMS
setting takes time and practice, and working with a trusted mentor can greatly shorten and
enhance this journey.

SUMMARY
EBM combines “current best evidence” with our training and experience, taking account of the
situation at hand to make sound treatment decisions aimed at optimizing patient care. Research is
an important source of evidence for WEMS systems. Knowledge on how research is conducted,
and how to critically appraise research is an essential skill for all WEMS personnel, regardless of
training level. WEMS personnel will provide a critical role in both conducting future research
that will further develop the evidence base informing WEMS systems, and appropriately
translating this evidence into local practice.

References
1. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t.
BMJ. 1996;312(7023):71-72.
2. Evidence-Based Medicine Working Group. Evidence-based medicine: a new approach to teaching the practice of medicine.
JAMA. 1992;268(17):2420-2425.
3. Canadian Institutes of Health Research. Glossary of Funding Related Terms. [Internet]: Canadian Institutes of Health
 Research. Available at: http://www.cihr-irsc.gc.ca/e/34190.xhtml#r5. Accessed May, 2016.
4. Haynes B. Can it work? Does it work? Is it worth it? The testing of healthcare interventions is evolving. BMJ.
1999;319(7211):652-653.
5. Nellans K, Waljee JF. Health services research: evolution and applications. Hand Clin. 2014;30(3):259-268.
6. Sullivan MJL. PCS: The Pain Catastrophizing Scale User Manual. [Internet]. Montreal, Quebec: McGill University; 2009.
Available at: http://sullivan-painresearch.mcgill.ca/pdf/pcs/PCSManual_English.pdf. Accessed July, 2016.
7. Cone DC. Knowledge translation in the emergency medical services: a research agenda for advancing prehospital care.
Acad Emerg Med. 2007;14(11):1052-1057.
8. Moher D, Hopewell S, Schulz KF, et al. CONSORT 2010 explanation and elaboration: updated guidelines for reporting
parallel group randomised trials. Int J Surg. 2012;10(1):28-55.
9. Devereaux PJ, Manns BJ, Ghali WA, et al. Physician interpretations and textbook definitions of blinding terminology in
randomized controlled trials. JAMA. 2001;285(15):2000-2003.
10. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-
analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.
11. Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting.
Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA. 2000;283(15):2008-2012.
12. Hanson JL, Balmer DF, Giardino AP. Qualitative research methods for medical educators. Acad Pediatr. 2011;11(5):375-
386.
13. Johnson R, Onwuegbuzie A, Turner L. Toward a definition of mixed methods research. J Mixed Method Res. 2007;1:112.
14. Petticrew M, Roberts H. Evidence, hierarchies, and typologies: horses for courses. J Epidemiol Community Health.
2003;57(7):527-529.
15. Kuper A, Lingard L, Levinson W. Critically appraising qualitative research. BMJ. 2008;337:a1035.
16. Mays N, Pope C. Qualitative research in health care. Assessing quality in qualitative research. BMJ. 2000;320(7226):50-52.
17. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for
interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-357.
18. Schopfel J. Towards a Praque definition of grey literature. Grey J. 2011;7(1):5.
19. PubMed [Internet]. Bethesda MD: US National Library of Medicine National Institutes of Health. Available at:
http://www.ncbi.nlm.nih.gov/pubmed. Accessed July, 2016.
20. Graham ID, Logan J, Harrison MB, et al. Lost in knowledge translation: time for a map? J Contin Educ Health Prof.
2006;26(1):13-24.
21. Sudsawad P. Knowledge Translation: Introduction to Models, Strategies, and Measures. Austin, TX: Southwest
Educational Development Laboratory, National Center for the Dissemination of Disability Research; 2007.
22. Grading of Recommendations Assessment, Development and Evaluation (GRADE) [Internet]: The GRADE Working
Group; 2016. Available at: http://www.gradeworkinggroup.org/. Accessed July, 2016.
23. Runcie H, Greene M. Femoral traction splints in mountain rescue prehospital care: to use or not to use? That is the question.
Wilderness Environ Med. 2015;26(3):305-311.

*http://www.ncbi.nlm.nih.gov/pubmed
†http://www.cochranelibrary.com/cochrane-database-of-systematic-reviews/
INTRODUCTION
Wilderness event medicine (WEM) can be defined as medical support for competitive events
outside the usual scope of traditional emergency medical services (EMS). A more specific
definition of WEM proposed in the medical literature is “a healthcare response at any discrete
event with more than 200 persons located more than one hour from hospital treatment.”1 This
definition is helpful in that, by including “healthcare response” in the out-of-hospital
environment as a definitional characteristic of WEM, it emphasizes that WEM is at least in some
ways a subgroup of wilderness EMS (WEMS). However, this definition does not take into
account limited resources or specific skills and logistics (such as prolonged extrication times or
difficulty in transport) that may be required in a more remote or austere setting. In 2015,
Hawkins et al.2 proposed a definition of WEMS that is also helpful in defining WEM:
Although some authors define WEMS [Wilderness Emergency Medical Services] as any situation that involves a minimum 1
to 2 hour transport time, this definition does not encompass every WEMS experience. There may be situations that require
specialized medical care prior to extrication or transport even if the area is near a roadside, such as a patient injured on the
hill at a ski resort or a hiker in a large urban nature preserve. Due to the specialized skills required to manage these patients,
the inability to get supplies to the patient easily, or a complex extrication without the aid of an ambulance, these situations
must also be considered wilderness. It is important to understand that WEMS is substantially more complex than the
application of traditional medical training in a wilderness environment, and the indiscriminate application of traditional care
and standards often proves to be dangerous to patients and/or providers in a wilderness setting.2

Specialized WEM skills that may be required to manage patients depend upon the race
disciplines and venue, such as swiftwater rescue for river-based events, avalanche or snow
rescue for alpine mountain events, or high angle rescue for climbing events. (Technical rescue
interfaces such as these are all covered in more detail in Section 3 of this book.)
For the purposes of this textbook, we will define WEM as any wilderness or obstacle event
that exceeds the usual capacity of traditional EMS either in distance or time to hospital, or in the
skills and equipment required for expedient extrication.3 This definition encompasses the broad
range of WEM coverage, which includes, but is not limited to, obstacle racing, adventure racing,
mountain bike racing, trail running, and ultra-endurance events, as well as other events that occur
beyond the typical scope of practice and subject matter expertise of urban, suburban, and even
rural EMS.
Competitions such as ultra-running or adventure racing may be held in remote locations
where well trained and highly skilled participants must be self-supported and navigate unmarked
remote terrain for extended periods or long distances. These races have inherent risks related to
location and environmental hazards, and may require very specialized WEMS skills such as
search and rescue (SAR) skill sets or extrication and transport skill sets beyond standard medical
training.
Obstacle course racing has attained great popularity and is an event type that may be located
in less remote areas than other WEM events.4 Races such as the Spartan Race, Tough Mudder,
and Warrior Dash had an estimated 1.5 million participants in 2014.5 These races typically are
held on a predefined course wherein participants navigate multiple obstacles and challenges,
such as crawling through mud pits, running through flames, risking electric shock, or leaping
from a height into cold water.
Obstacle races tend to draw more novice athletes as compared to traditional adventure races,
and the large number of participants has led to an associated increase in local emergency
department (ED) and traditional EMS use. In a report from a single Tough Mudder event, the
local ED reported treating 38 participants related to this single two-day event alone.6 ED volume
alone may not reflect the increased burden on the local emergency services infrastructure. This
same series reported that “the burden on [traditional] EMS during this event was unanticipated.
Reportedly, more than 100 advanced life support responses were activated, with many patients
receiving initial treatment and then refusing transport.”6
The variability of disciplines, settings, number of participants, and distance or time from
hospital for each event prevent development of standardized protocols for all WEM situations.
However, procedural guidelines and principles can be developed, and are described below.

1. While an attraction for athletes to participate in obstacle and adventure races may be the
challenge of the unknown, information provided to competitors prior to each event should
include details such as specific disciplines, challenges that require special skills, the
distance and/or expected duration of the event, and required gear for participant safety.
2. Nutrition and hydration sources should be made known, whether supplied by the event at
established stations or required self-supported nutrition with racers being responsible for
finding and detoxifying water (in which case maps indicating water sources should be
provided).
3. With challenges that require a specific skill, such as those involving ropes/climbing, event
organizers should be responsible for assessing the ability of participants to safely
participate, as well as the quality and safety of their gear. All mandatory gear should be
inspected.
4. Organizers of each event should be responsible for informing all staff, volunteers, and
competitors of available emergent and non-emergent WEM procedures and other event
support resources.

EPIDEMIOLOGY OF MEDICAL PROBLEMS IN WEM

To prepare for providing appropriate medical care, WEM practitioners should know the most
common injuries and illness that occur in the given environment of the race being covered.
However, data found in the current medical literature regarding these conditions are extremely
limited.
Information from endurance events with similar race disciplines (running, cycling, etc) held
in urban settings can be used to predict WEM conditions.7–13 Musculoskeletal injuries, skin
injuries, and dehydration are the most commonly encountered conditions treated in urban
running events,14,15 as well as in urban triathlon and cycling events, with orthopedic injuries and
dehydration being the leading causes for competitor withdrawals and ambulance transfers.16–19
The most commonly reported conditions in remote endurance events are similar to those in
urban events of similar disciplines, yet also can vary greatly based on the characteristics and
conditions of the race location. Temperature extremes or altitude may play a role in certain
settings.1,15,20,21 The most commonly encountered conditions in endurance events include
blisters,9–12,22–24 nausea and vomiting,25 respiratory illness,22,24 orthopedic injuries,12,23,26 and
dehydration/heat illness.11 Most conditions are not life-threatening, and fatalities are rare. For
example, the estimated mortality rate in adventure racing is 1 per 100,000 racer-days.1 Reported
adventure racing fatalities are few: one due to drowning,27,28 one due to hypothermia, and two
due to head injuries.1
Obstacle races are typically less remote. However, unique injuries and illness are
encountered at these races. The popular press have reported injuries and fatalities due to
heatstroke, spinal cord injury, and drowning.29–32 There is very little scientific literature
addressing medical conditions that occur in obstacle races. Greenberg et al.6 published a case
series showing that obstacle racing participants experienced a high incidence of skin, soft tissue,
and musculoskeletal injuries, as well as some unusual reported conditions of altered mental
status, stroke, cardiac demand ischemia, near syncope, rhabdomyolysis, and myocarditis from
electrical shock.33 Electrical shock morbidity may be unusually common relative to other WEMS
operational environments due to the use of electric shock challenges by at least one major race
company (Tough Mudder). The Tough Mudder organization promises (“as our way of saying
congratulations”) the delivery of 10,000 volts of electricity to racers via the Electroshock
Therapy obstacle.34 In a case series of five obstacle course patients published in Annals of
Emergency Medicine in 2013, 80% of the injuries seen were associated with electrical obstacles.6
Travel to austere race sites carries all the inherent risk of travel to remote locations, and can
result in systemic illness, such as traveler’s diarrhea or malaria. All competitors should have up-
to-date immunizations appropriate for remote or foreign travel. There have been rare infectious
diseases contracted at both adventure and obstacle races including Campylobacter infection,35
leptospirosis,1,36–39 myiasis,1,40 and rickettsia.1,41
Preparation for individual considerations unique to each competitor, volunteer, and staff
member should be attained by gathering information via medical questionnaires at the time of
registration, well before the event itself begins.

LOGISTICAL CONSIDERATIONS IN WEM

Standards of Care and Operational Standards

There is no universal published standard for medical care delivery at wilderness events.42,43
However, since these events can attract large numbers of participants and spectators, and pose
significant risk for illness and injuries, there is a compelling need for defining appropriate
provisions for medical services. In a position paper by the National Association of EMS
Physicians on medical care at mass gatherings, the creation of a medical action plan is deemed
essential.44
Medical support planning should occur well in advance of the event and take into account the
size and scope of the event, anticipated medical needs of participants, inherent health risks,
resource logistics, and conditions specific to the event environment (eg, weather, altitude, and
terrain).45,46 Ideally, the event organizer should be invited to participate in planning sessions with
the medical team to assure seamless coordination and collaboration during the event. Although
every plan will be unique to the event venue and circumstances, elements to always incorporate
include details pertaining to equipment and supplies, communications, medical team composition
and orientation, criteria for removing participants who are medically compromised from the
event, documentation requirements, transportation needs and considerations both on and off the
course, and a detailed EMS integration plan. Checklists are very helpful as a tool or guideline to
assure that all elements of the medical support plan are addressed.44
An essential aspect of medical event planning is the need to discern the capabilities and
resources available within the local EMS system and area hospitals. In areas where hospital
capabilities for providing advanced care or managing multiple casualties are limited, planning
must include how to access and use alternative health care systems and resources, including
contracted services. Finally, no plan is complete without addressing overall event quality and
safety considerations, as well as developing risk mitigation strategies to lessen the chance of
harm to participants, spectators, and medical team members. A designated and dedicated event
medical director is considered fundamental to all aspects of the event planning process and
assuring overall medical care quality.44,46,47
Obstacle races, in particular, deserve special mention because they are significantly gaining
in popularity and tend to attract large numbers of participants.5 These events are usually held at
ski areas, parks, and other recreational areas. Though not typically characterized as “wilderness”
venues, they often have challenging terrain features that may call for WEMS skills to facilitate
rescue, treatment, and transport of patients to definitive care. Obstacle races have led to multiple
injuries and illnesses among participants which can place a significant burden on traditional
EMS providers and hospital EDs.6

Removing Unsafe Participants from the Race

Experienced athletes in wilderness events such as adventure races typically train long and hard to
achieve the fitness level necessary to be physically prepared for the competition. They also may
have made a significant financial investment to register, travel, and equip themselves properly
for the event. It is in this context that when participants become injured or feel ill, there may be a
real reluctance to seek medical support or discontinue the race when recommended. An
alternative scenario involves the novice adventure athlete who does not train adequately for the
rigors of the competition. This individual may not be experienced enough to recognize the
prodrome of a major illness, such as heat stroke. Such a situation is more common in the popular
obstacle races that draw large numbers of participants from the general population as opposed to
elite, adventure athletes. However, in both scenarios, it is important to recognize that ill or
injured participants can place rescuers at risk if their condition further deteriorates, requiring
rescuers to carry them off the course or perform a hazardous technical evacuation.
Because receiving medical support can disqualify or result in penalties in some adventure or
wilderness competitions, participants may refuse to seek medical assistance or voluntarily
withdraw from the event. From a competitive perspective, this position is logical: for example, it
would be unfair for an ultra-runner to receive intermittent intravenous fluid boluses and win a
race while other competitors had to slow down due to dehydration.42 At the same time, ethical
issues arise when event organizers create disincentives for participants to seek medical care when
it is indeed warranted. Some ultra-endurance events have protocols in place that allow—and
even encourage—participants to consult with medical staff, but treatment options are limited if
the competitor is to continue.
In our opinion, and that of other experts, adventure competition protocols should include a
provision in the operational standards that ultimately gives the person who assumes medical
command within the WEMS Incident Command system (ICS) the authority to disqualify a
participant on the basis of safety when deemed necessary.1,45 ICS in WEMS are discussed in
more detail in Chapter 3. This authority should be made very clear in the event registration
materials and pre-competition briefing to the athletes. If a situation arises in which the WEM
team feels it is unsafe for a participant to continue, a conversation with the athlete is warranted
that informs of the specific risks and the reasons for disqualification on the basis of medical
judgment. The event organizer may need to become involved if serious disputes arise to enforce
the final decision.42

Integration Plan with Local EMS and Emergency Resources

EMS requirements and coverage needs will vary depending on the size of the event, potential for
serious injury or illness, proximity to definitive medical care, weather, geographic coverage of
the event, and other factors. A minimum standard for any WEM venue is the ability to transport
ill or injured persons to a medical facility, either via their own services or via interface with
traditional EMS.42 Therefore, collaboration and seamless coordination with local EMS agencies
and area medical facilities is vital, whether the event involves a single basic life support (BLS)
unit parked near the finish line or multiple BLS and advanced life support (ALS) units staged
throughout the course. While large urban areas may be able to assist and supply an event with
sufficient ambulances and other EMS resources, more rural or wilderness locations, where these
events are frequently located, are often unable to support the race without depleting the
surrounding community of needed assets and significantly impacting medical facility operations.
Contact must be made in advance of the event with the local EMS agency and the primary
receiving medical facility or facilities to determine if they have the capacity and capabilities to
support the event. Such support may take the form of extra EMS shifts and vehicles that are
dedicated to the race, as well as pre-scheduling additional ED staff, or designating other area
medical facilities as receiving locations for selected patient types based on resource capabilities
(eg, minor care, trauma, cardiac, stroke, hyperbaric chamber). In the case where the local
jurisdiction cannot provide sufficient primary coverage, event managers often arrange for
external EMS resources to avoid overwhelming the responsible agency. In this situation, it is
important to determine in advance whether or not the external EMS resources meet licensing and
regulatory standards established by the state or jurisdiction, and if their standard operating
procedures, medical protocols, and support capabilities are compatible with those of the WEM
team and those of the local medical facilities. Reliable communication methods with these EMS
units must be preestablished, particularly if their communication equipment differs from what is
typically used in the event venue or area medical facilities. Another factor to investigate is
whether or not the EMS providers can receive medical control from a WEM physician or
hospital medical command physician, and if both, whose orders take precedence or are sought
first. If neither, what methods exist to allow the WEM physician to communicate with the EMS
agency’s medical command physician as well as the receiving medical facility when necessary?
As in the out-of-hospital medical care setting, the potential impact on the local medical
facility or ED must be evaluated if a large number of event-related casualties require transport
for care. While an additional 20 to 30 patients in an 8-hour period may not significantly
compromise the function of a large urban ED, a rural ED or clinic that treats that many in a
single day could be completely overwhelmed. A major surge in patient volume or acuity for any
medical facility that exceeds typical resource capabilities can severely stress the emergency care
system. This situation could actually trigger the need to activate the facility’s disaster response
plan and hinder the facility’s ability to manage the patients they normally serve in their own
community. Physician field involvement in EMS operations is a major theme of this textbook.
Deploying physicians (and presumably other clinician-level providers) to mass gatherings has
been shown, in at least one study, to decrease the percentage of patients transported. However,
physician deployment also increased the absolute number of patients seen and the number
transported, leading the authors to suggest that physician field deployment likely had a minimal
impact on local EMS and ED burden. This mass-gathering data may or may not correlate with
clinician deployment to obstacle races.48
The availability of a medical evacuation helicopter should also be determined in
communications with local EMS. Depending on the size and layout of the venue, it may be
desirable to have a predetermined landing zone or zones established and approved by the flight
crew to minimize delays in evacuation. The identification of additional local emergency
resources including SAR, high angle rescue, swiftwater rescue, and law enforcement should be
made in the event they are required given the potential risks specific to the event venue.1 If
additional EMS support becomes necessary, especially in the case of a mass casualty scenario, it
is also important to predetermine both the contact information and the mutual aid capabilities of
the out-of-hospital agencies as well as those of the medical facilities on a more regional scale.
Integration with local or event EMS resources includes distributing the protocols and
procedures that the event medical team will follow in treating participants (eg, how long will the
team attempt to orally rehydrate a patient before initiating EMS transport, the use of ice water
baths to cool heat stroke prior to transport, the criteria for helicopter evacuation, and
predetermined landing zones or staging areas). Typical indications for air medical transport
include a patient with a Glasgow Coma Score < 13 or an oxygen saturation of < 89% via pulse
oximetry.49
The interface of WEMS teams with traditional EMS systems and hospital-based providers is
discussed in more detail in Chapter 6.

ORIENTATION AND COMMUNICATIONS

Orientation
A well-conceived orientation program for all WEM support staff, including the dissemination of
written plans and medical protocols via hard copy or electronic means, is an important
component of event preparation.42 Ideally, orientation should occur in advance so that the
medical team can be fully prepared to function according to plan the day of the event. This
timing allows for a more thorough overview of content as well as the op portunity for questions,
discussion, and refinements if gaps are identified.
However, when circumstances permit only a briefing session on the day of the event, it
should involve all WEM team members. If that is not possible, other potential orientation
methods might include one-to-one education and the provision of hard copy or electronic
reference materials. Consideration should also be given to conduct additional briefings at
specified time intervals during the event to communicate information such as status updates,
hazards, and changes to the original plans.
Key aspects of the orientation include team member introductions, chain of command, team
member scope of practice and staffing guidelines, event logistics, equipment and resource
availability, medical protocols, record keeping and documentation requirements, communication
methods and expectations, and the integration plan with EMS and local health care facilities. In
addition to being fully informed of the medical and operational plans, the wilderness medical
team should be made aware of the anticipated illnesses, injuries, and health hazards associated
with both the event and the environment, as well as personal safety considerations to reduce
risks. If known in advance, the orientation should also specify whether persons with special
needs are expected to be present as event participants, race crew, or spectators (eg, the blind,
hearing impaired, diabetic), and include any predetermined care or support instructions.

Communications
Another critical logistical component is a well-established communications plan with team
members, race personnel, and with external resources. For events that are limited in scale that
primarily occupy a fixed medical facility, telephones may suffice for contacting the local EMS
agency for transportation. For larger scale events, several communication strategies and
methodologies may be used. Communication devices will vary depending on the characteristics
of the event venue. In general, high quality handheld radios work well in most locales and are
excellent for communicating with event team members, race personnel, water and aid stations,
and medical command. It is often necessary to have multiple radio frequencies in use to connect
with the separate sectors that are involved in race operations since race communications and
medical communications can compete for airtime if only one frequency is employed. However, if
extended or private communications are necessary, especially with external resources that will be
involved in patient care activities, landline, cellular, or satellite phones may be utilized,
depending on availability and event location.
In very rugged or remote areas, it is important to evaluate whether or not a cellular signal is
available or if portable radios have the range necessary for reliable communications over the
entire course area prior to the event. Communication “dead zones” may exist that require the use
of alternative communication methods or strategies, including the need for portable repeaters to
bolster the effective radio range.1
Since radio communications can easily become overwhelming at large events, medical
operations should have their own dedicated frequency or channel whenever possible. Otherwise,
calls from the medical tent to request ambulance transport for a seriously injured participant may
be interrupted by requests for food supplies or announcements of race results.
A detailed contact list of critical race personnel should be available to all medical team
members and medical stations. The list should include phone numbers, radio channels and radio
identification of the race director and key race personnel, department heads, event medical team
members, the medical director, EMS agencies, and other critical resources such as the local
hospital. Radio protocols should be determined in advance and be included in the training of
medical staff and volunteers unfamiliar with radio operations. Race participants and event staff
must be clearly informed about how to contact medical operations if the need arises.
Consideration should also be given to the need for on-site interpreters, or a defined means to
access an electronic or telephonic interpreter service when necessary.

Documentation
There are both operational and medical needs related to documentation during a WEM event. For
the WEM staff, a standard sign-in sheet or log should be used to record the names, credentials,
assigned areas or roles, and time in/time out of the team members for tracking purposes.1 The
medical director or WEM team members may also elect to keep event-specific administrative
records of operational decisions or issues that arise. These notations can assist in real-time
incident management, issue investigation, and for post-event quality review and future planning
purposes. Equipment logs can assist the WEM team in tracking the location and function of
specific resources necessary for patient care or transportation, as well as those items that are sent
to the hospital with the patient that require eventual retrieval.
Like in any other EMS or health care setting, documentation of the treatment provided by the
WEM team is also considered an essential aspect of care delivery. Depending on the format, this
documentation may serve as a record of the incident or encounter, a hand-off tool to
communicate with subsequent caregivers, or a part of the out-of-hospital report to facilitate care
transitions with EMS agencies and subsequent health care settings. In addition, during the event,
records may be useful in tracking the location of participants who do not arrive at established
checkpoints when expected or who require transport. These records also provide the primary
database for generating illness and injury-related statistics and subsequent analyses, as well as
the foundation for the medical quality and safety review. Considering current and future uses of
the information contained in the patient care record should influence form design as well as the
information fields to be included.
As with any documentation of a medical encounter, there are legal implications. Personal
health information should be protected to the best degree possible to maintain patient
confidentiality.42 WEM records could potentially be subpoenaed if litigation related to the event
or medical care occurs. The process for maintaining, securing, and possibly disposing of the
records after the event should be determined.1
As part of the planning process well in advance of the event, the WEM team should consider
requesting that event organizers incorporate questions about significant medical history, such as
active health conditions, allergies, implanted devices (eg, insulin pump, pacemaker) and current
medications, on the participant registration forms. Having this information printed on the back of
the event bib is optimal for easy access by the WEM team. When that is not possible, medical
personnel and event organizers should determine the best way to quickly obtain critical
participant medical information from the race registration system in emergency situations if
needed. In an emergency situation when the patient is unable to provide information (eg,
impaired consciousness), retaining the bib or recording the number written on the patient’s body
can help to associate the encounter with the patient’s registration and emergency contacts.
In general, the patient encounter and any subsequent care provided should be documented for
participants who seek or require medical assistance. For simple requests such as dispensing of
Band-Aids, abrasion care, or ice packs for musculoskeletal sprains or strains, a basic contact log
may suffice. If it is necessary to create such a log, consider including the following column
headings: encounter date/time, patient name, age, bib or event number (if applicable), chief
complaint or request, exam findings, treatment or service provided, and the WEM team member
names.
Treating a patient with a higher acuity illness or injury necessitates more thorough
documentation, including a section for reevaluation if extended care is required.42 Beyond the
basic demographic information that is needed for post-race follow-up, this record might include
sections for timing and documentation of serial vital signs, pertinent assessment or examination
findings, the treatment provided (medications, procedures, first aid, etc), progress notes, and any
instructions given for follow-up care. When ambulance transportation to a hospital is indicated,
include the name and/or vehicle number of the EMS unit and the medical facility. If possible,
include a copy of the patient care record to facilitate hand-off communication and transition of
care.

TRANSPORTATION
Transportation is an essential logistical component of WEM.42 The remote location, terrain, and
the potential need for multiple transportation modalities can pose difficulties in patient access,
stabilization, and evacuation to definitive care. Rescue efforts can be challenged or even
hampered by crowds of people, steep trails that are inaccessible to all but foot traffic, bodies of
water, and expansive or complex courses that require technical mountaineering skills to navigate.
Depending on the venue, terrain, and environment, medical teams on foot, mountain bike,
snow mobile, cross-country skis, all-terrain vehicles, boats, or four-wheel drive vehicles might
be employed to reach and transport patients off of the course, depending on their location. If
vehicles will be used, assure that all are in good working order so that they can be relied upon to
perform as expected.1 Though some vehicles used by the WEM team might be equipped with
emergency care supplies, splints, AEDs, oxygen, and rescue baskets, they may not be able to
reach the injured or ill in certain event locations; the WEM rescuers may have to proceed on
foot. Additional resources for difficult extractions may need to be rapidly assembled.
A pre-event appraisal of the planned course to establish optimal staging areas for EMS
vehicles, especially in any areas of challenging terrain, will help to assure a well-coordinated
response to rescue efforts. While EMS units are usually staged at the medical stations, general
knowledge of the predetermined access points for ambulances and medical evacuation
helicopters among wilderness event medical personnel can facilitate smooth medical operations
during the event, especially during very busy periods.
Along those same lines, fundamental to an expedient rescue response is full knowledge of
the course and event venue. An accurate map is essential. If route changes are necessary, revised
maps should be made available to all WEM personnel as “real time” as possible. To make
navigation easier, these maps should include identifiable landmarks, directional aids, roads,
resources such as medical aid and water stations, event facilities and checkpoints, vehicle access
points (including areas that may be used for EMS vehicles or helicopter landing), shelters,
hazardous terrain, and obstacles.1
Further details regarding vehicle operations in WEMS care are discussed in Chapter 28.

MEDICAL STAFFING AND PLACEMENT OF PERSONNEL

The number and composition of WEM providers should be determined by the number of
competitors as well as the anticipated risks related to the setting, distances, environment, and
challenges included in the event itself. Placement of medical tents and personnel on the race
course can be challenging. It has been reported that in some urban events, most medical
presentations occur near the end of the race,14,15,17 and recommendations have been made for
“increasing support by 20%” in the latter sections of long-distance triathlons, “starting at hour
14, to 3 physician and 9 nurses/other medical volunteers per 100 competitors.”50 Reports from
wilderness events vary from reports of injury rates all throughout the course1 to others reporting
injuries that are higher in the middle third of the race.25 One 5-day ultramarathon reported the
highest rate of injury on the longest stage and last day of the race.26
Obstacle races have physical challenges with significant risks, which make it appear obvious
that skilled rescue and medical personnel should be staged at each of these high-risk challenges.
Those individuals or teams should be skilled in the discipline employed in the challenge itself:
for example, water challenges should have open water lifeguards (Chapter 27), swiftwater rescue
experts (Chapter 26), or rescue divers (Chapter 17), whichever are most appropriate for
conditions and challenges included in the race.51
Typical EMS training does not include many of these specialized skills for rescue, and in
every case it is essential that the WEM staff includes rescuers trained in skills relevant to the
disciplines which are included in the race itself.1 These could include open water lifeguards
(Chapter 27), swiftwater rescue technicians (Chapter 26), rescue divers (Chapter 17), high angle
rescuers (Chapter 25), mountaineers and ski patrollers (Chapter 31), climbers, or those skilled in
SAR (Chapter 30), just to name a few.
Medical tents are often located at nutrition/hydration “aid stations” but should remain
separate in focus. Some urban events have “water stations” every 2 miles and a medical station
or ambulance only at the start/finish area. Events in austere settings may have aid stations every
10 km, at set checkpoints, at convenient road crossings/entry points or only at the finish. It would
be impractical to attempt to impose strict guidelines for all austere events; the appeal of many of
these events is the remote nature of the course itself and its inherent risks, along with the self-
reliance or teamwork required to “ conquer the challenges.” The WEM providers should be
aware of the intent of the race organizers in this regard, and prepare for the logistics and
communications issues involved. The location and number of medical aid stations should be
determined based on the anticipated risks of the course, which may include physical and
environmental challenges.52 Evacuation plans and protocols should be in place for monitoring
competitor safety as well as for emergent treatment and evacuation.

EQUIPMENT
Medical equipment should be based on the type of event, the associated disciplines and risks
involved, natural hazards, climate/environment, as well as the qualifications of WEM
providers.13 Items for specific treatments or interventions, such as advanced airway equipment or
hypertonic saline, should be obtained based on the estimated risk. Prior events may provide
helpful historical information which can also guide equipment choices. Table 9.1 provides a list
of basic and advanced medical supplies and equipment for consideration.3
IMPLICATIONS FOR PRACTICE LEVELS
First and foremost, as in all situations encountered by EMS personnel, safety of the WEM crew
is paramount. Scene safety must be assessed and all risks mitigated as much as possible prior to
engaging in patient rescue or care. WEM personnel should be briefed and educated about the
potential perils and pitfalls at specific scene sites and locations where risks lie outside the usual
purview of urban EMS training.
As mentioned, there are specific skill sets above and beyond medical care skills that may be
necessary for individuals or teams. Staffing needs are unique to each event, and should be based
on the length of the race, the specific challenges or obstacles in the event, and the environment
and conditions. Race organizers should be aware of the need for those specific skill sets, as well
as the qualifications and certifications of those providing such specialized services (Table 9.2).
WEM providers should have a unique fund of knowledge that is adapted from and built upon
standard EMS training and organized into an operational EMS medical support team.52 The
National Association of EMS Physicians states:
Operational EMS programs should function within and not outside the mainstream healthcare system. Therefore, it is
important that their constituent agencies and providers, regardless of the level of care provided or scope of practice, have a
qualified medical director and that established standards of care are met. Operational EMS providers should function within
their defined scopes of practice, as established by their training and certification or licensure as applicable within the state in
which they are functioning.53

First Aid
Many expedition length events require competitors to provide their own first aid kits and be
proficient in its use, thus providing their own basic first aid. Other events may have medical
stations and personnel who provide basic first aid for both competitors and spectators. These
stations are typically for shorter events with a single aid station at the start/finish. The goals and
intent of the type of race may drive the type of staffing and location of these stations.
Communication is one of the most important responsibilities of those WEM team members
providing basic first aid. Not only should they be provided with basic first aid equipment, but
they should also be provided with a reliable means of communication to reach a higher level of
care. WEM providers should be knowledgeable regarding all safety and medical protocols and
should be able to call for assistance whenever needed. They should know definitively where they
are located on the race course, and how to direct others to their locations. If ambulance
rendezvous sites or helicopter landing zones are part of the medical protocols, first aid providers
should know their locations and the roles that are to play in transporting patients to those sites.

Basic Life Support

In addition to their standard level of training and delivery of care, BLS WEM providers should
be intimately familiar with the course itself, its accessibility and risks, as well as the transport
modalities available. These may be the individuals or teams tasked with SAR, and if so, should
be proficient in that arena. BLS crews should be familiar with all protocols, and access sites to
the more dangerous or risk-laden areas and challenges. WEM personnel should be staged at
appropriate access site, have reliable means of transportation and communication at all times.
Table 9.1 Considerations for Basic and Advanced Medical Supplies and Equipment
Basic Equipment Advanced Equipment
Gloves Intravenous (IV) fluids
Bag-valve-mask (BVM) IV start kits/IV tubing/alcohol pads
Oral/nasal airways of various sizes Hypertonic saline
Automatic external defibrillator (AED) O2 saturation monitor
Blood pressure cuff Blood glucose monitor
Stethoscope Point-of-care blood analyzer
Hypo/hyperthermia thermometer Pregnancy test
Splinting supplies (eg, SAM splints; traction splints) Portable ultrasound
Triangular bandages/cravats Cardiac monitor/defibrillator
Zip-ties Intubation equipment
Trauma sheers Oxygen cylinders
Ice and/or chemical cold packs Non-rebreather masks
Wound Care Syringes/needles
Gloves Laceration repair supplies
Wound irrigation supplies #11 blade scalpel
Gauze Medications
Adhesive bandage Epinephrine IM and IV
Medical tape Albuterol MDI
Elastic bandage Diphenhydramine IM/IV, PO
Kinesiology tape Cimetidine or ranitidine
Blister care supplies: antiseptic, needle, moleskin, non-adherent dressing or commercial Acetaminophen
film/gel-type blister dressing
Tissue adhesive Aspirin
Comfort/Personal Hygiene Ondansetron
Tampons/pads Omeprazole
Vaseline Antacid tablets
Sunblock Oxycodone
Mylar blankets Nitroglycerin
Prednisone
Ciprofloxacin

IM, intramuscular; MDI, metered-dose inhaler; PO, per os (by mouth).

Adapted from Laskowski-Jones L, Caudell MJ, Hawkins SC, et al. Extreme event medicine: Considerations for the organisation
of out-of-hospital care during obstacle, adventure, and endurance competitions. Emerg Med J. 2017. [Epub ahead of print].
Available at: http://emj.bmj.com/content/early/2017/08/06/emermed-2017-206695. Accessed August 16, 2017.

Table 9.2 Appropriate Certifications Based on Specific Event Characteristic

Event Characteristics Appropriate Certifications
Urban event with access to traditional EMS EMT (Emergency Medicine Technician)
EMR (Emergency Medicine Responder)
Remote and wilderness environments DiMM (Diploma in Mountain Medicine)
 WFR (Wilderness First Responder)21,38
WEMT (Wilderness Emergency Medicine Technician)
AWFA (Advanced Wilderness First Aid)
WAFA (Wilderness Advanced First Aid)
AWLS (Advanced Wilderness Life Support)
WALS (Wilderness Advanced Life Support)
WUMP (Wilderness Upgrade for Medical Professionals)
Kayaking events SRT (Swiftwater Rescue Technician)
Open water swimming Lifeguard, Wilderness StarGuard14
Climbing or Rappelling AMGA (American Mountain Guide Association) Rock Guide4
Skiing OEC (Outdoor Emergency Care) through the National Ski Patrol11,22

Adapted from Laskowski-Jones L, Caudell MJ, Hawkins SC, et al. Extreme event medicine: Considerations for the organisation
of out-of-hospital care during obstacle, adventure, and endurance competitions. Emerg Med J 2017. [Epub ahead of print].
Available at: http://emj.bmj.com/content/early/2017/08/06/emermed-2017-206695. Accessed August 16, 2017.

Advanced Life Support

Trained to administer advanced care and medications, ALS WEM providers should be stationed
appropriately to be able to reach crucial areas of the course at any given time. The number of
individuals needed will vary depending on race length, duration, conditions and accessibility.
ALS teams and individuals should have all crucial medications/supplies available and with them
ready for transport at all times during a WEM event. Often, fewer ALS personnel are on-site and
need to be within a reasonable distance from ALS crews or first aid tents in order to attain a
reasonable response time if dispatched to one of several locations. They should have reliable
means of communication and the ability to be transported to necessary locations. Adaptability
and improvisational skills are very important as some WEM scenes and conditions lie outside the
typical urban ALS purview.

Clinician
All levels of WEM personnel may provide care at many stations based on their level of training,
and this holds true for physicians, physician assistants, and advanced practice registered nurses.
However, the most important role to be filled at the clinician level for an event is that of medical
director. The medical director is responsible for developing and providing plans for the safety
and care of everyone on the course: staff, volunteers, competitors, and spectators. As such, the
medical director should ensure adequate staffing, as well as placement of appropriate staff and
medical aid stations. Adequate supplies, medication, and equipment should be made available
based on anticipated scope of injuries, which should be based on the event conditions and
challenges, as well as competitor, staff, and volunteer medical information. Protocols should be
developed in conjunction not only with race organizers, but also other WEM personnel to ensure
utmost safety. The input of other team members in development of protocols should not be
discounted or overlooked. Availability of outside resources should be assessed, and the medical
director should be knowledgeable about local EMS resources and hospital facilities. If traveling
outside the usual location of practice—be it region or even country—medical directors should
visit the local hospital and personally assess and familiarize themselves with the resources level
of specialty care available. Occasionally, the event medical director is a liaison between the race
organizers and local WEM providers, which may include local EMS, SAR, or even ski patrol
personnel. It is imperative that agreements are reached between these entities to avoid any and all
confusion or potential conflict regarding the provision of care, and it is the responsibility of the
medical director to facilitate these agreements. The nearest hospital to many remote event
locations may not have advanced specialty/subspecialty medical care, and evacuation planning
should consider the potential need for this. The ability to reliably communicate with personnel is
crucial as the event is being developed and during the event itself. The medical director should
also provide feedback to race organizers after the event, in order to improve processes as
necessary.

SUMMARY
WEM is unique with many variables and challenges. These variables make it both appealing and
challenging to provide medical care for austere events. WEM providers with many levels of
training and skill sets are crucial to providing adequate medical coverage in these austere
settings. While no specific standards can reasonably be developed that will fit every wilderness
event, the principles and guidelines provided in this chapter should aid the WEM practitioner in
the development appropriate plans and protocols for any austere event—from shorter trail runs,
mountain bike races, or obstacle races, to expedition length multi-day ultra-endurance or
adventure races.

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INTRODUCTION
Few responders travel through their careers without being deeply affected by a stressful event or
experiencing the cumulative effects of responding in challenging environments. Few individuals
who experience unexpected or overwhelming events in the wilderness will not be impacted by
them. Unfortunately, psychological treatment in emergency situations is often neglected, both
because it has not been felt to pose a threat to life and because emergency response personnel
often feel ill-equipped in recognizing and mitigating psychological injuries. Often providers feel
there is nothing to do to prevent psychological injuries, often referred to as stress injuries. A
growing body of knowledge suggests the opposite is true. Stress injuries, like physical injuries,
can be recognized and mitigated, with practical and accessible tools. Fortunately, for the remote
provider, these tools can be practiced and utilized in all remote settings.
The concept of stress mitigation and treatment of psychological trauma is not new. Patients
presenting with a number of disturbing psychological symptoms following combat stress in
World War I (WWI) were said to have “shell shock.” Treatment consisted of treatment of
patients near battle lines, where the din of battle could still be heard, and where soldiers could
remain with their units, rather than returning home to peaceful surroundings of home. Indeed, it
was found that those who returned home, or experienced delays in treatment, experienced longer
lasting and more debilitating symptoms than those who were treated by military personnel who
understood their plight and expected them to make a full recovery.1 The principals of treatment
of stress injuries during WWI2 such as immediacy, treating patients as soon as possible following
the injury, and proximity, treating in the environment in which they occurred, can still be seen
reflected in the current recommendations of psychological first aid (PFA).
Field treatment during of psychiatric injuries continued throughout World War II (WWII). In
1944, a staggering 43 in every 1,000 admissions were related to psychiatric causes, compared
with 86 per 1,000 for physical injuries3 in WWII. The concept of forward treatment of
psychiatrically wounded soldiers was again adopted,4 with soldiers maintained in field hospitals
for the first 7 days following the stress injury, rather than being evacuated to long-term treatment
away from combat.
The Vietnam war saw continued implementation of the previously developed treatment
strategies, such implementing forward treatment of casualties in the war zone, with a resulting
lower rate of psychological injuries (11 in 1,000) in combat; however, the lasting effects of
psychological trauma were pervasive and devastating among returning veterans. It is estimated
that almost a quarter of those who served in Vietnam from 1964 to 1972 required some form of
psychological help on return.4 A more recent study demonstrated that four out of five Vietnam
Veterans reported symptoms of posttraumatic stress disorder (PTSD) when interviewed 20 to 25
years afterward.5 This phenomenon suggested that more was needed to protect soldiers from
stress injuries, and fueled the pursuit of approaches to preventing and treating stress injuries that
exist today.
Early models of PFA, as it exists today, began to emerge in the 1980s, with many of the
components first discussed in the literature—such as the need for social support, caring for
physical needs, and allowing individuals to express their feelings—still utilized today.6 Around
the same time, growing effort to address traumatic exposure in emergency medical personnel
first took shape as mandatory gatherings referred to as critical incident stress debriefing (CISD).
These debriefings were typically initiated when a group of providers had been through an
incident that was deemed a “powerful and overwhelming event that lies outside the range of
usual human experience”7 thought to hold the potential to cause psychological harm to the
participants. Responders were asked to recount aspects of the event that were particularly
troubling to them. Many found this helpful; however, there was growing concern that, while
these gatherings did address the issues of the provider witnessing traumatic situations, research
began to reflect that they might not be helpful in prevention of stress injury, particularly the
mandatory recounting of traumatic details. In 2002, a review of the literature revealed that while
several studies demonstrated improvement in stress-related injury, other studies demonstrated no
effect in outcome, and even more troubling, two studies demonstrated worsening in outcomes of
stress-related symptoms following CISD.8
Out of this concern, the world’s experts on psychological trauma and its mitigation gathered
to explore elements of intervention that were confirmed to be helpful in reducing symptoms of
stress injuries following traumatic exposures. In 2007, Hobfoll and colleagues recommended five
broad, evidenced-based treatment principles that became the cornerstone of a new
psychotherapeutic technology, now known as PFA.9 These recommendations include promoting
a sense of safety, calm, sense of collective and individual self-efficacy, connectedness and hope
serving as a foundation for the majority of recommendations, and programs related to PFA.10
In 2006, the first PFA manual was created by the National Child Traumatic Stress Network
(NCTSN) and the National Center for Post-Traumatic Stress Disorder (NCPTSD),11 and now
serves as a foundation for other PFA in specific populations, such as combat veterans (Combat
and Operational Stress First Aid), fire and rescue (Stress First Aid), schools (PFA-S), and is
incorporated by the Red Cross, the Federal Emergency Management Agency (FEMA), and the
World Health Organization (WHO) for use in disaster settings.12 PFA is now being taught to
wilderness medicine providers. NOLS Wilderness Medicine is now one of several wilderness
medicine schools to incorporate treatment of stress injuries into their curriculum.
This chapter discusses stress injuries across the continuum. There are two distinct issues
surrounding stress injuries. The first will describe injuries in formation that may be mitigated by
PFA, and the second, treatment of presentations related to already formed injuries, and the
expression of troublesome reactions that interfere with wilderness travel and expedition
behavior. Finally, attention will be given to recognition, support, and prevention of stress injuries
in the responder.

STRESS INJURIES
The human machine is designed for stress. Stress is the foundation of human growth and
survival. Everyone experiences stress throughout their lifetime; most overcome stressful
situations and grow from them. According to the NCPTSD, an estimated 6.8% of the adult
population in the United States will experience PTSD during their lifetime,13 despite the fact that
a majority of individuals in the United States report at least one lifetime stressful incident.14 This
implies that most who encounter overwhelming events in their lifetime will not suffer long-term
or debilitating effects.
A question resounds among those studying stress injuries:15 Why do some who experience
overwhelming events, go on to develop stress injuries, and some, who have experienced the
same types of stressors, are never again bothered by symptoms, or even more interesting, thrive
because of their experiences? There is no short answer to this human mystery. What is clear is
that multiple factors work in congress to protect or predispose a person to stress injury.
It is now clear that vulnerabilities in existence prior to the provoking event, such as earlier
traumatic events, genetic and neuroendocrine factors, and family or personal history of mental
health disorders sensitize the brain to development of stress injuries in the presence of
overwhelming stress. Contributing to each individual’s expression of stress injury will be the
confluence of the magnitude of the stressor, how prepared the individual was for the event
(financial and emotional resources with contingency for disastrous or catastrophic stressor), and
the available support during the initial period immediately following the disaster. Initial response
to the trauma (dissociation, activation, or coping responses and participation with one’s own
rescue), as well as the post-trauma factors (severity of reaction, availability of social support, and
existence of other life stress) work in conjunction to determine the level of each individual’s
ongoing distress.16
At the foundation of every stress injury is an event or a stressor that overwhelms the patient’s
ability to integrate it. Each person will experience a stressor with a unique landscape and
capacity to respond, requiring flexibility and receptivity of the responder, given that no two
people will respond to stressful events in the same way.

Signs and Symptoms of Stress Injury

The Diagnostic and Statistical Manual-V describes that the foundation for the most commonly
diagnosed stress injury, PTSD, must include a stressor. Specifically identified stressors in DSM-
V include death or threatened death, actual or threatened serious injury, and actual or threatened
sexual violence.17 The stressor may be subtle, dramatic, or perhaps even a part of one’s routine
work responsibility. Stressors can occur as one overwhelming or horrific event, or continuous,
insidious exposure to troubling stories or experiences that occur routinely in the course of one’s
work experiences, as is often the case of emergency medical service (EMS) providers and
military personnel. The DSM-V criteria do not distinguish between personal experience of the
stressor and exposure to an experience by someone to whom one feels an emotional connection;
both cause a stress injury.
 In plain terms, trauma can happen to someone else and still cause stress injury. This includes
directly experiencing the stressor, personally witnessing the stressor happening to another, or
indirectly experiencing the stressor, for instance, learning that a friend or close relative was
injured, killed, or exposed to trauma. Now recognized is the fourth means of experiencing the
stressor: repeated or extreme exposure to aversive details of events, usually in the course of
professional duties. This could include the park ranger who, as part of her duties, must routinely
participate in body recovery and informing next of kin of the news of a loved one’s death.
The description of reactions to stress is clinically categorized into four reaction types:
intrusive symptoms, avoidance, alterations in cognition and mood, and alternations in arousal
and reactivity. More subtle expressions of stress injury are sometimes left unrecognized.
Intrusive symptoms are likely the most apparent to the outside observer, and those most
likely to be identified and associated with PTSD. Reminders of previous trauma retain their
capacity, sometimes for months or years after an event, to elicit panic, dread, terror, grief and
despair, and the physiologic symptoms that accompany them. Graphic nightmares and vivid
daytime images that come without warning, as well as the feeling that one is experiencing the
event again in the present (flashback), all intrude on the individual and may interfere with daily
activities. Benign sensory reminders of the event, such as the faint smell of smoke in the air, the
gathering of thunderclouds overhead, or the sound of rustling outside a tent have the power to
evoke mental images, physical sensations, and emotions that were experienced at the time of an
overwhelming event.
Reactions of avoidance are the actions an individual takes to avoid reexperiencing the
sensations, feelings, and emotions associated with the trauma. For some, this can be subtle or
elaborate efforts to reduce the chance of encountering trauma-related stimuli (reminders of
trauma). This may include avoiding conversations, situations, people, or activities that serve as
reminders. The climbing guide who experienced a terrifying avalanche may convince himself
that he no longer likes to ski in an effort to avoid being in a situation that feels similar to the
conditions on the day of the avalanche. The EMS provider who responded to a gruesome
accident involving a child may respond by wanting to spend less time or avoiding spending time
with the children in her life. When avoidance is extreme, it may limit one’s ability to leave the
house, work, or live a productive or enjoyable life.
Negative alternations in cognition and mood demonstrate that PTSD is distinct from anxiety
disorders, in that the effects of traumatic stressor also alter the individual’s view of themselves
and the world around them. This change in world view, for example, a new belief that the world
is no longer a safe place, can create persistent thought patterns that change the way one looks at
the world after exposure to a traumatic stressor. These reactions are most synonymous with those
of depression, including decreased interest in things once enjoyed, isolation, guilt, negative self-
beliefs, or contorted beliefs about the event (“this is all my fault”). Persistent moods such as
anger, irritability, sadness, and hopelessness are often associated. Concentration and memory can
be affected, with decreased ability to concentrate or inability to recall the specific details of the
event. Distorted appraisal of the cause of the event, or the bleakness of the future, is not
uncommon. A survivor of a serious climbing accident may fixate on the belief that she should
have or could have prevented the accident, and that she is not competent to continue her work.
Often accompanying this is the feeling of being detached or separate from others, or not able to
express positive emotions such as love, joy, or pleasure. It is easy to imagine how this restricted
affect would sabotage one’s ability to sustain satisfying work life, marriage, close relationships,
and family connections.
 Alterations in arousal and reactivity arise from one constantly waiting and anticipating the
re-occurrence of the event that one dreads. These reactions are similar and indeed could be
mistaken for symptoms of general anxiety or panic disorder, if not for the fact that the symptoms
arise as a result of stress injury. Exaggerated startle response and always being “on edge,”
searching for exits, or creating “what if” scenarios all reflect a state of constant arousal and
watchfulness that again interferes with one’s ability to enjoy the moment or relax. When a
reminder does trigger a reaction, physical reactions of heart racing, sweating palms, difficulty
breathing, and shaking can occur immediately and often persist. Hypervigilance, or the constant
watching of the environment for escape routes and things that may cause harm, become so
intense that it may be mistaken for paranoia.
Behaviors that result from the persistent emotional states described above have been added to
the national conversation on stress injury via the DSM-V. These behaviors are often highly risky
or self-destructive behaviors such as unsafe sex, reckless driving, or suicidal behaviors.
Increased anger and irritability are known to lead to aggression, especially for those whose
trauma involves violence, such as combat veterans and law enforcement. The diagnosis of PTSD
is often accompanied by comorbid diagnosis, such as substance abuse, depression, anxiety, or
other mental health diagnoses.18
It is not uncommon for rescuers to encounter an individual, who, in addition to incurring
physical injuries at the scene of an accident, may have already been overwhelmed by reminders
of previous trauma when the current trauma occurred. Hyperarousal, hypervigilance, irritability,
aggression avoidance, and reexperiencing may all confuse the initial presentation of the
individual. Rescuers will do well to engage a high level of clinical curiosity when clusters of the
above reactions accompany physical injuries. The helpless feeling that often accompanies the
experience of becoming a patient may be all that is needed to trigger the stress response.
Rescuers must consider their own safety when encountering a patient who is reexperiencing
trauma. Treatment and prevention of PTSD and stress injuries are discussed later in the chapter.

Stress Injury Formation

Under normal circumstances, a stressor signals a cascade of hormonal, behavioral, and emotional
responses via the autonomic nervous system and physical responses. The rescuer who suddenly
encounters a bear on the trail will likely experience immediate elevation of heart and respiratory
rate, fear, and may begin running away, all before the “thinking” aspect of the brain, the cortex,
has time interpret or consider what has occurred. These “subcortical” responses, such as
sympathetic nervous system stimulation, allow for action and rapid resolution of the crisis.
When a rescuer experiences that the danger has passed, either because the rescuer escapes
the bear, or, on second glance, discovers it was not a bear at all, the brain releases an “all clear”
signal to the body. This sets off a separate set of chemical mediators to stimulate the
parasympathetic nervous system, responsible for slowing heart rate and reestablishing the
baseline or pre-arousal state. This state effectively communicates to the body and brain that the
threat has passed.
How, then, are stress injuries formed? Much like physiological vulnerabilities that set the
stage for overwhelming infection or injury (eg, the elderly diabetic who is more likely to
succumb to a urinary tract infection than a healthy teenager), there are genetic, social, and
historical factors that contribute to setting the stage for stress injuries. Stress injuries are formed
when a stressor or series of stressors overwhelms the person experiencing its capacity to
integrate it or make sense of it. The injury often occurs in association with a sense of
helplessness, when an individual is not able to respond or defend themselves with definitive
actions. Commonly in the remote setting, isolation and prolonged distance from definitive care
contributes to a sense of helpless. As discussed previously, individuals who have previously
encountered trauma are often sensitized to interpret benign cues as harmful and have already
established brain pathways to respond to stressors. When the stressor is introduced, the same
protective pathways of hyperarousal are cued, with the resulting signals to the fight or flight
system, and initiation of action. All the sensory input stored at the moment of the event is
captured, as if on camera. The sights, sounds, smells, and sensations of that moment are
imprinted in the brain’s memory, and will later likely become the triggers to tell the nervous
system that the stressor may be reoccurring.
What distinguishes stress injury formation from the adaptive response discussed above also
includes the failure of the “all clear signal,” alerting the body that the threat has passed.
Individuals may continue in the same hyperaroused and hypervigilant state for days or weeks.
Indeed, research has demonstrated that those who have elevated resting heart rates one week
after the event are more likely to develop symptoms of PTSD.19 This ongoing state of
hyperarousal demonstrates that the brain has not registered that the danger has passed, and the
individual continues to live in a state of persistent threat and readiness for action. The individual
has now established the neurobiological groundwork to respond immediately to any future cues
that resemble those associated with the initial event. Smells, sights, sounds, internal states, even
elevated heart rate, thoughts, and emotions may all trigger the brain to initiate the same levels of
arousal and preparedness for action this time without any real evidence of danger. This is seen in
the WEMS helicopter crew member who experiences his heart racing, difficulty concentrating,
and excessive worry each time he is in a helicopter taking off on a clear autumn day. Though no
clear danger exists in the present moment, the recall of a near miss on a clear day in autumn in a
previous year will still signal the brain to ready for danger.
It is important to note that some events are so overwhelming, or the feeling of helplessness
so great, that some individuals will experience a phenomenon where the fight or flight response
system itself is overwhelmed and a “system shutdown” is initiated. The nervous system or brain
causes a slowing of vital processes, such as heart rate and respiratory rate. The individual may
look as if they are in shock and be minimally responsive or confused. This state of “overwhelm”
is associated with a more serious presentation of ongoing stress injuries, and referral to higher
level of care when appropriate should always be the priority.
Anyone can experience a stress injury if the stimulus is sufficiently overwhelming. Still, it is
a curious phenomenon that two people can witness the same event and have widely different
reactions to it. This should be instructive to providers to anticipate the possibility of stress injury
formation, but also to respect and support those who truly deny reactions to what the rescuer may
consider a traumatic event or situation.

TREATMENT OF STRESS INJURIES

To discuss the treatment of stress injuries, it is important to discuss the trends in language used to
describe these conditions. Rather than semantics, these terminology and language changes
represent a significant alteration in perspective and treatment priorities and as discussed below,
changing the language may eventually influence the treatment of a stress reaction.
Current Language of Stress Injuries
The discussion of stress-inducing injuries is shifting away from descriptions such as “trauma”
and “traumatized” to “stress injuries.” Symptoms are now better described as reactions. In this
context, it may be preferential to refer to those having dysphoric reactions to stress as “patients”
or “survivors” rather than “victims.” This discussion has been in the pipeline for more than a
decade, and the Inter-Agency Standing Committee (IASC), the primary mechanism for
humanitarian response globally, has encouraged disaster workers responding to psychologically
overwhelming events to change the way they refer to the individuals they are serving.20 Intrinsic
in the words “traumatized” and “victim” is the helplessness projected on those to whom
something has happened. Words such as “overwhelmed” and “survivor” normalize and
empower. Indeed, suggesting a normalized adaptive response to stress with the word “reaction”
is preferable to pathologizing the stress response with the word “symptoms.” In other words, a
healthy person has a “reaction”; a sick person has a “symptom.” Reflect again that while the
reactions may be interfering with one’s ability to function in a preferred way, the underlying
mechanism remains incredibly adapted for survival. This, too, should be reflected to the patient
to deflect the shame and isolation that often accompanies stress injuries. Changing the way
rescue personnel discuss and treat these injuries will indeed be instrumental in changing the
culture of stigma and avoidance often associated with stress injury. See Table 10.1 for examples
of recommended language.

Treatment Principles for Acute Behavioral Exacerbations Related to Stress

Acute exacerbations of previous stress injuries may present with extremes of panic, dissociation,
reexperience of the stressor, agitation, and dramatic mood presentations. These conditions may
require advanced care. Principles of PFA will be discussed below and are often appropriate to
help reduced fear, anxiety, and agitation in the presence of preexisting stress injuries. In the
remote setting, it may be most helpful to treat each presenting reaction when behaviors are
extreme. Acute agitation, panic, self-harm, or extremes of mood are examples of extreme
behavioral reactions, and are expressed in detail in Chapter 23.

Table 10.1 Recommended terminology for working with stress-exposed persons

Recommended Terminology Commonly Used Terminology
Distress Trauma
Anguish
Tormented
Overwhelmed
Psychological and social problems
Terrifying/life-threatening/horrific events/devastation Traumatic events
Reactions to difficult situations Symptoms
Signs of distress
Problems
Reactions to difficult situations Traumatized children or traumatized adults
Signs of distress
Problems
Structured activities, community social support Therapy, Counseling, Treatment
Survivors Victims
From Inter-Agency Standing Committee. Guidance Note for Mental Health and Psychosocial Support. Port of Prince, Haiti:
IASC; 2010.

However, the management of PTSD deserves special attention in the context of PFA. PTSD
remains difficult to treat once symptoms are well established, and the use of polypharmacy to
target all accompanying symptoms is common. Theoretically, support for basic physiologic
needs, sense of safety, and assurance of safety, connection with care providers or people
important to them should all be initiated as soon after the onset of incident as possible. A
multitude of pharmacologic interventions have been proposed; however, no clear evidence-based
recommendations have been made for pharmacological interventions preventing chronic
symptoms of stress injury. This continues to be an important area of study. Among the multitude
of PTSD symptoms, symptoms of hyperarousal and mood (irritability, anger, and depression) are
most likely to improve with medication.
Given intensive resources and the time needed for therapeutic first-line treatment modalities
of PTSD such as treatment-focused trauma therapy, field treatment of existing PTSD is not
realistic. The PFA principles discussed below will support stabilization. Specific medications
such as venlafaxine (Effexor) and sertraline (Zoloft) are considered to be the most effective
SSRI/SNRIs in their treatment class.21 However, response to medication requires up to 4 to 6
weeks to reach full affect, and some will experience debilitating side effects such as increased
anxiety, increased suicidal thoughts and insomnia, making them unsuitable for treatment to be
initiated.
Given the severity of anxiety and hyperarousal some experience, benzodiazepines are
frequently prescribed for patients with acute symptoms, but are not supported by research to be
useful in the long term. Benzodiazepines may be tempting for the wilderness provider to use,
given frequent availability in WEMS medical kits and the frequency of their use in traditional
emergency psychiatric care. However, the risks may outweigh the benefit of their use in PTSD,22
with the exception of treatment of acute and severe anxiety when safety of the patient or rescuer
is compromised. Benzodiazepines have not been shown to decrease symptoms of PTSD, and
evidence suggests that, when used shortly after traumatic exposure, benzodiazepines are actually
associated with significantly increased risk of developing PTSD.23 Also, in comparison to the
general population, those with already-diagnosed PTSD who use benzodiazepines are at higher
risk of increased overall severity, worsened psychotherapy outcomes, aggression, depression,
and substance use.23 This may be explained in part by the idea that an individual’s ability to
integrate the experience, reestablish safety, and assist with their own rescue to counter a sense of
helplessness may be hampered by the cognitive impairment and memory disruption brought on
by benzodiazepines. It is worth considering whether benzodiazepines given to the patient are
actually aimed at assisting the provider who is attempting to respond and soothe the anxious
individual. Providers must consider whether this may be medicating the patient to treat the
provider’s anxiety, which is neither ethical nor beneficial to the patient. It is true that emergency
responders often have little training in the actual management of distressing or frightening
behaviors. Added to the difficulty is the fact that providers may feel themselves overwhelmed,
helpless, or isolated when responding to a distressing scene or a distraught individual. Remaining
in the present, utilizing tools discussed below, or de-escalation tools discussed in Chapter 23 has
the power to transform the experience for both patient and rescuer alike.
α-adrenergic receptor blockers such as prazosin are currently used with success in treating
symptoms of nightmares, supporting sleep initiation, and reducing hyperarousal in those
suffering from symptoms of PTSD.24 Due to concerns for side effect profile as well as such a
specific and narrow treatment indication, it would not likely be realistic to carry and initiate
treatment in the remote setting.
Clonidine, an α-2 adrenergic agonist, is used widely in the treatment of hyperarousal,
difficulty in concentration, sleep, and hypervigilance. This is due to its efficacy in decreasing
sympathetic nervous system response, physically decreasing heart rate and blood pressure, both
physical sensations that signal the body that no further action is needed. Clonidine works quickly
and is used in children as young as five in the treatment of PTSD, though likely unrealistic to
carry in the remote kit because of its narrow use profile and potential cardiac side effects. Indeed,
many providers often screen patients with electrocardiogram, a screening tool which is likely not
routinely available in a WEMS setting, prior to the use of clonidine. It should be noted for those
who encounter patients using clonidine in the remote setting that acute withdrawal of clonidine is
often associated with rebound hypertension (high blood pressure) and can lead to a hypertensive
crisis.

Treatment Principles of PFA

The responsibilities of the responder to psychological injury do not differ from those of the
responder to physical injury: recognize and treat threats to life, stabilize the injury, mitigate or
minimize ongoing injury, and evacuate or refer to higher level of care when needed.
Stress injuries occur on a continuum, and while some individuals will demonstrate obvious
symptoms of distress right away, some may not express these reactions to the stress for weeks or
even months. Some will mitigate their outward expression of inward responses based on fear,
shame, or a sense of how one should respond to overwhelming events, especially when in the
line of duty.
PFA is an evidence-based and expert consensus-driven approach to support individuals and
communities who have experienced an overwhelming event. The interventions consist of a
systematic set of supportive and therapeutic actions aimed at reducing initial post-trauma distress
and supporting short- and long-term adaptive functioning.11
These concepts, once developed with an emphasis on disaster and mass casualty incidents,
have been adapted to the military, fire, and community response settings. Concepts of PFA can
be adapted to response to incidents that occur in remote settings, where transport times are
decreased, resources are few, and first hours and days after overwhelming events are critical to
the formation or prevention of stress injuries.
The five elements are practical, flexible interventions known to be supportive of decreasing
arousal, establishing calm and sense of safety, in order to decrease the time one spends in a state
of fear, terror, helplessness, or hyperarousal. Decreasing any of these also decreases the
likelihood of longer term stress injury formation.
The now well-established principles of PFA are foundational to every level of WEMS
practice. Because there are few medications and reproducible modalities to mitigate the
formation of stress injury, it is the basic elements of PFA that are the most crucial in the early
minutes, hours, and days following overwhelming stress. Often first aid and basic life support
(BLS) providers offer more in-depth and complete care because they are able to spend time with
the patient and are not distracted by trying to implement more advanced interventions. The pitfall
of these simple, yet fundamental, tools of PFA is that they seem commonsensical, potentially
assumed to be already intrinsically part of patient care, and thus overlooked. Although they are
indeed fundamental, they are not always simple. It will not suffice simply to be “nice” to the
patient. These tools require a paradigm shift in the way rescuers take responsibility for the
impact of their own state on the response of the individual, and courage to involve the patient
(even join a partnership with the patient) where previously a culture of only “providing care for”
the patient existed. The rescuer must implement each with intention and focus, as if providing a
practical skill such as bandaging or control of bleeding. Indeed, calming one’s self before
attempting to calm the patient may be easy to say, but at the moment of catastrophe for the
patient, it will take a great deal of self-awareness, and perhaps even practice to truly remain calm
and be able to transmit that calm to the patient.
The real difficulty of PFA tools is that one is using his or own sense of safety, calm,
connection, hope, and feelings of self-efficacy to communicate these to the patient. The provider
will reflect what they themselves are experiencing. This is much like listening to an airline pilot,
who, with strain in her voice, tells her passengers to expect turbulence, but adds, “there is
nothing to worry about.” The passengers will certainly hear the words nothing to worry about,
but the true assurance would come from the calm demeanor, conviction, and tone of the pilot’s
announcement.
The core actions established by the NCTSN include contact and engagement, safety and
comfort, stabilization, information gathering, practical assistance, and linkage with collaborative
services.11 These have been shown to be helpful in disaster settings, or settings where multiple
agencies or rescuers are responding, and there is need to link survivors to multiple services.
Perhaps even more applicable in the remote setting is the model used by Combat and Operational
Stress First Aid (COSFA), which involves seven aspects of care, including cover, calm, connect,
confidence, confidence, with a return between each steps to check and coordinate.25 Both employ
the five elements established by Hobfoll.10
The five elements of PFA, discussed below in the context of the remote setting, can and
should be used across all levels of care. They can be an adjunct to care both in mitigating the
development of stress injury and responding to patients who are in distress as a result of
previously formed stress injury. It is also critical to note that these practical tools add to a
provider’s own sense of self-efficacy and can be protective against formation of stress injuries in
the provider responding to psychologically traumatic events.
Safety– The goal of this primary intervention is to enhance the affected individual’s sense of
safety through direct and specific actions in response to the initial overwhelming event.11 This
may mean attempting to decrease the emotional effect of a scene’s impact on an individual, by
increasing their perception and awareness that they are now safe (if that is true) or removing or
blocking ongoing stimuli that may communicate to them that they are not safe. Ideally, this
represents a distinct environmental change from the overwhelming stimulus of the emotionally
stressful scene. Sheltering individuals from ongoing details of the incident, perhaps by asking to
turn toward the rescuer and away from the scene of an avalanche recovery, enhances an
immediate sense of their own safety. Intentionally use words such as “safe,” “secure,” “solid
ground.” This may mean, for example, telling the avalanche survivor, “we can do a physical
assessment now that you are safe here on solid ground.” This cues the brain, in the present
moment, to decrease the mechanisms for hyperarousal, given concrete evidence that this incident
is over. This may involve information sharing, when appropriate, about known facts about the
event, rather than allowing a state of uncertainty, with rumors that are often worse than fact.
“Your son has been found, and we know that he is alive and talking to his rescuers.” Rumors and
a state of uncertainty stimulate the fight or flight response and heighten fear and anxiety, the
opposite of decreasing arousal. When the brain registers safety, it can then sound the “all clear”
signal, initiating the return to pre-stress functioning. Reducing the amount of time in a state of
hyperarousal is thought to affect memory consolidation and neuronal pathways that create the
stress response, and mitigates the formation of stress injury.26
Calm- Reducing hyperarousal is the underlying rationale for calming the patient. This can be
among the most important, yet most difficult, of interventions, especially when the patient is
known to the provider, or the provider is uncertain about their own safety in the remote context.
In the midst of stressful situations, some patients experience “Amygdala hijack.”27 This refers to
the phenomenon of the emotionally reactive part of the brain, the amygdala, which takes over the
“thinking brain,” the cortex, associated with problem-solving, working memory, concentration,
and decision-making when survival is threatened. This is an oversimplification of the complex
neurobiological response to fear, but does demonstrate that when the limbic system is
dominating the survival response, the thinking brain goes offline and is unable to process lengthy
words and conversation. For the individual experiencing stress, creating a plan or problem-
solving self-rescue can feel impossible. Calm, regulated responders who speak with a positive,
directive tone, communicate more than words in these moments. This is an opportunity, in a
sense, to communicate from the rescuer’s own limbic system or emotional center to the patient’s,
bypassing complex or unhelpful words such as “calm down!” or “everything is going to be fine,”
which can be meaningless when coming from a fearful rescuer. Here again, taking time to
authentically calm one’s self down prior to responding to the patient is, in essence, like the
practice of putting on one’s own oxygen mask prior to assisting someone traveling with you. The
importance of communicating with authentic calm to the overwhelmed patient cannot be
overstressed.
Grounding techniques are thought to be beneficial in assisting patients to return to the
present moment, where there is likely relative safety. To the medical provider, the intentional use
of the patient exam, taking a deep breath while one listens with a stethoscope, or having patients
recount three things they are able to hear that tells them that are now safe may serve to assist the
patient in noting that the present moment is not unsafe, and the harm is no longer occurring.
COSFA also reflects the importance of simply getting the patient to stop moving and sit or
lie down to decrease heart rate,25 reflecting the importance to decrease heart rate as a means to
decrease the time spent in a state of hyperarousal, as elevation of heart rate in the hours and days
following the accident has been identified as a predictor of development of stress injury in
children.19 One two-year prospective study demonstrated that those with elevated heart rates at
discharge from the hospital following motor vehicle accidents had higher rates of developing
stress injuries,28 likely from what is now understood to be prolonged hyperarousal, creating a
sustained state of fear and anxiety.10 In the state of hyperarousal, individuals may misinterpret, or
“code” benign stimuli as dangerous, leading to fear-mediated fight or flight response,
perpetuating the formation of stress injury.
Connection- The need to establish connection for an individual is paramount. Lack of a
sense of social connectedness has been found to be the primary controllable risk factor for
subsequent development of PTSD.16 In simple terms, this means that the treatment and support
given to or withheld from those experiencing psychological stress is crucial to the prevention or
formation of stress injury, respectively. Establishing connection with the rescuer, or even better,
connection with a loved one communicates to the brain that the person has survived the event.
Connection with others who are important to the individual, including pets, can be the antidote to
isolation that contributes to the formation of stress injury. It is important to remember that
remote context, connecting individuals to fellow soldiers, relief workers, divers, lifeguards or ski
patroller who are comrades can be as meaningful as trying to connect them with far away loved
ones. If other friends, relatives, or colleagues were involved in an overwhelming event,
connecting both of them also allows for the decrease in hyperarousal, knowing that the person
they love is also safe. Often in EMS culture, reuniting loved ones can feel fraught with
complication, the need to explain their injuries, and bear witness to their emotion. It can be
tempting to refrain from sharing details about family members until all the facts are known.
Indeed, sometimes this is necessary and provides safety and management of the scene. There are
times, however, when grouping patients together in the midst of the medical response, or even
allowing one loved one to assist the response of the other, may contribute both to a sense of self-
efficacy and connection.
One may ask what is to be done if the patient is not doing well or death is imminent. The
International Liaison Committee on Resuscitation (ILCOR), based on extensive research, has
since 2010 recommended offering that loved ones be present at the time of resuscitation, citing it
as both “comforting for them and helpful in their life adjustment.”29 Difficult as it may seem,
allowing a father to participate in the carrying of his son’s body during a search and rescue
mission may be the single most powerful intervention that the rescuer offers to the family in their
recovery from grief.
If, given the remote setting, contact with loved ones is not available, much will still be
gained by building an on-scene relationship with the patient. Asking the patient’s name and
using it frequently, or allowing oneself to ask questions about the individual that allows them to
feel known or seen by the provider, reduces the sense of isolation. Prolonged transport times and
remote setting will contribute to this naturally, but the provider who recognizes the need for
connection with the individual and does this with intention will do much to mitigate the effect of
stress injury.
Self-Efficacy- Formation of stress injury can also be conceptualized as stemming from a
failure of the natural physiologic activation and hormonal secretions to organize an effective
response to threat. This may explain why helplessness is such a prominent ingredient to the
formation of stress injury. Helplessness has been described as the realization that no action can
be taken to stave off the inevitable.26 Helplessness can be felt by an individual, as in the case of
one hiker trapped by an animal, or collective, as experienced by whole communities in the wake
of Hurricane Katrina. This is demonstrated in those who mount a physical fight or flight response
but are then not able fend for themselves, effectively communicating that they will remain
helpless in the face of threat in the future, so that the only defense is to recognize and respond to
cues that resemble the event in order to avoid or escape it.
Involving a patient in their own care instills a sense of confidence that the individual is
capable of being part of their own rescue. It allows for an opportunity to participate and problem
solve, both allowing for some form of action in a state of hyperarousal, and engaging the
prefrontal cortex in problem-solving. This involvement requires a shift from the dominance of
emotion in the limbic system to executive functioning, or engagement of the thinking brain,
which also works to calm the patient and integrate the experience. This, in effect, counters the
“amygdala hijack” discussed earlier. Individuals allowed to support their own rescue, even in
simple tasks, such as remembering vital signs, holding bandages, or planning evacuation routes,
also benefit from a sense of connection with their rescuers. There is an additional effect of
countering the negative cognitions formed in stress injury of poor self-esteem and loss of
confidence in one’s ability to respond to one’s own needs.
This can be harder than it seems in rescuer culture. After many years of training to remain in
the role of the rescuer, with a specific boundary that allows for one-way support from rescuer to
patient, it can be difficult to ask the “patient” to help or do anything.
In particular, this helps explain the difficulties faced by formal WEMS responders who
themselves become patients during the course of an operation, or who become patients while
recreating and serve as the objects of a WEMS operation. For EMS, law enforcement, medical,
and military personnel, there is a loss of identity and some degree of role confusion intrinsic to
becoming a patient, which increases the sense of helplessness at the time of the event, and often
breaks connection with peers who were once colleagues, but are now rescuers, and who are
making plans without them and doing things to them rather than with them.
The remote setting creates an opportunity for this paradigm shift to occur for those who are
willing. Often, the lines blur between rescuer and patient by nature of limited supplies and
support personnel, long transportation times, adverse conditions necessitating teamwork, and
likelihood of rescuing peers or colleagues. Encouraging self-efficacy and inclusion in one’s own
rescue, whether by including a patient in findings and decision-making or literally involving
them in the plans of the evacuation when appropriate, does much to diminish the psychological
effects of the overwhelming events.
Hope – Hobfoll notes that hope, though somewhat intangible, is crucial in mitigation of
formation of stress-related injuries like PTSD; “mass trauma is often accompanied by a shattered
world view, vision of shortened world view and castrophizing, all of which undermine hope and
lead to despair, futility and hopeless resignation – that feeling that “all is lost.”10 This negative
cognition shapes the way that survivors see the world. Benign facts or events may be interpreted
through the dark glasses of despair, leading to the sadness, depression, isolation, and anxiety
discussed as symptoms that mark the expression of stress injuries. Assisting people to find
reasons for hope with honest, heartfelt, and realistic reflections on what is going well can help
patients tune to the frequency of possibility rather than despair, and decrease panic that may once
again initiate hypervigilance and arousal. Responders may first have to overcome their own
potential feelings of hopelessness, or may find it difficult to find specific reasons for hope. Even
when it seems all hope is lost, the presence of a trained and caring rescuer is a reason for hope,
and should be stated as such. It is important to remember that the individual who is experiencing
terror or fear, may be experiencing the “amygdala hijack” discussed previously and may need to
first rely on their rescuer’s executive function in order generate reasons for hope until they can
find their own.
Finding stable ground, having supplies on hand, radio contact, or having survived with
minimal injuries all are reasons for hope, and may be embraced by the responder and presented
to the patient even if the situation seems grim.
Victor Frankl, Austrian neurologist, psychiatrist and prisoner of the Holocaust, faced with
the loss of his dignity, loss of his possessions and freedom, facing the death of his mother,
brother and wife, concluded thus: “Everything can be taken from a man but one thing: the last of
the human freedoms—to choose one’s attitude in any given of circumstances, to choose one’s
own way.”30
Frankl, in the darkest of circumstances, refused to give up his right to still choose how he
would respond. The rescuer, even faced with the death of a patient, may still choose to see the
gift of being present to them; a witness for their family may choose find hope by staying in the
with the patient and providing for their needs. This remains a reason for hope, and, in this case,
may mitigate their own propensity to form stress injury as a result of the overwhelming event,
with connection, self-efficacy and hope.
First Aid
Regardless of the responder’s level of care, the principals of PFA should be the foundation of the
psychological interventions aimed at mitigating or preventing stress injuries. Establishing a sense
of safety, restoring calm, establishing or creating connection, involving the patient in their own
care, and instilling or reflecting reasons for hope should be the starting point of care of all
providers.

Table 10.2 Treatment Principles for Psychological First Aid

Create a sense of safety by
• Mitigating the scene by reducing chaos and removing patients from perceived threats
• Reflecting evidence of safety
Create calm by
• Calming yourself first
• Emphasizing the present, the practical, and the possible
Create self and collective efficacy by
• Involving the person in problem-solving, self-care, and rescue
• Recognizing and reminding people of existing strengths
Create connection by
• Building an on-scene relationship
• Helping people contact friends, family, loved ones (including pets)
Create hope by
• Reflecting specific, accurate, positive facts and predictable, realistic steps
• Personally maintaining and communicating hope

Adapted from Schimelpfenig T. NOLS Wilderness Medicine. 6th ed. Lanham, MD: Stackpole Books; 2017.

See Table 10.2 for summary of PFA principles.

ALS providers should not defer these skills to the first aid providers or BLS providers. First
aid providers should not assume that because they are not able to provide advanced care with
medications, their interventions are less important. PFA principals are vital to the care of the
patient.

Basic Life Support

BLS providers, often tasked with assessments and interventions such as monitoring vital signs,
splinting, and bandaging, are in an ideal situation to administer PFA. BLS providers may take
advantage of exposure to the patient over a long period of time to establish connection, reflect
safety, and be the primary provider equipped to model a sense of calm, and invite patients into
participating in their own care. BLS providers are in a unique situation to model PFA tools to
advanced providers who may feel more comfortable reaching for medications, to first implement
the foundational principals of care.

Advanced Life Support

Care of the patient experiencing psychological distress is much like a pyramid, with the
foundational elements of reflecting safety, promoting calm, nurturing connection, supporting
self-efficacy, and instilling hope all the most crucial and long lasting of the interventions, with
the most expert-guided support and greatest likelihood to prevent development of stress injuries.
Consider interventions such as administration of medications and referral to expert help, such as
psychiatry or psychotherapy at the top of the pyramid, with few confirmed medications known to
be supportive of decreasing stress injuries over time. While it may be more comfortable to reach
for medications, the evidence suggests that this is not what will support the individual in the long
run. Before giving a medication to treat stress response, the provider should first consider
whether all of the remote PFA tools have been explored and implemented. Also note that early
pharmacological treatment has not been shown to necessarily prevent chronic symptoms.33
Providers may consider the use of benzodiazepines under protocol for severe agitation and
anxiety, while considering the reason to avoid the use of this medication discussed earlier in this
chapter. Lorazepam is often considered the benzodiazepine of choice for acute symptoms given
its duration of action (4 to 6 hours). The dose range includes lorazepam 0.5 to 1 mg for acute
symptoms of anxiety. Doses may be repeated every 2 to 4 hours for persistent, acute anxious
symptoms. 31 Providers would be wise to avoid short-acting agents such as alprazolam (Xanax)
due to the rebound anxiety symptoms sometimes seen with short-acting agents; it would be
equally prudent to avoid long-acting agents such as clonazepam (Klonopin) due to cumulative
effects and risk for overdose and respiratory depression, particularly in the remote setting.
Given the relatively few options to treat severe anxiety in the remote setting, providers may
consider the anxiolytic (calming) effect of antihistamines commonly found in a wilderness
medical kit. In fact, hydroxyzine (Vistaril) is approved for this indication, and has been shown to
have equivalent efficacy to benzodiazepines.32 While this is not an unreasonable approach to
support sedation, it is important to recall that some patients, particularly children, will have a
paradoxical response to the antihistamine. Remember, too, that the patient’s operational safety
and ultimate recovery is connected to their capacity to maintain situational awareness and
register threats to their safety, which will be less possible for the sedated patient. If too sedated, a
patient may not be able to participate in their own rescue, which as discussed earlier in this
chapter is also a beneficial activity for multiple reasons. The benefit, then, must be perceived to
outweigh the risk if an antihistamine is to be used. The onset of action following oral
administration of diphenhydramine is typically 15 to 30 minutes, with peak concentrations
occurring in about 2 to 4 hours. Typical adult doses for sedation are 25 to 50 mg.31
Ketamine is also being used by multiple urban agencies, and by the National Park Service,
and may be considered in cases of severe agitation, which may be creating an unstable
environment for rescuers or the patient. It is important to keep in mind that patients with a
history of PTSD have described troubling dreams and reaction when emerging from ketamine
use. Ketamine should be used with caution with those with a known history of PTSD, with
benzodiazepines at the ready for distressing emergence reaction. Ketamine is discussed in greater
detail in Chapter 23.

Clinician
Few interventions will be unique to the Clinician. In essence, PFA in the remote setting is best
done by advanced clinicians comfortable, or at least willing to turn from well-worn pathways of
medications and referral usual practice settings, with willingness to first try the PFA tools
presented in this chapter.

STRESS INJURIES IN THE WEMS RESPONDER

The most recent addition to DSM-V is stressor criteria that now include repeated or extreme
indirect exposure to aversive details of an event, usually in the course of professional duties.16
What this means, practically, is that all rescuers are at risk of sustaining stress-related injury in
the line of duty. Stress-related reactions range from subtle avoidance, withdrawal and irritable
mood, to extremes of hyperarousal, substance abuse, loss of ability to work or sustain
meaningful activities or normal life, and, unfortunately, suicide.
It is widely accepted that those with occupational exposure to radiation, such as X-ray
technicians should wear dosimeters to detect occupation exposure to ionizing radiation
throughout the lifetime. Damage from ionizing radiation is cumulative and causes damage in
relation to the total lifetime dose or exposure. The use of a dosimeter allows an opportunity to
remove the hazardous materials (HazMat) responder from noxious stimuli if exposure is too
high. There is no such dosimeter for traumatic exposure, and the effects of exposure to persistent
and overwhelming events often go unnoticed. Further, cultural norms in EMS often act as a
barrier to providers reaching out to colleagues when experiencing distress. The burden then falls
on the provider themselves to recognize and intervene when symptoms are problematic, rather
than having a mechanism in place to anticipate and support reactions of stress.
Stress injuries in professional rescuers are often minimized and rarely discussed in training
programs for EMTs, paramedics, nurses, physicians, and other health care providers, who will be
exposed to hundreds, if not thousands, of overwhelming events in the course of their lifetime.
Contributing to the formation of stress injuries are ongoing stressors inherent in the work, such
as interpersonal conflict among providers, shift work stressors, sleep deprivation and fatigue,
lack of good nutrition and exercise, and feeling underappreciated. While all of these factors
contribute to the phenomenon of work-related stress, the most prominent is likely the culture of
toughness and the caregiver complex which establishes a norm that the responders need to take a
back seat to those of the patients, espoused in the well-known health care mantra, “this is not
about me.” While the perspective that a stressful situation is “not about me” can be protective in
the sense that it distances the caregiver’s emotional involvement, this disengagement can also be
destructive when it contributes to a failure to recognize the extent to which a stressful experience
can unexpectedly become “about” the caregiver as well. Experiencing emotions and reactions of
distress after difficult calls has often been interpreted as a sign of weakness. This necessitates
hiding, isolation, and cover-up by those who experience it. Imagine a firefighter, who suffered
burns while responding to a house fire, going home and covering up her wounds until the
external evidence of the injury was healed, then hiding the scars for the duration of her career,
making excuses for what she could no longer do, avoiding instances where she could no longer
function given her injuries. This is not dissimilar to the epidemic of stress injuries in industries
such as EMS, fire, law enforcement, and military context where it is not yet acceptable to express
reactions of distress.
Occupational stress injuries, such as PTSD, anxiety, depression, and insomnia, are difficult
to capture but likely occur to some extent in the lives of most responders. A survey conducted in
four American states in 2015, including over four thousand EMTs and paramedics, revealed that
87% of the responders had experienced critical stress, and that 37% of those had contemplated
suicide with 6.6% having actually attempted to take their own life.34 The continuous exposure to
graphic and heartbreaking situations, combined culture of shame surrounding sharing feelings
and signs that providers are struggling, can create a perfect environment to inflict silent injuries
from which responders struggle to recover. It is imperative to recognize how truly serious the
effects of these wounds can be on providers, with sometimes devastating results. All providers
would do well to understand that no one is immune to these injuries, not oneself, nor one’s
partner, or “chief,” and continue to create a culture of asking colleagues with regularity about
reactions to stress, such as sleep disturbance, distressing thoughts, changes in moods, loss of
enjoyment or zest of life, isolation, hopelessness or the like.

Preventing and Treating Stress Injuries in WEMS Personnel

Much discussion now exists in the literature about the prevention and treatment of stress injuries,
but there is still much to do in the application in real practice. The difficulty of stress that occurs
in a remote or wilderness environment is that providers often feel alone or helpless when
responding, often without the usual support systems or tools that accompany them in the urban
context. This helplessness can be a key ingredient to the formation of stress injury, and should be
treated with special attention. Training specifically for the remote setting, the tools found in this
text, increases self-efficacy and decreases feelings of helplessness.
Disaster literature has led the way in prevention, resilience building, and self-care. Self-care
describes taking the focus off the patient or job and back on caring for one’s self and taking care
of one’s own needs. Often found in the recommendations35 are taking time for one’s self,
journaling, exercise, good nutrition, moderate alcohol, and spending time with family or trusted
friends.36 While all these things are helpful, it is likely that recognizing one’s own response to the
stressful event, recognizing one’s self as different and separate from the individual being cared
for, and recognizing one’s own needs as on par with that of the patients, are most supportive of
resilience. Feeling comfortable talking with peers and being receptive to support by others who
share one’s job responsibilities has been immensely helpful in the fire and military context,25 and
is promoted as “peer support” in some police departments nationally, with a push for more
structural short-term, intermediate and long-term support of officers involved in critical
incidents, as well as the officer’s family.37
Also discussed is the need to recognize the “hypervigilance biological roller coaster ®,” a
term coined by Dr. Kevin Gilmartin, officer and behavioral scientist specialist in law
enforcement,38 which describes the physical toll of shift work, where heightened awareness and
increased levels of cortisol secretion in response to sustained periods of time in fight or flight
mode gives way to decreased levels of cortisol secretion on return home from work. Elevated
levels of cortisol result in an individual feeling alert, energetic, involved, humorous, whereas
decreased levels result in fatigue, detachment, isolation, and apathy, and explain the depressive
dullness of returning to home, dishes, and screaming children that providers may experience.
Without recognition of this phenomenon, career responders inadvertently develop a preference to
work, excitement, and drama at the expense of their own bodies, as increased cortisol levels lead
to inflammatory illnesses such as diabetes, heart disease, and obesity. It is thought that ongoing
secretion of cortisol decreases tissue sensitivity to cortisol which alters the effectiveness of
cortisol in regulating the immune response39 and suppressing inflammatory illness. This in turn
decreases physical resilience to fight disease and leaves responders without invaluable stores to
respond to cortisol when truly needed. This physiology may explain the epidemic of type II
diabetes and heart disease in high cortisol-secreting professions such as law enforcement.

Why Mindfulness Matters for WEMS Personnel

Mindfulness has now become foundational to provider self-care, and can be found throughout
the trauma intervention literature, as well as in the discussion of building resilience in
responders. Mindfulness allows for an opportunity for one to feel their own reaction and take
space to differentiate. Individuals who have sustained stress injuries have great difficulty
connecting to their inner sensations and perceptions.26 At the moment of overwhelming stress,
emotions and sensations become frozen in time, and often become inaccessible to the person
who experienced the trauma. Bessel van der Kolk, one of the world’s leading researchers on
traumatic stress, warns that although feelings, thoughts, and sensations may not be accessed and
discussed by the individual following an incident, the body continues to remember, experience,
and express responses to reminders of trauma.40 By learning to relate to internal emotions and
sensations in real time, survivors of overwhelming experience with fixed physical reactions
(shaking, sweating, fleeing) that occur in response to triggers in the environment do not translate
into currently occurring events. In essence, the greatest healing mechanism for survivors occurs
in the present moment, and by attending to the present moment as it unfolds, there is a greater
capacity to act (counter helplessness) and recognize by the mind and the body that there is
currently no threat necessitating response. This calls for awareness and the ability to remain
present in the present moment, a task that can be almost impossible for those who have
experienced trauma and have survived by dissociating from, distracting, or fleeing the present
moment.
Those who practice mindful meditation demonstrate a structural change in the areas of the
brain that gradually increase their capacity to navigate potentially stressful encounters that arise
throughout the day.26 Once they have regained the capacity to orient to the present, they are able
to regain the lost capacity to act and defend themselves in the present moment. Providers who
are able to identify and feel their emotions and sensations in response to highly stressful
environments have already established one of the most crucial mechanisms for resilience and
self-protection in the face of constant exposure to stress—the capacity to recognize where one’s
own experience ends and that of the other, often the patient’s, begins. Without this, providers
risk re-traumatization by living the experience that what is happening to the patient or their
family is actually felt to be happening to them. The same motor neurons that allow one to feel
empathy and connect deeply with those we love create the sensation that what has happened to
another is currently happening to oneself. This connection, associated with a sense of
helplessness, is the key ingredient in the formation of stress injuries. Simply becoming fluent in
the experience of one’s thoughts, emotions, and physical sensations that are currently occurring
is a practice that will open the door to resilience in the face of difficult and emotional responses.
A traditionally praised attribute of an EMS provider is the ability to respond to a terrible scene
without being affected by it, either physically or emotionally. Indeed, culture shared by fire,
EMS, law enforcement, and military personnel have in common the praise of one’s own ability
to stay emotionally detached from the scene.34 Training of novice medics may include the
familiar statement, “if this is getting to you, you may be in the wrong field.” Statements like
these are harmful and grossly misguided. If overwhelming stress is causing physical and
emotional reactions, this only stands to prove that the responder, novice or expert, is human.
Current evidence tells us that the opposite is true. The human experience actually dictates
that rescuers are wired, via circuitry known as mirror neurons, to feel and act as if what one is
witnessing is actually happening to him or her. In the witnessing and responding to horrific
trauma and heartache of car accidents, injured children, suicide attempts and sudden death, it can
be abnormal to feel nothing. The tremendous stress of maintaining that these things do not affect
the care provider demands an enormous toll on those who experience it. Those who are not able
to connect with the internal responses of such heartache will expend tremendous energy
suppressing and avoiding the experiences. From this arise the familiar expressions of stress
injury previously expressed—substance use, sleep disturbance, isolation, avoidance of
reminders, emotional numbness, and lack of intimacy in relationships, hyperarousal and
irritability. One soldier described his experience as a backpack stuffed with garbage. It would
only be a matter of time before the smell and the weight affected daily life.
See Table 10.3 for resources for EMS personal experiencing reactions of stress.
From this understanding arises new practices and interventions among those who work in the
jobs with greatest exposure to tragedy and trauma. Awareness of the impact of trauma, need for
self-care, peer support and mentoring for follow-up after incidents, mindfulness, screening tools,
and healthy sleep all provide a healthy foundation to enable providers to continue to serve and
respond to the populations they care about.

Table 10.3 Resources for Stress Injuries in First Responder

www.revivingresponders.com
www.codegreencampaign.org
Suicide Hotline:
National Suicide Prevention Hotline: Call 1-800-273-8255
Crisis Hotlines, staffed by current of retired firefighters, law enforcement, and EMS:
EMS: Safe Call Now (crisis hotline specifically for first responders) 1-206-459-3020
Law Enforcement: COPLINE (“There is always a cop on the other end of the line”) 1-800-267-5463
Firefighters: Share the Load—1-888-731-FIRE (3473)

Swiftwater rescuers, for instance, live with the full knowledge of the risks of entrapment and
drowning, but little is discussed about the risk of debilitating stress injuries sustained in the line
of duty. With growing awareness and culture change, tools for ongoing maintenance and real-
time integration of stress injuries hold the promise of a generation of providers who can remain
resilient, active, and engaged throughout a long and fulfilling career.

SUMMARY
Although stress injury formation can be subtle and the tools to treat it may feel elusive to
providers, the skills of implementing PFA are among the most readily available and portable in
the wilderness provider’s toolkit. Caregivers should be prepared to recognize the potential for
injury formation and apply the principles of PFA and other interventions discussed in this
chapter. Practice is essential, and fortunately, these skills will benefit all remote patients. The
provider need not wait until arrival in the remote setting to practice. Indeed, for those many
providers whose wilderness work is only episodic, incorporating these principals into daily non-
wilderness practice may be one of the most transformational additions to their practice, both in
the wilderness and in all other environments.

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23. Guina J, Rossetter SR, DeRhodes BJ, Nahhas RW, Welton RS. Benzodiazepines for PTSD: A Systematic Review and
Meta-Analysis. J Psychiatr Pract. 2015;21(4):281-303.
24. Raskind MA, Peterson K, Williams T, et al. A trial of trial of prazosin for compbat trauma PTSD with nightmares in active-
duty soldiers returned from Iraq and Afganistan. Am J Psychiatry. 2013;170(9):1003-1010.
25. Nash WW. Combat and Operational Stress First Aid Manual; Caregiver Training Manual. Washington, D.C.: US Navy,
Beaurea of Medicine and Surgery; 2010.
26. van der Kolk BA. Clinical implications of neuroscience. NYAS. 2006;1(2):1–17.
27. Goleman D. Emotional Intelligence: Why It can Matter More Than IQ. New York: Bantam Books; 1995.
28. Bryant RA. Acute and physiologic arousal and Post-Traumatic Stress Disorder: a two year prospective study. J Traum
Stress. 2003;16(5):439-444.
29. Resuscitation IL. 2015 Guidelines AHA. Available at: www.ilcor.com/home:https://cprguidelines.eu/. Accessed October 22,
2016.
30. Frankl V. A Man’s Search for Meaning. New York, NY: Simon & Schuster; 1984.
31. Stahl SM. The Prescriber’s Guide. 4th ed. New York, NY: Cambridge University Press; 2011.
32. Llorca PM, Spadone C, Sol O, et al. Efficacy and safety of hydroxyzine in the treatment of generalized anxiety disorder: a
3-month double-blind study. J Clin Psychol. 2002;63(11):1020-1027.
33. Ursano RB. Practice guidelines for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Am
J Psychiatry. 2004;161(11 suppl):3–31.
34. Newland CB, Barbara BA, Rose M, Young M. Survey reveals alarming rates of EMS provider stress and thoughts of
suicide; data suggests ways to reduce the impact of critical stress on EMT’s and Paramedics. J Emerg Med.
2015;40(10):30-34.
35. World Health Organization, War Trauma Foundation and World Vision International. Psychological First Aid: Guide for
Field Workers. Geneva, Switzerland: WHO; 2011.
36. Mathiea F. The Compassion Fatigue Workbook. New York, NY: Routledge; 2012.
37. Laura U, Friedhoff S, Cochran S, Pandya A. Preparing for the Unimaginable: How Chiefs Can Safeguard Officer Mental
Health Before and After Mass Casualty Events. Washington, D.C.: Office of Community Oriented Policing Services; 2016.
38. Gilmartin K. Emotional Survival for Law Enforcement. Tucson, AZ: E-S Press; 2002.
39. Cohen S, Janicki-Deverts D, Doyle WJ, et al. Chronic stress, glucocorticoid receptor resistance, inflammation, and disease
risk. Proc Natl Acad Sci U S A. 2012;109(16):5995-5999.
40. van der Kolk B. The Body Keeps the Score; Brain, Mind and Body in the Healing of Trauma. New York, NY: Penguin
 Books; 2014.
41. Schimelpfenig T. NOLS Wilderness Medicine. 6th ed. Lanham, MD: Stackpole Books; 2017.
PHARMACOLOGY BASICS FOR WILDERNESS EMS
One of the hallmarks of EMS (the formal delivery of health care in the field) versus ad hoc first
aid care is access to pharmaceutical treatments. While many factors may limit the range of
medications available to a wilderness EMS (WEMS) provider, it still represents an important
potential element of WEMS practice. This chapter is not intended to be an in-depth discussion of
the principles of pharmacology. Standard pharmacology texts can be consulted for a more
comprehensive treatment of the subject. The chapter’s focus will be the use of medications in a
WEMS setting. It will include basic pharmacological principles as they are relevant to the use of
drugs and medications in this environment.
The terms “drug” and “medicine” or “medication” are used interchangeably in standard EMS
texts, standards, and protocols. A medicine is a drug, substance, compound, or preparation taken
for prevention or treatment of disease. A drug, according to the Food, Drug, and Cosmetic Act,
is a substance recognized in an official pharmacopoeia or formulary; a substance intended for use
in the diagnosis, cure, mitigation, treatment, or prevention of disease; or a substance other than
food intended to affect the structure or function of the body.1
Pharmacology is the science of drugs, dealing with the origin, nature, chemistry, effects, and
uses of drugs. Pharmacology includes pharmacokinetics, the study of the fate of drugs in the
body (ie, what the body does to the drug), and pharmacodynamics, the study of the biochemical
and physiological effects of drugs on the body and the mechanisms of their actions (ie, what the
drug does to the body).

Pharmacokinetic Processes
Pharmacokinetic processes include absorption, distribution, metabolism, and excretion (Figure
11.1).

Absorption
Absorption is the process of drug movement from the site of absorption toward the systemic
circulation. The route of drug administration affects the rate and extent of absorption. Drugs
administered enterally (via the gastrointestinal [GI] tract) must go through an absorption phase.
This may be affected by the rate of gastric emptying, the presence of food or other drugs in the
stomach, and the formulation of the drug (eg, a sustained-release formulation is released into the
bloodstream more slowly). Drugs that are administered parenterally do not go through this
absorption phase through the GI tract. Figure 11.2 displays various routes of parenteral
administration. With orally administered drugs, there is also the phenomenon of the first-pass
effect, where drugs pass through portal (liver) circulation before reaching blood, thereby limiting
the extent of absorption by reducing the amount of unchanged drug that enters the bloodstream.

Distribution
The distribution of a drug represents its diffusion throughout the body, usually via blood with
ultimate delivery to various organs and tissues. Factors that affect drug distribution include blood
flow to tissues and organs and the lipid (fat) solubility of the drug, determined by its chemical
structure. For example, a highly lipid-soluble drug will penetrate into central nervous system
tissue, which has a higher lipid content than blood. Highly lipid-soluble drugs will also cross the
placental barrier, which could potentially cause harm to the developing fetus.
Figure 11.3 illustrates a blood concentration–time curve and various routes of administration
of drugs. Note that intravenous administration results in immediate absorption of drug into the
bloodstream, high concentrations, and a fairly rapid fall in concentration. Intramuscular
administration has delayed absorption (depends on blood flow through muscle) and a slower fall
in concentration. Oral administration has an even more delayed absorption and slower fall in
concentration.
FIGURE 11.1. Pharmacokinetic processes.

Metabolism/Excretion
Metabolism is the chemical transformation (biotransformation) of the drug into another form (eg,
parent drug to metabolite). The majority of drug metabolism takes place in the liver. Cytochrome
P450 enzymes are important when considering drug interactions, as many drugs are metabolized
by these liver enzymes and may interfere with each other, potentially resulting in antagonistic
(opposing), additive (increased results), or synergistic (enhancing) effects. Patients with hepatic
impairment may be at risk of toxicity if a drug is largely metabolized by the liver, and dose
adjustment may be necessary. It is essential to take a drug history before administering any new
medication to patients. This allows the provider to be aware of any potential drug interaction and
how to avoid or mitigate such interaction. Most drugs are eliminated by the kidneys via urine;
patients with renal impairment may be at risk of toxicity if the dose of renally excreted drugs is
not adjusted. Other possible routes of drug elimination are skin (perspiration), lungs
(respiration), breast milk, and bile/feces.
FIGURE 11.2. Various routes of parenteral administration. Reprinted from Stein SM. Drug administration. In: Boh LE, ed.
Pharmacy Practice Manual: A Guide to the Clinical Experience. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2001.
FIGURE 11.3. Blood concentration–time curve.

Pharmacokinetics: Route of Drug Administration

EMS Setting
Table 11.1 lists the different routes of administration for drugs that may be used in the EMS
setting, and the practice level for which the route is approved. This is a guide only; protocols
vary by state and may differ, so always follow local protocol. Preferred routes of administration
for the wilderness EMS setting will be discussed later in the chapter.
The intracavitary, intrathecal, intralingual, and umbilical routes are other possible routes of
drug administration, but are used extremely rarely, and are only available on a clinician level.
Some drugs are administered via nebulizer, but the equipment needed for this is not likely to be
used in WEMS.

Drug Formulations
Table 11.2 lists the major formulations in which drugs are available depending on the route of
administration. Note that “parenteral” encompasses a number of routes listed in Table 11.1.
There may be advantages or disadvantages to certain formulations in a wilderness setting and
these are noted. Figures 11.4 to 11.8 illustrate various drug formulations.

Table 11.1 Major Routes of Drug Administration in the EMS Setting2–9

Route Description/Formulations Rate of Absorption Advantages/Disadvantages Practice Levela
Oral (PO) By mouth Slow; through GI Patient must be conscious, FA (assist)
tract able to swallow EMT (assist)
EMD (assist)
AEMT
Paramedic
Clinician
Orogastric (OG) Directly into stomach via Same as oral If patient unable to swallow Paramedic
tube in mouth Clinician
Nasogastric (NG) Directly into stomach via Same as oral If patient unable to swallow Paramedic
tube in nose Clinician
Buccal/Sublingual Drug placed on oral Fast; avoids first-pass Patients must be conscious FA (assist)
(SL) mucosa (between cheek and alert or may choke EMT (assist)
and gum) or under tongue AEMT
(drug must be formulated Paramedic
for this) Clinician
Intravenous (IV) Into vein (by needle) Gets directly into Can’t establish access (eg, AEMT (fluids only)
bloodstream; 100% dehydration); drug Paramedic
absorption extravasation Clinician
Intraosseous (IO) Needle inserted into bone, Same as IV Use when IV cannot be AEMT
gets into vein established, hypovolemia/ (pediatric only)
(proximal tibia/popliteal; hemodynamic instability, AEMT (may be
femur/femoral); distal tibia GCS<8, respiratory failure; limited)
(medial malleolus)/great cannot use in fractured Paramedic
saphenous; proximal bone7 Physician
humerus/axillary;
manubrium
(sternum)/internal
mammary and azygos
Intramuscular (IM) Into muscle (use 22-25- Slower rate than IV; When IV access cannot be AEMT
gauge needle; 5/8-1.5 in depends on blood obtained; prolonged serum Paramedic
depending on age, size of flow and which levels; less effective in low Physician
patient) muscle (deltoid, muscle mass (elderly, Some states permit
gluteus, thigh) malnourished) or diabetics; FA, EMR, EMT via
Not as effective in can cause pain, hematoma auto-injector
shock (decreased (use lidocaine)
blood flow to
muscles)
Subcutaneous (SC) Under the subcutaneous Slower than IV, but When oral administration is AEMT
layer of skin (use 23-25- fairly rapid difficult or not feasible Paramedic
gauge, 5/8-inch, needle); (some pain, nausea/vomiting Clinician
<2 mL volume meds, insulin)
Intradermal Under dermal layer of skin Slower than IV May be advantageous for Paramedic
(use 26-28 gauge; 3/8-3/4 some vaccines (eg, rabies if Clinician
inch); <1 mL volume in short supply)
Rectal Via rectum Rapid, but can be When cannot be taken orally EMT, AEMT can
unpredictable assist Diastat (some
states)
Paramedic
Clinician
Intranasal Spray Rapid; high drug No needle AEMT
levels; avoids first- Paramedic
pass Clinician
Dermal (topical) Cream, ointment, spray, Slower absorption; Convenient FA
etc. local effect EMT
AEMT
Paramedic
Clinician
Transdermal Through the skin (patch) Slower absorption Convenient; sustained Paramedic
release Clinician
Inhalation Goes directly into lungs Rapid; gets directly Effective FA (assist with
(eg, MDI) to lungs MDI)
EMR (assist with
MDI)
 EMT (assist with
MDI)
AEMT
Paramedic
Clinician

Otic Into ear Local effect Specifically for ear Clinician

Ophthalmic Into eye Local effect Specifically for eye Clinician
Vaginal Into vagina Local effect Systemic absorption Clinician
possible
Intra-articular Into the joint For local effect Rarely used in EMS except Clinician
by specialists
Endotracheal Via endotracheal tube (use Need 2.5× IV dose Lidocaine, epinephrine, Paramedic
only if IV or IO access atropine, naloxone, Clinician
cannot be established) vasopressin

FA, first aid; EMD, emergency medical dispatcher; EMR, emergency medical responder; EMT, emergency medical technician;
AEMT, advanced emergency medical technician; EMS, emergency medical services; GI, gastrointestinal; GCS, Glasgow Coma
Scale; MDI, metered dose inhalers.
aNote that “Practice Level” are general national standards in the United States. These may vary by local or state practice or
legislation and are intended merely to be a guideline.

Table 11.2 Drug Formulations

Route Formulation(s) Advantages/Disadvantages in Wilderness Setting
Oral Capsules, tablets, sublingual tablets, buccal Capsules may be less likely to break than tablets
tablets, orally disintegrating tablets, powder (to Unit dose packaging protects the contents
be mixed with water), syrup, solution, drops, Powder that needs to be mixed is lighter than a bottle of liquid,
troche, tincture, suspension, spirit, elixir, but clean water must be used to reconstitute
emulsion
Parenteral Single dose vial, multidose vial, syringe, prefilled Single dose vial may be less prone to medication errors
syringe (eg, Tubex), ampule, bag Multidose vial may conserve space; should contain a
preservative
Ampules may crack
Topical Cream, ointment, gel, paste, solution, drops, Some formulations are more susceptible to extremes of
tincture, spray, patch temperature (discussed later in the chapter)
Rectal Suppository, enema Suppositories more convenient
Inhalation Metered dose inhaler, spray, nebulizer Metered dose inhalers are convenient
Intranasal Spray Some drugs in intranasal form are more susceptible to
extremes of temperature (discussed later in the chapter)
Otic Solution, suspension, drops Suspensions must be shaken
Ophthalmic Solution, suspension, drops Suspensions must be shaken
Vaginal Cream, ointment, suppository Some formulations are susceptible to extremes of temperature
(discussed later in the chapter)
FIGURE 11.4. Various oral drug formulations. (Left to right, top) Tablets, caplets, and enteric-coated tablets. (Bottom)
Capsules, gel-caps, chewable tablets, and troche. Photo by Caroline Bunker Rosdahl. In: Rosdahl CB and Kowalski MT.
Textbook of Basic Nursing. 11th ed. Philadelphia, PA: Wolters Kluwer; 2017.

Pharmacodynamics
Pharmacodynamics is the study of what a drug does to the body, or the way it exerts its clinical
effects, also known as the mechanism of action (MOA). The MOA of drugs may involve
receptor interactions (inhibition or stimulation) or enzyme interactions (inhibition or
stimulation).
FIGURE 11.5. Powder for oral suspension (powder that needs to be mixed is lighter than a bottle of liquid, but clean water must
be used to reconstitute). From Kronenberger J, Ledbetter J. Lippincott Williams & Wilkins’ Comprehensive Medical Assisting.
5th ed. Philadelphia, PA: Wolters Kluwer; 2016.
FIGURE 11.6. Ampule‚ vial‚ and prefilled syringe (clockwise from top left). Courtesy of B. Proud. In: Taylor C, Lillis C, Lynn
P. Fundamentals of Nursing. 6th ed. Philadelphia, PA: Wolters Kluwer; 2006.

The body’s endogenous hormones or neurotransmitters interact with receptors to produce

pharmacological activity; drugs are exogenous compounds that are structurally similar to these
endogenous compounds and may produce similar pharmacological effects. Similarly, enzymes
are proteins produced endogenously that catalyze chemical reactions within or outside of cells;
drugs are designed to alter enzymes by blocking an enzyme (inhibitor) or by stimulating an
enzyme (inducer).
After a drug is administered, its clinical effects can be described in humans as a specific drug
response curve, encompassing maximal (peak) effects and minimal (trough) effects. Increased
dosages of a drug produce an increased effect to a certain level, at which no further beneficial
effect is attained with any higher dosage. If that level is exceeded, an adverse effect (adverse
reaction) may occur. A side effect is a nuisance effect that is annoying but not dangerous,
whereas toxicity of a drug is a potentially harmful or even fatal effect, and is usually dose-
related. A non-dose-related adverse effect can occur at high or low dosages, with the first dose or
after a period of time, and is typically an allergic reaction.

Special Populations
There are certain populations in which the pharmacokinetics and pharmacodynamics of a drug
may be different than in a healthy adult.

Pediatrics
Infants and children should not be thought of as merely smaller adults, as the pharmacokinetic
processes may be different depending on age. The U.S. Food and Drug Administration (FDA)
requires that drugs be studied specifically in pediatrics to determine efficacy and safety and the
most optimal dosing.10 Many drugs in pediatrics are dosed based on weight or body surface area,
and pediatric dosage guidelines must be consulted before administration of medications in this
population. The Broselow Pediatric Emergency Tape (often simply known as “Broselow Tape,”
seen in Figure 11.9), a color-coded tape measure that relates a child’s height to their weight, is a
useful tool for calculating pediatric dosages of drugs, in addition to size of emergency equipment
and voltage for an automated external defibrillator. As well, some pediatric patients may not be
able to swallow pills, so instead of a solid oral dosage formulation, they will need an oral liquid,
granules, or other route of administration.

FIGURE 11.7. A, Multidose vial. B, Multidose vial label (note the preservative benzyl alcohol, needed for multidose).
FIGURE 11.8. Metered dose inhaler.

Geriatrics
There are age-related changes in handling of drugs, especially a decrease in renal function, so the
dose of renally excreted drugs may need to be adjusted, although this will not be able to be
measured in the field. The elderly are more prone to dehydration, which will also impact the
renal handling of drugs. They are also more likely to have an increase in the number of comorbid
conditions, and may be taking numerous medications (polypharmacy), so drug interactions must
be taken into consideration when administering a new medication.

Pregnancy/Labor and Delivery/Nursing

It is essential to know if the patient is or could possibly be pregnant or is breastfeeding before
administering a drug. The FDA issued the “Pregnancy and Lactation Labeling Rule” in late
2014, which removed the former pregnancy categories of A, B ,C, D, and X that health care
professionals were familiar with, but often found complex and confusing.11 The new rule
provides simplified guidelines for drug manufacturers to summarize the risks of using a drug
during pregnancy and lactation. The “Pregnancy” and “Lactation” sections of the prescribing
information should be consulted before administration of any drug in pregnancy.

FIGURE 11.9. Broselow tape. Used for calculating pediatric dosages of drugs. (From Ricci SS, Kyle T, Carman S. Maternity
and Pediatric Nursing. 3rd ed. Philadelphia, PA: Wolters Kluwer; 2017.)

Renal Impairment
While renal impairment will not be assessed in the field, dehydration and shock can lead to renal
dysfunction and decreased excretion of renally processed drugs, so this must be kept in mind
when administering these medications (See Box 11.1 for tips on taking a Drug History).

ADMINISTERING DRUGS IN A WILDERNESS

ENVIRONMENT
The previous section provided a foundation for understanding the basic pharmacology of drugs,
including the different routes of administration and how they may differ for WEMS providers,
and reviewed the importance of taking a drug history. This section will focus on what factors to
consider when administering drugs in a wilderness environment, the effect of different
environmental conditions on medication use, and the effect of these environmental conditions on
the storage and stability, and expiration dating of medications.

The “Rights of Medication Administration” in a Wilderness Setting

The “Rights of Medication Administration” are ingrained in all health care processes. In a
wilderness setting, some of the “Rights” may be more or less pertinent than in a traditional
emergency or institutional setting, as seen in Table 11.3. These “Rights” need to be followed for
over-the-counter (OTC) drugs as well.
Table 11.4 lists important principles for medication use in a wilderness EMS setting.

Drug Information
It is important to be fully informed about the drugs that are carried in a medical kit and are being
administered. It is important to be familiar with brand (trade) and generic names, because a drug
may be available as the generic version but is still referred to by the brand name, for example,
Cipro (ciprofloxacin). Also be familiar with a drug’s indications, dosage and administration,
dosage forms and strengths, contraindications/warnings/precautions, adverse reactions, drug
interactions, use in different populations such as children and pregnancy, and safe storage and
handling considerations.
Be aware that any information that comes from the drug prescribing information is
considered on-label. Drugs can also be used off-label, which means that the drug is used for an
indication, route, dose, or dosage form that is not specified in the prescribing information.12 Off-
label use may be common in WEMS, but should always be done under the direction of a
physician. See Chapter 5 on the legal implications of this practice.
Table 11.5 lists examples of sources of drug information for EMS providers in a traditional
setting, and those that are more specific for WEMS. Local EMS protocols also contain detailed
information about drug administration and safety considerations. A drug information source
should be considered an integral part of the medical supply kit as it is often difficult to remember
dosing schedules, drug interactions, and similar details in a stressful environment.

Effect of the Wilderness Environment on Medication Use

Different environmental conditions can have an effect on preexisting medical problems, or on
medications that are already being taken by a person for a medical condition. As well, certain
medications that are taken can exacerbate environmental conditions. The effect on preexisting
medical problems, such as multisystem trauma, blood loss, shock, vomiting/diarrhea, moderate
to severe burns, fever secondary to infection (all of which can lead to dehydration), and
hyper/hypothermia will be discussed in further detail in Chapter 22.
Table 11.6 presents the effect of some environmental conditions on medications already
being taken, or those medications exacerbating environmental conditions.13–18

Drug Storage and Stability in the Wilderness Environment

This section will discuss the effect of different environmental conditions on the storage and
stability of drugs, an important factor to consider especially when traveling at extremes of
temperature. In the examples of the different environments above, proper storage conditions for
drugs may not always be easily met.

Box 11.1 Take a Drug History

Always take a drug history before administering any drug to an ill or injured person. Include frequently taken over-the-
counter (OTC) and herbal preparations/natural supplements as well. Ascertain the following:
• Name of medication
• Reason for taking it
• Dose/strength
• Route
• How many times daily it is taken
• How long has it been taken
• Is it taken regularly
• Who prescribed it
It is also important to know if the person has a history of an allergic reaction to any drug or inactive ingredient, and
previous possible adverse reactions to the drugs that will be administered. This does not mean there is an absolute
contraindication to use of the drug, but it is useful to know.
Table 11.3 Rights of Medication Administration in a Wilderness Setting
“Right” Description Difference in Wilderness Setting (if any)
Patient Medication belongs to the correct If patient needs to take their own medication for an acute condition,
person make sure it is theirs
Medication Correct medication If patient needs to take own medication for an acute condition, check the
label
If a prescription medication in a group medication kit needs to be given,
it must have the correct certification or authorization
If it is from the medication kit, check the label to make sure it is the
correct one
Reason Medication is correct for the reason If patient needs to take their own medication for an acute condition,
check that they are taking the correct medication for the condition
(especially if they are on multiple medications)
If a prescription medication in the group medication kit needs to be
given, it must have the correct certification or authorization to administer
If the medication is over-the-counter (OTC), make sure it is for the
correct condition
Dosage The correct dosage for the person As above
and the condition
Route Appropriate for drug, condition, The route may be different in a wilderness setting as not all possible
and patient formulations of the drug may be available in a medical kit
Time Dosed correctly according to Patients may be on medications for a much longer period of time in the
recommended dosing schedule wilderness if there is a prolonged evacuation period
Documentation Document after giving medication Documentations must always be done, even in the wilderness
environment
Response Ascertain that drug resulted in This is especially important in an acute setting, hazardous environmental
desired pharmacologic effect conditions, or when there is a delay to definitive medical care
Expiration Drug is within date Discussed later in the chapter
Date

Storage Recommendations for Drugs

The correct and optimal storage temperature for prescription drugs is printed on the drug carton
and drug container. This information also appears in the manufacturer’s prescribing information
found on the drug company’s website, the Physician’s Desk Reference, or a copy that is provided
by the pharmacy and in drug handbooks, although the information from the manufacturer is the
most official. A typical room temperature product reads: Store at 20°C to 25°C (68°F to 77°F),
excursions permitted to 15°C to 30°C (59°F to 86°F). (See USP Controlled Room Temperature.)
A typical section for a refrigerated product reads: Store refrigerated at 2°C to 8°C (36°F to
46°F). Products that have to be refrigerated of course present a level of complexity in wilderness
environments. Fortunately, not many products need to be frozen, which would nearly be
impossible to assure. Some products also contain the caution: Do not freeze. Protect from light.
This may also present a complex storage issue when working in very cold environments.
Protecting from light should be much easier. See Figure 11.10A and B for examples of storage
requirements for a room temperature and refrigerated drug, and see Box 11.2 to between °F and
°C.

Table 11.4 Principles of Medication Use in a Wilderness EMS Setting

The medication “Rights” still apply although they might be slightly different
May need repeat dosing of drugs/monitor for possible cumulative effects
May need to help a patient with their own medication
May need to use a different route of administration than usual
The environment may impact the stability of the medication (discussed later)
The environmental impact on the patient may affect their handling of the medication (discussed later)
May need to use drugs that would not ordinarily be used in an urban environment
Practice must always be within scope of care; always follow standard protocols

OTC drugs display the storage range on a blister pack or the “Drug Facts” label which is
easily found (see Figure 11.11). However, for prescription drugs, unless they are administered
from the original manufacturer’s container as is usually the case for parenteral drugs, the amber
or white plastic bottle the pharmacy dispenses does not usually contain the proper storage range
unless the drug needs to be stored at a particular temperature, for example, refrigerated, protected
from light. Prescription drugs dispensed in blister packs may contain this information, which is
why they are preferable in a wilderness environment, as well as the fact that drugs are more
stable in an airtight blister pack versus an amber bottle. However, not all drugs are available
from the manufacturer in blister packs.
Table 11.7 lists some environmental conditions to which a drug can be exposed during
transport. Any of these conditions could potentially impact the proper storage of drugs.19

Stability of Drugs in the Wilderness Environment

Drug manufacturers follow standard stability testing guidelines for testing drugs under long-term
and accelerated storage conditions and compatibility with the container in which they will be
shipped. If temperature controls are needed during distribution of the drug (ie, “cold chain”) and
these are not met, for example if there are transport delays and extreme temperatures, then a
temperature excursion occurs, possibly putting the drug at risk of losing its efficacy or even
becoming toxic.20 Transport of a drug in a wilderness environment or travel setting can be
thought of as somewhat analogous to this production, testing, and distribution of the drug by the
manufacturer called the “supply chain”.

Table 11.5 Examples of Sources of Drug Information

Traditional
Drug Prescribing Information (also known as Product Labeling, Package Insert, Product Circular, Product Information,
Directions for Use)
Physician’s Desk Reference (PDR)
Drugs@FDA https://www.accessdata.fda.gov/scripts/cder/drugsatfda/
Drug Facts and Comparisons (F&C)
American Hospital Formulary Service (AHFS) Drug Information
USP Dispensing Information (USP DI)
Lexi-Comp Drug Information Handbook
Handbook of Nonprescription Drugs
Special populations: Harriet Lane Handbook (pediatrics), Geriatric Dosage Handbook, Briggs’ Drugs in Pregnancy and
Lactation
Field Use (Handbooks/Online/Apps)
Pharmaceutical company website
Nursing Drug Handbook
Mosby’s Drug Reference for Health Professions
EMS Pocket Drug Guide
Epocrates
Informed Pocket Guides
Wilderness Medicine Textbooks/Handbooks
Auerbach’s Wilderness Medicine (Paul S. Auerbach, editor)
Field Guide to Wilderness Medicine (Paul S. Auerbach)
Wilderness Medicine: Beyond First Aid (William W. Forgey)
NOLS Wilderness Medicine (NOLS Library) Tod Schimelpfenig and Joan Safford
Wilderness First Responder: How To Recognize, Treat, And Prevent Emergencies In The Backcountry (Buck Tilton)
Wilderness and Travel Medicine (Eric Weiss)
Medicine for Mountaineering & Other Wilderness Activities (James A. Wilkerson, editor)
Improvised Medicine: Providing Care in Extreme Environments (Kenneth Iserson)
Special Operations Forces Medical Handbook (Department of Defense)
Wilderness and Rescue Medicine (Jeffery Isaac and David E Johnson)
Wilderness First Aid Field Guide (American Academy of Orthopaedic Surgeons (AAOS), and Alton L. Thygerson)
Oxford American Handbook of Disaster Medicine (Oxford American Handbooks of Medicine) (Robert A Partridge and
Lawrence Proano)

Table 11.8 displays how the stability of certain dosage forms of drugs can be affected by
different types of environmental conditions. Also included are examples of a medication that
might be used in WEMS. Figure 11.12A to C illustrate drug formulations that have been
exposed to extremes of temperature, moisture, or light, and time. Parenteral drugs that are
lyophilisates (freeze-dried) are in general very stable at extremes of temperature before they are
reconstituted.
Table 11.9 lists other medications that may be used in wilderness or travel medicine and
possible effects of the environment on stability.

Published Studies on Stability of Medications in EMS, Extreme, or Wilderness Environments

EMS
A review in EMS World discussed the proper storage of medications in the EMS environment
and summarized the literature on storage of medications in drug boxes, warehouses, and rescue
vehicles.22 Of no surprise was that medications were frequently exposed to temperature extremes,
in some cases up to 140°F and as low as <10°F, underscoring the need for EMS providers to
establish appropriate measures for proper medication storage. Included in the review were a
summary of guidelines from the United States Pharmacopeial Convention (USP) for storing
medications in EMS vehicles and ambulances.23 A summary of the guidelines appear in Table
11.10. Of note, however, for WEMS, storage of medications in wilderness environments may
present many more challenges than in urban environments.
EXTREME ENVIRONMENTS
There is not a large amount of data on temperature stability of drugs in extreme environments. A
review in the Journal of Travel Medicine published in 2006 contains the most comprehensive
information to date.18 Consider that temperatures can reach very high extremes in some deserts of
the world and very low extremes in high altitude areas such as the Himalayas and polar regions.
As noted above, extreme temperatures can occur on ships or planes, as well as rescue helicopters
or other rescue vehicles (especially in a vehicle trunk). For performance of stability studies,
“outdoor” conditions can be defined as >50°C (120°F), freezing and oscillating temperatures,
and UV exposure. The authors of this review found that some drugs used in EMS are stable at
certain extremes of temperature. These include lidocaine, diazepam, ketamine, midazolam, and
naloxone vials. Atropine is stable at higher temperatures. Note that robust clinical studies are
lacking and this is a guide only.18
EPINEPHRINE IN THE WILDERNESS
Epinephrine is of special importance to the wilderness medicine community. Longleaf
Wilderness Medicine tested the effects of various temperature conditions in wilderness outings
on epinephrine stability.24 These temperatures included the ambient temperature, temperature
inside a first aid kit, at the base layer of the test subject (using the LogTag data logger), with an
insulated thermos, next to a chemical heat pack, or an evaporative cooling towel. The study
found that body heat provided the most consistent temperature (between both cold and hot
extremes). One suggestion for carrying medication on a wilderness trip was to put it into a soft
bag and then into an avalanche beacon harness. This might be ideal for medications such as an
EpiPen, which has the following storage recommendations:

Table 11.6 Effect of Environmental Conditions on Medication Use

Environment Physiologic Effect Medication Examples
High altitude Effect on respiratory (hypobaric hypoxia), Increased insulin requirements in Type 1
circulatory systems, solar radiation, dehydration diabetics
Increased effect of certain drugs (eg, sedative,
nitroglycerin)
Sun Photosensitivity, phototoxicity Sulfonamides
Looks like bad sunburn or other type of allergic Tetracyclines
reaction Tricyclic antidepressants
Extreme heat (eg, Some drugs can exacerbate heat illnesses hot Inhibit sweating: anticholinergics, antihistamines
desert) environments by interfering with the body’s Decrease blood flow to skin: narcotics,
ability to dissipate heat or by causing dehydration pseudoephedrine
Cause dehydration (urination): caffeine, diuretics
Cause dehydration (increase thirst): selective
serotonin reuptake inhibitors (SSRIs)
Cause damage to kidneys in setting of
dehydration: nonsteroidal anti-inflammatory
agents (NSAIDs)
Diving The depth of a dive or gas mixture that is being See information from diving organizations such
used can potentially have effects on a medication; as Divers Alert Network (DAN), Professional
also consider underlying medical condition that is Association of Diver Instructors (PADI), National
being treated Association of Underwater Instructors (NAUI)
Extreme cold Some drugs can suppress shivering, so can No published examples
complicate the diagnosis of hypothermia No published examples
Drugs that cause poor circulation can contribute Can possibly cause increased protein binding or
to the development of frostbite decreased absorption of drugs which may lead to
Hypothermia decreased effectiveness

Adapted from Pietroski N. Can I Take This While Climbing, Diving, Flying, Hiking...? Effects of the Wilderness Environment on
Medications. Wilderness Medicine Magazine. Available at: http://wildernessmedicinemagazine.com/1159/Base-Camp-Rx-
Effects-on-Meds. Updated August 14, 2015. Accessed June 8, 2017.
FIGURE 11.10. A, Examples of storage requirements for drugs (room temperature). B, Examples of storage requirements for
drugs (refrigerated).
FIGURE 11.11. Over-the-counter (OTC) “Drug Facts” label (showing storage recommendations).

Box 11.2 Converting Fahrenheit to Celsius (°F to °C)

 From Craven RF, Hirnle CJ, Henshaw CM. Fundamentals of Nursing: Human Health and Function. 8th ed. Philadelphia,
PA: Wolters Kluwer; 2017.

Table 11.7 Environmental Conditions to Which Drugs Can Be Exposed During

Transport
Environmental Condition Example
High temperatures Desert, ships, aviation
Low temperatures High altitude, polar regions, caves
High humidity Tropics, jungle, caves
Light exposure Tropics, desert, high altitude
Oxygen Air (only an issue for oxygen-sensitive drugs that are not
stored properly)
Shocks/vibrations Ship, aviation, dropped medication (backpack, falls off shelf
during earthquake)
Pressure Diving, high altitude (note: the pressure in cargo and passenger
compartments are the same in commercial aircraft)
X-rays Airport x-ray machine; radiation in cargo hold of plane
Pests and rodents Any environment, especially if medication is stored near food

Adapted from Pietroski N. Not Too Hot, Not Too Cold. . . Just Right Temperature Stability and Storage of Medications.
Wilderness Medicine Magazine. May 11, 2016. Available at: http://wms.org/magazine/1183/Temperature-Stability. Accessed
June 8, 2017.

Table 11.8 Environmental Conditions and Effect on Drug Stability18,21

Example of Drug That
Environmental May Be Used in
Condition Dosage Form Effect WEMS
High temperature Oral solutions Lose flavor/taste Albuterol syrup
Precipitation
Discoloration
Oral suspensions Form caked solid phase Pepto-Bismol
Loss of dose uniformity
Semisolids Change in consistency Hydrocortisone
(creams, ointments) Lose drug uniformity—results in change in drug cream/ointment
release
Suppositories Harden or shrink; melt Promethazine
suppositories
Tablets Changes in disintegration/dissolution time Antibiotics
Uncoated tablets Changes in hardness (ciprofloxacin)
Coated tablets Changes in appearance Aspirin
Effervescent tablets Excessive powder visible Sildenafil
Appearance of crystals Antacids
Discoloration
Swell with moisture
Swell with moisture
Gelatin capsules (hard Change in appearance Cephalexin
and soft) Hardening or softening
Capsules sticking together
Sprays Can become inactivated Naloxone
Low temperature Solutions Inactivation of active ingredient Viscous lidocaine
Ampules Glass may crack Naloxone
Contamination
Oxidation of drug
Suspensions/emulsions Can disintegrate Antibiotic suspension
(oral or IV)
Suppositories Can crack Prochlorperazine
Capsules Can crack Cephalexin
Moisture (optimally Drug cartons May soften or collapse, exposes drug inside Any drug that comes in
store drugs in < 60% a box
room humidity)
Tablets Low humidity—increased disintegration time Many medications are
High humidity—decreased disintegration time subject to this
Inhaled powders Clumping Asthma medications
Light exposure Photosensitive drugs Undergo photodecomposition Nitroglycerin tablets
Potency loss (not packaged in
Reduced therapeutic activity amber-colored bottles)
Some drugs if packaged
in ampules

Data from Kupper TEAH, Schraut B, Rieke B, Hemmerling A-V, Schoffl V, Steffgen J. Drugs and Drug Administration in
Extreme Environments. J Travel Med. 2006;13(1):35-47 and Coleiro Daphne. Storage of Medicines and Medical Devices. 2012.
Available at: https://www.um.edu.mt/__data/assets/pdf_file/0016/153160/Storage_of_Medicines_and_Medical_devices.pdf.
Accessed October 23, 2016.
Adapted in Pietroski N. Not Too Hot, Not Too Cold. . . Just Right Temperature Stability and Storage of Medications. Wilderness
Medicine Magazine. May 11, 2016. Available at: http://wms.org/magazine/1183/Temperature-Stability. Accessed June 8, 2017.

Epinephrine is light sensitive and should be stored in the carrier tube provided. Store at 25°C (77°F); excursions permitted to
15°C to 30°C (59°F to 86°F). (See USP Controlled Room Temperature). Do not refrigerate. Before using, check to make sure
the solution in the autoinjector is not discolored. Replace the auto-injector if the solution is discolored or contains a
precipitate.25

A study was conducted on the impact of multiple freeze-thaw cycles on the stability of
epinephrine in auto-injectors.26 This study found that epinephrine concentrations increased after
multiple freeze-thaw cycles, but still remained within standards. While the authors recommended
that the drug be stored under appropriate conditions when possible, this type of information is
very useful when EpiPens are to be carried in a wilderness setting.26
One caveat about epinephrine at higher temperatures is that the active ingredient may be
stable, but the buffer may be affected. A slight opacity of the liquid indicates degradation of the
drug.18

Expiration Dates of Drugs

One more topic that should be of interest in WEMS is whether drugs can be used past their
expiration date, especially if drug supplies are limited or may have to be carried for extended
periods of time, for example on an expedition.

FIGURE 11.12. A, Crushed broken capsules with discoloration of drug contents. B, Separated cream. C, Discolored parenteral
drug (solution was originally clear).

The expiration date is a guarantee by the manufacturer of the safety, potency, and stability of
the product up until that date; the drug must be at least 90% of the original potency. Importantly,
this applies to drugs in the original container and stored per the manufacturer’s recommendations
(Code of Federal Regulations, CFR).27 Once a drug product is removed from the manufacturer’s
container and is repackaged into a different container, eg, into an amber pharmacy bottle, or unit
dose packages for hospitals, a “beyond-use date” (BUD) is placed on the label of the new
packaging; this is the date after which a drug product should not be used. The BUD should be no
later than the expiration date on the original manufacturer’s container or 1 year from the date the
drug is dispensed, whichever is earlier. Pharmaceutical companies may state that drugs can
maintain some potency after the drug’s expiration date, but stop short of recommending their use
after the date has passed (See Box 11.3 for how to read an expiration date).

Table 11.9 Other Medications and Effects of Environment on Stability

Medication Condition Example
Vaccines Light sensitive MMR
Freezing-potency loss (especially with aluminum adjuvant) Hepatitis B, DTP
High temperatures—denaturation/degradation of vaccine Oral polio vaccine, measles, yellow fever,
protein or antigen hepatitis B
Biologics High temperatures—degradation of protein Crotalidae antivenom
Insulin Needs refrigeration Different types of insulin have differing storage
Do not expose to direct heat or light requirements
Do not freeze (protein becomes unstable)
Epinephrine Protect from light Epinephrine auto-injector
Do not refrigerate
Medical Electronic devices may give false readings if stored Glucometer
devices improperly

Adapted from Pietroski N. Not Too Hot, Not Too Cold. . . Just Right Temperature Stability and Storage of Medications.
Wilderness Medicine Magazine. May 11, 2016. Available at: http://wms.org/magazine/1183/Temperature-Stability. Accessed
June 8, 2017.

Table 11.10 Summary of Recommended Practices from the USP-NF Chapter

“Emergency Medical Services Vehicles and Ambulances—Storage of
Preparations”
Monitor and verify temperature profiles to compare with established limits, especially on hot summer and cold winter days.
On-board cabinets must be insulated, and should use active heating and cooling if necessitated by the local climate.
Consider using insulated portable carrying cases and, when they are not in use, keep them inside or in a climate-controlled
cabinet to maintain controlled room temperature.
Consider using portable cases exclusively, instead of on-board cabinets, to facilitate rotation. Time–temperature indicators can
be used to monitor temperature exposures of the portable case’s entire contents.
Consider using time–temperature indicators to monitor individual medication packages, especially for environmentally sensitive
and thermally sensitive preparations.
All medications should be protected from excessive heat (40°C+). Some medications may need to be stored in a cold and/or dry
place, and “environmentally sensitive” medications should not be stored on EMS vehicles unless the storage cabinet is
temperature-controlled or individual time–temperature indicators are attached to each medication package.
Consider stock rotation on a schedule based on local climate, perhaps every 3 days or so. The stock should be rotated into a
climate-controlled environment. Stock rotation may be especially necessary for environmentally sensitive preparations.
Consider temperature exposures when parking ambulances. Park in heated and air-conditioned garages if possible. When
parking outside, attempt to park in the shade.

NF, National Formulary; USP, United States Pharmacopeial Convention.

The Strategic National Stockpile, overseen by the Centers for Disease Control, is a large
supply of drugs and medical supplies used to protect American citizens in the event of a public
health emergency like a terrorist attack, influenza outbreak, earthquake, or other disaster.28 If
these medical countermeasures reach their expiration date before being used, they must be
discarded, which can be very expensive. To help prevent the loss of potentially still potent
medication, the FDA is involved in several expiration dating programs. The Shelf-Life Extension
Program (SLEP) was established in 1986 by the U.S. Department of Defense to conduct
extended stability studies on a number of drugs in federal stockpiles such as the Strategic
National Stockpile.29 In 2006, a summary report was issued on 122 different drugs (>3,000 lots).
It was found that 88% of the lots were extended by at least a year past their original expiration
date; the average extension was ˜5.5 years. Multiple drugs such as ciprofloxacin tablets,
naloxone HCl, and potassium iodide had many year extensions past their labeled expiry date.30

Box 11.3 Reading an Expiration Date on a Medication Container

Even though the Code of Federal Regulations (CFR) specifies that expiration dates must be put on medication bottles or
other types of packages, they do not specify how they have to be expressed. Does “05/18” mean May 1, 2018 or May 31,
2018? Does “04/03/20” mean April 3, 2020 (dating convention in the United States) or March 4, 2020 (dating convention in
European Union and other countries)? What does “JN19” mean? (January or June 2019?) There have been efforts by groups
like the United States Pharmacopeial Convention (USP) to improve the clarity of expiration dating. Some pharmaceutical
manufacturers are using a three-letter month abbreviation instead of the number of the month. When the day of the month is
not specified, it is the last day of the month. The expiration date of the EpiPen seen below is February 28, 2018.

Another program is the Emergency Use Authorization (EUA) for CBRN (chemical,
biological, radiological, and nuclear defense) emergencies. Under this program, the FDA can
approve the use of a product (that would typically be used in a CBRN emergency) beyond its
labeled expiration date, provided that the product has been proven to be safe. An example is the
“Doxycycline EUA Fact Sheet for Recipients,” given to persons exposed to anthrax. The sheet
contains the following statement: “If you have received doxycycline with an expired date on the
package, FDA has authorized its use. Testing of the medicine found it is safe to use past the
expiration date.”31

The Effect of the Formulation and Environment on a Drug’s Expiration Date

The extended stability studies discussed above have been conducted on drugs in their original
containers and stored according to the manufacturer’s recommendations. Storage at extremes of
temperature (hot or cold), exposure to oxygen, moisture (high humidity), or exposure to light
may affect the potency of drugs, and therefore, the true potency may not be reflected in the
expiration date. In general, most drugs are most stable when stored at colder temperatures than
warmer temperatures than recommended, although adherence to the manufacturer’s
recommended storage range in the prescribing information or on the package carton for OTC
products is the best way to ensure potency.
Solid dosage forms (tablets, capsules) are much more stable than solutions or suspensions
and injectable formulations.

Drugs That Should Not Be Used Past Their Expiration Date

There are no reports on currently used medications regarding the toxicity of using a drug past its
expiration date, whether taken orally, by injection, or topically.32 For years, it was well known
that taking outdated tetracycline caused Fanconi syndrome (renal proximal tubular damage) due
to the degradation products epitetracycline and anhydrotetracycline; however, this formulation is
no longer available. But the toxicity of expired medications is an area that is not well researched.
Any drugs that become discolored, powdery, or are emitting an odor should not be used.
Drugs that are injectable solutions should not be used if they appear cloudy or have precipitates.
Table 11.11 lists some drugs utilized in WEMS that should not be used past their expiration
date.
EPINEPHRINE
In SLEP studies, epinephrine in a cartridge needle (brand not specified) failed ~50% of lot
extension expiration evaluations. An oft-quoted prospective, randomized, crossover study in
rabbits of administration of expired EpiPen and EpiPen Jr. found a significantly reduced
epinephrine bioavailability after injection of the expired auto-injectors (1 to 90 months) versus
those that were in-date. The decrease was proportional to the months past the expiration date.
However, the authors concluded that if an expired EpiPen is all that is available during an
anaphylactic reaction, it is reasonable to use it if there are no discolorations or precipitates in the
solution.34

Table 11.11 Examples of Drugs That Should Not Be Used Past Their Expiration Date33
Drug Reason
Antibiotics, suspensions Very quickly lose potency
Anticonvulsants Narrow therapeutic index
Dilantin, phenobarbital Very quickly lose potency
Insulin Very quickly loses potency
Nitroglycerin Very quickly loses potency
Ophthalmic drops Loses sterility once preservative degrades

Donating Drugs for Medical/Humanitarian Relief Efforts

Medical teams participating in a disaster medical relief mission may wish to bring some newly or
nearly expired medication. The U.S. Transportation Security Administration (TSA) offers clear
guidelines on how to travel with drugs: “Prescription medications should be in their original
containers with the doctor’s prescription printed on the container. It is advised that you travel
with no more than a 90 day supply. If your medications or devices are not in their original
containers, you must have a copy of your prescription with you or a letter from your doctor.”35
 It is not clear what is meant by “original containers,” but likely refers to the prescription
bottle. As discussed above, once drugs are out of the original manufacturer’s container, the
labeled expiration date cannot be guaranteed, so special care needs to be taken to store the
product as close to the recommended conditions as possible, especially if a supply of medication
is to be left in the affected country which may have extremes of temperature or improper storage
facilities.
For relief organizations, the World Health Organization (WHO) and the FDA have clear
guidelines on donating expired or nearly expired drugs for humanitarian relief efforts. According
to the FDA’s “Questions and Answers for the Public Donating Drugs to International
Humanitarian Relief Efforts”36:
FDA and the World Health Organization (WHO) strongly discourage donation of expired drugs, even to affected nations
during an emergency or crisis. Additionally, nations may consider the dispensing of expired drugs to be illegal, including
during a crisis. Guidelines from the WHO state that drugs with less than one year before their expiration date will
automatically be destroyed.37 Depending on the nature of the emergency, and on a case-by-case basis, FDA is prepared to
exercise enforcement discretion on the exportation of a designated product as long as it is to fulfill a request from the
importing country and found acceptable by that country; and the expiration issues have been evaluated by an appropriate
component of FDA, or when reasonable assurance is provided to the receiving country and FDA that the product meets
quality specifications. The FDA would not object to the donation of drugs that are past or within one year of the expiration
date shown on the label when provided with sufficient information to show the expired lot(s) are safe and effective.
Furthermore, the FDA expects that no U.S. marketplace shortage would occur due to the exportation of the donated drugs,
and that within expiry supplies would be preferentially used before the expired or near expiration supply, if practical. FDA
has and will allow the use of a drug under similar circumstances when needed to alleviate a U.S. shortage.*

DRUGS COMMONLY USED IN WEMS

The last section of this chapter will discuss the different types of medications that will potentially
be used in WEMS, starting with an overview of medical kits focusing on medications. This will
be followed by a discussion of EMS skills and drugs classes that are commonly used for that
skill set, the route of administration preferably used in WEMS, and the practice level at which
the drugs are permitted to be used in a WEMS setting. As mentioned previously, this is a guide
only; protocols vary by state and may differ, so always follow local protocol.

Medical Kit Preparation18,38-45

Creating a medical kit for a wilderness care situation depends on a number of factors, and there
is no one-size-fits-all rule. The kit should be customizable and equipped to deal with the care of a
range of injuries and illnesses, although wound management and stabilization of soft tissue and
orthopedic injuries generally occur with the most frequency. The types of medical kits range
from personal medical kits; community medical kits; those specifically to be carried on
expeditions, which can include environmental and recreational hazards; those for disaster relief;
and those for a variety of other reasons. Bear in mind that it is difficult to prepare for every
circumstance, and a balance must be struck between having too many supplies that will not be
used, and not being properly equipped.

Factors to Consider When Creating a Medical Kit

Table 11.12 lists factors that should be taken into consideration when choosing supplies for a
medical kit. This section of the chapter will focus primarily on drugs in a medical kit; other
chapters, particularly Chapter 7, discuss diagnostic equipment and other supplies (eg,
stethoscope/BP cuff, airways, suction, chest tubes).
CONTAINERS/PACKING DRUGS
These are characteristics of an ideal medical kit container:

Sturdy, but lightweight, especially if they have to be manually carried into a remote
environment
Kits that unroll or open for easy display are preferable (see Figure 11.13)
Easily identified (bright color/marked with reflective material/cross)
If loss of equipment may occur (eg, whitewater trip), divide components of kit into several
separate kits

Consider the following when packing drugs in a medical kit:

All medications should be labeled with the storage and expiration date visible if removed
from the original packaging; the prescribing information or another drug reference should
be included
Drugs for each medical condition or use, eg, cardiac, infection, allergy/anaphylaxis should
be packed together and labeled (Figure 11.14A–C)
The lid of the kit should label the contents contained within (Figure 11.15)

Table 11.12 Factors to Consider When Creating a Medical Kit

Factor Example(s)/Comments
Purpose of the trip Recreational, high altitude trek, SAR mission, disaster area
Level of medical training Use only equipment/drugs for which the group is trained, ie, MD, Paramedic, EMT
Destination Terrain, weather conditions, endemic diseases in country
Participant medical conditions Have participants bring their own medications; have backup supply in general medical kit
and age
Length of trip Amount of supplies needed might not be directly proportional to the length of trip (eg, blisters
might be more common at beginning of trip); much longer trips might need different supplies
Also consider the ability to resupply medications from local area on longer trips
Time for evacuation or Depending on the wilderness setting, may need to plan for an extended evacuation (eg, accident
medical rescue, time to occurs on a river trip in a remote canyon)
definitive care, anticipated
duration of care
Size of the party Equipping each member of the party with some supplies will decrease the amount that has to be
carried in the general medical kit
Also consider whether additional rescue personnel will be available at destination (eg, base
camp for high altitude trek)
Bulk, weight, and cost Bandaging and splint supplies are bulky, so may consider using improvised materials
Use drugs and supplies that are multifunctional
Use a modular approach to packing

SAR, search and rescue.

FIGURE 11.13. Expedition medical kit. (Photo taken by Nancy Pietroski, PharmD; courtesy of Eric Bowman, MD, FACEP,
FAWM.)

Bring extra supplies of chronic medications

Drugs must be able to be protected from environmental conditions discussed above, such as
impact, moisture, and contamination.
Blister packs for tablets/capsules are preferable to drugs in plastic bottles; alternatively,
loose tablets can be put in small ziplock bags (try to avoid crushing, though) (Figures 11.16
and 11.17)
Liquids for oral administration should be avoided if possible to decrease weight and bulk;
 alternatively, bring powder that can be reconstituted
Drugs for parenteral administration are preferably packaged in plastic versus glass
Drugs that need to be protected from light should be kept in their original boxes or placed
into opaque or amber containers and should not be exposed to direct sunlight
Drugs that are oxygen sensitive should be stored in airtight containers
There should be a separate locked compartment for narcotics (discussed below)

Know which drugs in the medical kit have specific storage requirements, like refrigeration
(eg, insulin, snake antivenin). It is important, although challenging, to calculate how long these
types of medications might potentially be out of range and what temperature extremes they will
be exposed to. They may need to be stored in specialized pouches, such as Frío kits
(www.frioinsulincoolingcase.com). Using ice packs and vacuum food/drink flasks are other
ways to keep medication that needs to be cold at the right temperature, or to prevent drugs that
are in extremely hot environments from becoming heat unstable. However, these types of
insulation may be of limited effect on longer expeditions. The same applies for carrying
medication in clothing; this is fine for shorter expeditions, but would not be effective for a longer
expedition. Short of using a temperature probe, it is difficult to assure that medications are stored
at the proper temperature. Temperature monitoring devices, such as time-temperature indicators
from 3M can be included in containers with temperature-sensitive drugs.*
FIGURE 11.14. A-C, Medical kit components by medical condition/use. Photo taken by Nancy Pietroski, PharmD; courtesy of
Eric Bowman, MD, FACEP, FAWM.

CONTROLLED SUBSTANCES
Controlled drugs need to be under strict supervision. These include narcotics such as fentanyl,
morphine, meperidine, oxycodone, and codeine for pain control, benzodiazepines (diazepam,
lorazepam, midazolam), and phenobarbital. Strict records on the use of these drugs, including the
quantity, date, and place of receipt, and after administration, the name of the drug, name of
person, time and quantity administered, and any disposal of drugs, must be kept. They should be
kept in a locked container. If controlled substances are to be transported across borders on an
international trip, the U.S. Drug Enforcement Administration may request information on
narcotic supply both in and out of the country. The International Narcotics Control Board has a
useful website on regulations for transporting medications: www.incb.org.
When using opioids (fentanyl, morphine, codeine, etc.) for pain management, they should
only be reserved for moderate to severe pain; try other analgesics first (acetaminophen,
NSAIDs). As opioids are constipating, a stool softener should be included in the medical kit, as
well as naloxone to manage possible overdose.
Injectable drugs are not used as much for trauma sustained in the wilderness; most drugs to
treat conditions associated with trauma (pain, infection) are available in alternative formulations
such as oral or transdermal. Intravenous drugs often have more stringent storage requirements
and shorter expiration dates than oral drugs, as well as needing special equipment to administer
(needles, syringes, IV line), so are not as preferable as other formulations.
FIGURE 11.15. Contents of medical kit label. Photo taken by Nancy Pietroski, PharmD; courtesy of Eric Bowman, MD,
FACEP, FAWM.
FIGURE 11.16. Medication in blister packs. Courtesy of Nancy Pietroski, PharmD.

FIGURE 11.17. Tablets packaged in small, labeled ziplock bags. Courtesy of Nancy Pietroski, PharmD.

Table 11.13 gives an example of medication modules that might be used in a community or
expedition medical kit.†

Wilderness EMS Skills and Medications: Implications for Practice Levels

As discussed in the introductory chapters of this book, the ability to administer and prescribe
medications in any EMS setting, including a wilderness environment, is dictated by local
regulations and protocols. Building on the pharmacology topics presented earlier, this discussion
will focus on major skills needed for WEMS, some drug classes that may be used, and their
preferred routes and formulations.
For respiratory conditions, beta-agonists, primarily albuterol, are preferred as a metered dose
inhaler in a wilderness setting, since no special equipment is needed to administer it. In general,
most First Aid and basic life support (BLS) providers are allowed to assist patients with their
own inhalers. Advanced life support (ALS) providers and clinicians can prescribe and/or
administer this formulation.
Long-term care of wounds may be necessary in a WEMS in ways not true for a traditional
EMS setting. Topical antibacterials may be used, but systemic agents may be necessary. An oral
antibiotic, whether a tablet, capsule, or oral powder that can be mixed into a suspension, is
preferred to a parenteral antibiotic, unless there is a clear indication for the latter (patient has
nausea and vomiting or the antibiotic needed is only available parenterally). Long-term care of
musculoskeletal injuries may be needed in the wilderness or remote setting, and pain control will
be a key component of care. Oral analgesics (including opioids) are preferred, unless the patient
cannot tolerate oral intake. When opioids are available in a medical kit, naloxone should always
be included for potential overdose. The preferred route for this drug in WEMS is intranasal; this
route is being increasingly adopted by EMS providers. The drug can also be given parenterally
by providers credentialed to do so.
For anaphylaxis, an epinephrine auto-injector is often preferred; although the actual safety
profile of needle-and-syringe epinephrine has shown this option to be quite safe as well, it does
add an extra amount of training and administration complexity. The appeal of auto-injector
simplicity of use must be balanced against its cost, which is dramatically higher and sometimes
excludes use by EMS teams, and the fact that it involves more machinery and mechanical
complexity. As with the albuterol MDI, BLS providers are allowed to assist patients with their
own injectors. ALS providers and clinicians can prescribe and/or administer an auto-injector, or
if necessary, administer epinephrine subcutaneously or intramuscularly from a vial or ampule.
However, there may be greater chance for error in dosing when an epinephrine vial (especially a
multidose vial) is used, although a multidose vial may be more convenient (and less expensive)
to carry on a longer expedition. The risk of significant overdose in adults can be mitigated by
only carrying 1 mL syringes. Also, the acceptance of auto-injectors—which to date only exist in
two fixed versions, a 0.3 and 0.15 mg version—already speaks to a degree of acceptance of
underdosing and overdosing in many patients when compared to an exact weight-based dose.
As well, requirements for epinephrine labeling have changed, which may decrease the
possibility of dosing errors. The latest update of the United States Pharmacopeia (USP) and The
National Formulary (NF) (USP39-NF34), which became official on May 1, 2016, no longer
allows the use of ratio expressions on single entity drug products. This means that manufacturers
should only display epinephrine 1:1,000 injection as 1 mg/mL, and 1:10,000 must only be
displayed as 0.1 mg/mL. See Figure 11.18 of an epinephrine label before and after this required
change. If a product contains an additional ingredient, such as local anesthetics with lidocaine
1% and epinephrine 1:100,000 injections, the ratio expressions for the epinephrine component
will remain the same, as a decimal notation for this very low strength could be misread and lead
to dosing errors.46,47

Table 11.13 Medication Modules for Medical Kit Examples41,42

OTC Oral Medications RX Topical/Oral Medications
Acetaminophen (Tylenol)
• Antimicrobials: doxycycline, azithromycin, levofloxacin,
Aloe vera gel
fluconazole
Aerosolized epinephrine (Primatene Mist)
Antibiotic/antiseptic ointment (Polysporin or Neosporin) • Pain: hydrocodone/acetaminophen, morphine (also
Bismuth subsalicylate (Pepto-Bismol) naloxone)
Calamine lotion • Cardiovascular: atropine, nitroglycerin
Diphenhydramine (Benadryl)
Docusate (Colace); bisacodyl (Dulcolax) • Psych: alprazolam, diazepam
Famotidine (Pepcid) • Derm: metronidazole, triamcinolone, mupirocin
Glucose paste or tablets
Glycerin rectal suppositories • ENT: antibiotic ointment/drops, steroid ointment/drops,
Hemorrhoidal ointment/witch hazel pads cyclopentolate, anesthetic drops
High-SPF sunscreen and lip balm • GI: ondansetron, prochlorperazine
Hydrocortisone cream 1%
• Respiratory: albuterol, beclomethasone, ipratropium
Ibuprofen (Advil, Motrin) 200 mg
Loperamide (Imodium) • High altitude: acetazolamide, dexamethasone, sildenafil
Meat tenderizer for bee stings
Meclizine (Antivert, Bonine, Dramamine II) RX Injectable Medications (also need administration
Omeprazole (Prilosec) supplies)
Oxymetazoline (Afrin) • Antibiotic: ceftriaxone (Rocephin)
 Phenylephrine (Neo-Synephrine or Sinex) • Allergic reactions, altitude illnesses:
Pseudoephedrine (Sudafed)
• Dexamethasone (Decadron)
Ranitidine (Zantac)
Saline eyewash • Anaphylaxis, status asthmaticus: Epinephrine
Simethicone (Gas X) • Wound care: lidocaine 1%
Tolnaftate antifungal cream (Tinactin)
• Pain: morphine

GI, gastrointestinal; SPF, sun protection factor.

In many systems, aspirin and nitroglycerin may be offered with assistance to patients with
angina or possible myocardial infarction by BLS providers. In most systems, ALS and clinician
providers may administer the drugs. For seizures, parenteral drugs may be needed, although
rectal diazepam (Diastat), allowed in some states to be administered by AEMTs or higher, may
be an easier formulation to deliver versus a parenteral product. However, it may be unlikely to be
included in a routine wilderness medical kit.
Oral glucose for hypoglycemia can be given with assistance by BLS providers. ALS
providers (under physician supervision) and clinicians may administer D50 or glucagon,
although these parenteral preparations most likely also will not be included in a routine
wilderness medical kit.
In a poisoning or disaster zone, atropine sulfate/pralidoxime chloride (ATNAA, DuoDote)
may be administered by BLS providers or above for organophosphorus insecticide or nerve agent
poisonings. This is supplied as an auto-injector.2–7,48,49

FIGURE 11.18. Epinephrine label before and after required change. From Michael Cohen, RPh, MS, ScD (hon), DPS (hon),
Institute for Safe Medication Practices, with permission.

SUMMARY
EMS and other health care providers study pharmacology in varying degrees during their
training. In addition to being competent at their level of practice in understanding pharmacologic
principles, WEMS practitioners need to be familiar with pharmacologic factors that are unique to
the wilderness environment. Certain routes of drug administration may be preferred in the
wilderness because they are more convenient and may be more effective. Some drug
formulations are more advantageous because they are less susceptible to environmental
conditions which may impact their stability, the way they need to be stored, and their expiration
date. When drugs are chosen for a medical kit that will be used in a wilderness environment,
whether it is recreational, for an expedition, SAR, disaster relief—these environmental
conditions and their impact on drug administration, formulation, stability, and expiration date,
govern the final drug selection. There are certain conditions and scenarios that are unique to
WEMS versus EMS, most notably the possible need for long-term care of wounds and
orthopedic injuries, which dictate which drugs, formulations, and routes are used. Medical
conditions or injuries due to environmental impacts such as cold, altitude, and extreme heat may
require different drugs altogether to manage than would be seen in a traditional EMS setting. In
addition to the chapters in this text, WEMS practitioners will benefit from consulting wilderness
medicine textbooks and handbooks (examples in Table 11.5) to supplement their knowledge
about appropriate drug use in a wilderness setting.

References
1. US Food & Drug Administration. Federal Food, Drug, and Cosmetic Act (FD&C Act). Available at:
http://www.fda.gov/regulatoryinformation/legislation/federalfooddrugandcosmeticactfdcact/. Accessed October 23, 2016.
2. National EMS Scope of Practice Model. The National Highway Traffic Safety Administration. DOT HS 810 657. February
2007. Available at: www.nhtsa.gov. Accessed October 23, 2016.
3. Emergency Medical Services. Agenda for the Future. National Highway Traffic Safety Administrator. 1996. Available at:
www.nhtsa.gov. Accessed October 23, 2016.
4. Pennsylvania Statewide Basic Life Support Protocols. Pennsylvania Department of Health. Bureau of Emergency Medical
Services. Effective July 1, 2015. Available at: www.health.state.pa.us. Accessed October 23, 2016.
5. New Hampshire Department of Safety. Division of Fire Standards and Training and Emergency Medical Services. State of
New Hampshire. Patient Care Protocols. January 2013 Version 1.7. Last updated May 1, 2014. Available at:
http://www.nh.gov/safety/divisions/fstemt/ems/advlifesup/patientcare.html. Accessed October 23, 2016.
6. The Maryland Medical Protocols for Emergency Medical Services Providers. Maryland Institute for Emergency Medical
Services Systems. Effective July 1, 2015. Available at: www.MIEMSS.org. Accessed October 23, 2016.
7. Maine EMS Prehospital Treatment Protocols. Maine Emergency Medical Services. Effective December 1, 2015. Available
at: http://www.maine.gov/ems. Accessed October 23, 2016.
8. Principles of Pharmacology. Jones & Bartlett, Learning, LLC. www.jblearning.com. 2013. Available at:
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9. Centers for Disease Control and Prevention. Chapter 6. Vaccine Administration. In: Hamborsky J, Kroger A, Wolfe S, eds.
Epidemiology and Prevention of Vaccine-Preventable Diseases. 13th ed. Washington DC: Public Health Foundation; 2015.
10. U.S. Food & Drug Administration. Science & Research. Pediatrics. Last updated September 8, 2016. Available at:
http://www.fda.gov/ScienceResearch/SpecialTopics/PediatricTherapeuticsResearch/default.htm. Accessed October 23,
2016.
11. Department of Health and Human Services. Food and Drug Administration21 CFR Part 201. [Docket No. FDA-2006-N-
0515 (formerly Docket No. 2006N-0467)] RIN 0910-AF11. Content and format of labeling for human prescription drug
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inspection.federalregister.gov/2014-28241.pdf. Accessed October 23, 2016.
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2012;87(10):982-990.
13. deMol P, de Vries ST, de Koning EJ, Gans RO, Tack CJ, Bilo HJ. Increased insulin requirements during exercise at very
high altitude in type 1 diabetes. Diabetes Care. 2011;34(3):591-595. doi:10.2337/dc10-2015.
14. Krakowski AC. Exposure to radiation from the sun. Chapter 14. In: Auerbach PS, ed. Wilderness Medicine. 6th ed.
Philadelphia, PA: Elsevier Mosby; 2012:311-312.
15. Summer Heat Can Put You at Risk! Available at: http://netwellness.org/healthtopics/pharmacyw18.cfm.
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Philadelphia, PA: Elsevier Mosby; 2016:1583-1635.
17. Zafren K, Giesbrecht GG, Danzl DF, et al. Wilderness Medical Society practice guidelines for the out-of-hospital
evaluation and treatment of accidental hypothermia: 2014 update. Wilderness Environ Med. 2014;25(4 Suppl):S66-S85.
18. Kupper TE, Schraut B, Rieke B, Hemmerling A-V, Schoffl V, Steffgen J. Drugs and drug administration in extreme
environments. J Travel Med. 2006;13(1):35-47.
19. Briese BB, Briese MM. Appendix: drug stability in the wilderness. In: Auerbach PS, ed. Auerbach’s Wilderness Medicine.
7th ed. Philadelphia, PA; Elsevier Mosby; 2016:2621-2631.
 Ammann C. Stability studies needed to define the handling and transport conditions of sensitive pharmaceutical or
20. biotechnological products. AAPS PharmSciTech. 2011;12:4:1264-1275.
21. Coleiro Daphne. Storage of Medicines and Medical Devices. 2012. Available at:
https://www.um.edu.mt/__data/assets/pdf_file/0016/153160/Storage_of_Medicines_and_Medical_devices.pdf. Accessed
October 23, 2016.
22. Brown LH, Campagna JD. Medication storage in the EMS environment: understanding the science and meeting the
standards. 2005. Available at: http://www.emsworld.com/article/10324134/medication-storage-in-the-ems-environment-
understanding-the-science-and-meeting-the-standards. Accessed October 23, 2016.
23. Emergency Medical Services Vehicles and Ambulances—Storage of Preparations. USP 32 NF 27: United States
Pharmacopeia [and] National Formulary, Volume 21070. Available at: www.usp.org. Accessed October 23, 2016.
24. Luthy J. Temperature management of medication in remote environments. Available at:
http://wildernessmedicinemagazine.com/1170/Temp-Management-of-Medication. Accessed October 23, 2016.
25. EpiPen Prescribing Information. Available at:
http://www.accessdata.fda.gov/drugsatfda_docs/label/2008/019430s044lbl.pdf. Accessed October 23, 2016.
26. Beasley H, Ng P, Wheeler A, et al. The impact of freeze-thaw cycles on epinephrine. Wilderness Environ Med.
2015;26(4):514-519.
27. CFR Code of Federal Regulations Title 21. US Food and Drug Administration. Subchapter C—Drugs: General, Part 211—
Current Good Manufacturing Practice for Finished Pharmaceuticals. Subpart G—Packaging and Labeling Control. Sec.
211.137 Expiration Dating. Available at: http://www.accessdata.fdagov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?
fr=211.137. Revised as of April 1, 2016. Accessed October 23, 2016.
28. Strategic National Stockpile (SNS). Office of Public Health Preparedness and Responses. Centers for Disease Control and
Prevention. Available at: http://www.cdc.gov/phpr/stockpile/stockpile.htm. Updated June 17, 2016. Accessed October 23,
2016.
29. Food and Drug Administration (FDA) Shelf-Life Extension Program. Available at:
http://www.usamma.army.mil/dod_slep.cfm. Last modified September 12, 2015. Accessed October 23, 2016.
30. Lyon RC, Taylor JS, Porter DA, Prasanna HR, Hussain AS. Stability profiles of drug products extended beyond labeled
expiration dates. J Pharm Sci. 2006;95:1549-1560.
31. Doxycycline EUA fact sheet for recipients. Available at:
http://www.fda.gov/downloads/EmergencyPreparedness/Counterterrorism/UCM265824.pdf. Accessed October 23, 2016.
32. The Medical Letter. Drugs past their expiration date. Med Lett Drugs Ther. 2009;51:101-102.
33. eMedExpert. Expired medications. Available at: http://www.emedexpert.com/tips/expired-meds.shtml. Updated February
2016. Accessed October 23, 2016.
34. Estelle F, Simons R, Gu X, Simons KJ. Outdated EpiPen and EpiPen Jr autoinjectors: past their prime? J Allergy Clin
Immunol. 2000;105(5):1025-1030.
35. U.S. Customs and Border Protection. Traveling with medication. Available at:
https://help.cbp.gov/app/answers/detail/a_id/1160/kw/traveling%20with%20medications. Updated October 18, 2016.
Accessed October 23, 2016.
36. Questions and answers for the public. Donating Drugs to International Humanitarian Relief Efforts. Available at:
http://www.fda.gov/downloads/NewsEvents/PublicHealthFocus/UCM249617.pdf. Accessed October 23, 2016.
37. Guidelines for Drug Donations. World Health Organization. Revised 1999. Available at:
http://apps.who.int/medicinedocs/pdf/whozip52e/whozip52e.pdf. Accessed October 23, 2016.
38. Dallimore J, Mason NP, Moore J. Chapter 87. Expedition medicine. In: Auerbach PS, ed. Wilderness Medicine. 6th Ed.
Philadelphia, PA; Elsevier Mosby; 2012:2205-2214.
39. Chapter 25. Wilderness medical kits. In: Forgey WW, ed. Wilderness Medical Society Practice Guidelines for Wilderness
Emergency Care. 5th ed. Guilford, CT: The Globe Pequot Press; 2006:114-117.
40. Forgey WW. Chapter 3. Expedition medical kit. In: Bledsoe GH, Manyak MJ, Townes WA, eds. Expedition & Wilderness
Medicine. New York, NY: Cambridge University Press; 2009:30-39.
41. Lipnick MS, Lewin MR. Chapter 102: Wilderness preparation, equipment, and medical supplies. In: Auerbach PS, ed.
Auerbach’s Wilderness Medicine. 7th ed. Philadelphia, PA: Elsevier Mosby; 2016:2272-2305.
42. Forgey WW. The expedition medical kit. Appendix. In: Bledsoe GH, Manyak MJ, Townes WA, eds. Expedition &
Wilderness Medicine. New York, NY: Cambridge University Press; 2009:709-714.
43. Forgey WW. Chapter 2. Assessing expedition medical needs. In: Bledsoe GH, Manyak MJ, Townes WA. Expedition &
Wilderness Medicine. New York, NY: Cambridge University Press; 2009:19-29.
44. Iserson KV. Medical planning for extended remote expeditions. Wilderness Environ Med. 2013;23:366-377.
45. Havryliuk T, Cushing T. Medication transport in the wilderness. Available at:
http://wildernessmedicinemagazine.com/1113/Medication-Transport-in-the-Wilderness. Accessed October 23, 2016.
46. SAFETYwire. Eliminating ratio expressions. NurseAdviseERR. ISMP (Institute for Safe Medication Practices). June
2016;14(6).
47. Labeling. In: United States Pharmacopeia, 39th ed, and National Formulary, 34th ed (USP39-NF34). Rockville, MD: U.S.
Pharmacopeial Convention.
48. Hubbell FR. Chapter 36. Wilderness emergency medical services and response systems. In: Auerbach PS, ed. Wilderness
Medicine. 6th ed. Philadelphia, PA; Elsevier Mosby; 2012:674-686.
49. Naloxone Use by EMS Providers. Exploring naloxone uptake and use. Food and Drug Administration. July 2, 2015.
 Available at: http://www.fda.gov/downloads/Drugs/NewsEvents/UCM454805.pdf. Accessed October 23, 2016.

*Note some content in this section originally appeared in Pietroski N. Expired Drugs: Immortal or DOA? Wilderness Medicine
Magazine. http://wms.org/magazine/1169/Base-Camp-Rx-Expired-Drugs. November 29, 2015. Accessed June 8, 2017.
†Note some content in this section originally appeared in Pietroski N. BaseCamp Rx: Medical Kits. Wilderness Medicine
Magazine 2017;34(1). Available at: https://wms.org/magazine/1201/Base-Camp-Medical-Kits. Accessed August 23, 2017.
*See 3M MonitorMark Time-Temperature Indicators at http://www.3m.com/3M/en_US/company-us/foradditionaldetails.
Most central to the practice of wilderness EMS is a sophisticated, evidence-based approach
to wilderness medicine. These chapters each analyze a core wilderness medicine topic from
a wilderness EMS perspective.
INTRODUCTION
It is important to understand what the psyche undergoes during a survival situation, for the
purpose of understanding a lost person’s behavior and preventing rescuers from succumbing to
the same situation. The most important factor determining success or failure in a survival
situation is the individual’s psychological state and ability to cope, rather than technical
expertise, or equipment.1 Oftentimes, survival elicits a stress response, be it from injury, thirst,
hunger, environmental extremes (cold, heat, or altitude, for example), fatigue, or fear.
Understanding the stress response can assist a rescuer in locating and rendering first aid to a lost
person.

THE STRESS RESPONSE

Many are familiar with the “fight or flight” response, which also includes an additional “freeze”
response,2 as a stressed individual simply gives up, and is unable to complete any task
whatsoever. Macias and Williams discuss the physiologic responses induced from a stress
response.3 An initial increase in pulse and respiratory rate occurs from a surge of endogenous
epinephrine, accompanied by an increase in glucocorticoid hormones. This sympathetic response
shunts blood from the gut to large muscle groups, allowing for increased work. Peripheral
vasodilatation causes skin flushing and perspiration, allowing the body to stave off any
deleterious heat accumulation. The limbic system of the brain, located in the center of the
cerebrum and above the brainstem, contains several important structures crucial to survival. A
specific region responsible for the fear, or pleasure response, is the amygdala, which modulates
the emotional response to stress.3,4 It is occasionally referred to as the “reptilian brain,” because
of its immediate, but not well thought out, response to a stress situation, be it escaping, fighting,
or freezing into a state of panic. These survival responses could also be counterproductive: the
reaction bypasses the neocortex of the cerebrum (responsible for making well-thought-out
decisions), literally “hijacking” the rational brain.5
The amygdala triggers the hypothalamic-pituitary-adrenal axis, resulting in the
catecholamine surge already described. Unfortunately, the amygdala can also trigger cognitive
disruption and inattention, as well as promoting a decompensated emotional state,3,6 unless the
highly cognitive, decision-making, and vigilant neocortex is trained to overcome the panic from
the amygdala. Furthermore, elevated glucocorticoid levels augment excitatory synaptic amino
acids and cause short-term memory loss. Ultimately, such elevated levels can atrophy the brain’s
memory center, the hippocampus.3,4 The reader may be familiar with this lack of recall and
difficulty with decision-making when overwhelmed by a medical or trauma code. For example,
routinely learned tasks, such as airway management, become difficult in stressful situations,
whereupon a provider might forget how to perform a task, or where to find equipment. In many
ways, a survival situation is similar to running a life-or-death code, with the exception that the
survivor is in an unknown environment and may be inexperienced.
Quality survival training is therefore important; adding progressively graded and realistic
stress situations will add helpful “stress inoculation.”7 Repetitive practice eventually produces an
appropriate and faster automatic response, termed limbic learning,8 where “muscle memory” and
intuition can be developed. Although preconditioned emotional control may not be present in a
lost person, wilderness medical providers trained with this type of learning benefit greatly with
regard to decision-making and teamwork, making a rescue more efficient.3,9 Additionally, being
in good physical condition clearly confers an advantage on a lost person, as well as a rescuer.10
However, some elite performers might struggle to find emotional control: highly trained
individuals and those from special operational backgrounds have succumbed to simple survival
challenges from overconfidence, or the belief that rescue is somehow dishonorable.11

ANALYZING LOST PERSON BEHAVIOR

One part of survival is ensuring, if lost, that behaviors point toward safety and being found. This
section analyzes typical behaviors and behaviors that are more functional for those goals. A more
complete discussion of search and rescue (SAR) methodology and philosophy for the rescuer can
be found in Chapter 30.
In a search, the level of training and perceived mental resiliency of the lost person is helpful.
However, these characteristics may not be evident. Gonzales, in examining why people live or
die in survival situations, wonders how a 17-year-old girl in a skirt could survive solo from a
plane crash and walk out of a Peruvian jungle11; and one author of this chapter has inquired about
the characteristics allowing one member of the 1999 American Shishapangma Himalayan
expedition team to survive a massive avalanche, where two equally trained mountaineers died.12
In the latter case, chance may have played a part; in the former, a certain humility and
determination were key roles. Others survive when they stick to a good plan (such as not
drinking sea water), or stay around a large object that can be easily seen (such as a vehicle).
Others do well when they have a higher purpose, have loved ones to return to, or hold on to
certain spiritual practices1; even anger can save a person.10 In short, a compelling will to live,
added with the right conditions, will result in a rescue, rather than a recovery.
 Syrotuck and Perkins’ analysis of lost person behavior is well known,13,14 categorizing the
lost according to age, and activity. Children 6 years old or less might understand being lost, and
usually do not understand the need for a return route. They are likely to find a spot to hide under
to keep warm, or hidden from perceived dangers; in the latter case, they might not respond to
whistles or calls. Survivability is good, because of the tendency to find shelter. Children from 7
to 12 years of age frequently become lost during play, or while attempting a short cut to some
destination. At this age, they are beginning to construct mental maps of their surroundings,
which may be inaccurate. This group, as well as older children, might attempt to travel a trail, or
up a hill to orient themselves when lost; the older ages, including adults, tend to panic and act
irrationally, but may respond better to being lost if with a friend or sibling. We postulate that
children know how to play, and are less accustomed to comforts that adults desire, since many
children play in the mud, and tend to play imaginary games in the outdoors readily. Special
situations with regard to hikers, climbers, hunters, and skiers are covered elsewhere in this book.

SURVIVOR CHARACTERISTICS
Mental models or roadmaps, discussed in the context of survival, are based on the interplay of
previous experiences, analysis, and emotions; in a crisis, survivors rapidly interpret their new
reality.15 In other words, they are flexible, do not adhere to rules, and can adapt. A survivor is a
learner and a keen observer, open to do anything, able to calm their emotions doing simple tasks,
conserve energy, and tolerate uncertainty and discomfort. Being optimistic, even laughing or
playing can also optimize survival.15,16 Perseverating on a fixed mental map, or in the case of
rescuers, falling into a trap of “rescue fever,” could worsen a situation.
If lost, decisions must be pared down, and panic controlled. A helpful acronym is STOP.16
S means to stop what you are doing. Blind action can be dangerous. Take the moment to
utilize tactical breathing. Accept that what happened cannot be undone. Conserve energy from
here on out. Stop blaming yourself, or others for the predicament.
T is for thinking. Think about what happened, and think through a future action’s
consequence, even if to take a step. Take efforts to utilize rationality. Turn on the ability to focus.
Rid yourself of extraneous information, or delegate; this cognitive off-loading improves working
memory.8
O is for observe and organize. Situational awareness of your new environment, of the
possibilities, and the dangers, is a must. Take stock in organizing what you have for equipment
and options. Survivors quickly organize, set up routines, and institute discipline.11
Lastly, P is for planning, and carrying out that plan. Prioritize the immediate needs and
resources as outlined below, and develop a plan to systematically put the plan into action. Follow
the plan, but be willing to reassess and adjust, based on new circumstances.

PREVENTION
The Accident Matrix delineates contributing causes of accidents and errors.17 The matrix has the
categories of Conditions, Acts, and Judgments.
Conditions would refer to the weather or terrain, for instance. Successful rescuers are
cognizant of conditions, and attempt to avoid their negative consequences.
 Acts are the sequence of events contributing to an accident, such as climbing without
adequate protection. Conversely, successful rescuers will preplan where and how to put rescue
anchors, or plan the best method to extract a patient out of the wilderness.
Judgments are often faulty. For example, a mountaineer or skier may feel overconfident in
their abilities. This could be labeled an overconfidence bias. The expert halo bias is exemplified
when team members assume that the rescue leader is qualified by “looking the part.” Scarcity
bias is seen when an opportunity is perceived as limited, necessitating competition with others to
obtain the opportunity.18 A familiarity bias is the tendency to believe that our behavior is correct,
since we have done it before. The social proof bias causes one to follow others in a group
blindly, without independent thought, or while ignoring a negative intuition about the situation.
Commitment bias is the tendency to believe that a current behavior is correct, if it is consistent
with a prior commitment we have made.19 A realistic rescuer can avoid this trap by recognizing
an “off-day,” not feeling well, or being inexperienced for the task. Honesty about abilities,
without fear of losing face, can avert a crisis for the rescuer and team. Other biases, such as one
that would deal with comfort, tends to make a person rush back into a comfort zone, such as a
warm car, a cabin, or another comfort trigger, while obviating avalanche danger or navigation
basics.

SURVIVAL PRIORITIES-THE RULE OF THREES

Our experience has shown that many who are lost instinctively try to find food. Yet, depending
on the environment, physiologic timetables prioritizing more urgent needs is crucial. Within the
first 3 seconds, one can step off a cliff if in a panic. The remedy would be to calm the mind and
STOP, as outlined above. Regardless of whether one is specifically near cliffs or not, the
underlying principle is clear: Massively inappropriate conditions can be made anywhere, and
most wilderness environments have some modality where such decisions could be immediately
lethal. Within 3 minutes, most die without oxygen, which is important in water rescue (Chapters
16, 17, 26, and 27) and cave rescue (Chapter 29)—the priority is air. Most humans die of
hypothermia within 3 hours; thus, for a terrestrial survival crisis, heat (fire) and shelter/clothing
become the immediate priorities, much before food! Incidentally, fire is a great morale booster as
well.20 (See Chapter 13 for a more complete discussion of cold injury treatment and prevention.)
Within 3 days for most, dehydration kills. Thus, water is a priority. Minimizing sweating, heavy
breathing, and other water losses are important until water can be found. One can survive
without food for about 3 weeks; thus, conserving energy, and recognizing that hunger is
unpleasant, but not life threatening, is crucial. Simple traps, snares, or eating edible plants and
insects may provide some sustenance. Lastly, 3 months without social contact can result in
depression, or be the limit of illness or injury incurred in the event. Chapter 23 discusses
behavioral medicine in the context of wilderness operations in more detail. Having a form of
signaling, with a radio, cell phone, whistle, signal mirror, flares, or even a fire, can help a lost
person to be found. Hopefully, the successful survivor, and rescuer, can address all these issues
in short order. As discussed in the Introduction, rescuers themselves are in a threatening
environment as well, and must be prepared to convert their mentality into one of a survivor if
their own operation becomes compromised and they themselves require assistance. More
importantly, their mentality should always be geared towards preventing the need to move into a
survival priorities mode.
 The rule of threes could also be extended to having three backups, or modes of initiation, for
the above contingencies. Gathering at least three times the amount of survival material in the
wild, and planning on expending at least three times the amount of time and energy needed for
an endeavor is insurance against chaos, and can add a mental edge to stave off frustration and
panic. Review and reassess frequently, and remember that pain and discomfort are temporary.
We recommend survival practice, adding incremental stress as you practice, until you have
mastered necessary survival and rescue skills.

PREVENTION
There is no question that the overall success of a mission is highly dependent on the preparation
that comes prior to the expedition itself. This truth is amplified in the wilderness environment.
Taking a team of rescue personnel into an unforgiving environment without physical and mental
preparedness, and proper gear, puts rescuers and patients in danger. If a provider is unable to
care for self, the provider will become ineffective, and can even become another patient. Proper
preparation is therefore essential to avoid falling victim to a well-established tenant of out-of-
hospital care: Don’t become a patient.
It is incumbent on the WEMS rescuer to be in proper physical condition to undertake a
rescue. Although not the scope of this chapter, proper cardiovascular fitness in the appropriate
setting, such as in high altitude, is extremely necessary. The ability to hike or climb rugged
terrain is crucial, depending on the environment. Proper technical expertise is a must. Without it,
the rescuer endangers the entire mission. An essential aspect of planning for a wilderness
excursion is to develop a logistic plan. Thought should be given to the duration of the mission,
weather and environment, type of travel and terrain, number of personnel involved, number and
injuries of casualties, and mission objectives. This plan will be the basis on which a preparatory
gear list can be generated.

General Wilderness Gear

Clothing and Footwear
Clothing is the first line of defense against the environment. Clothing material contains spaces
providing a layer of insulation between the skin and the environment. There are a variety of
different fabrics and insulating materials to consider, and each has its own pros and cons. The
most common natural fibers are cotton and wool. Cotton has been advised against in the
wilderness environment for decades, leading to the often-repeated saying, “cotton kills.” It
readily absorbs and holds water, and loses all insulating characteristics when it becomes wet.
Wool has very little absorptive behavior, and is able to maintain its loft, even when wet,
preserving its insulating properties, drying quickly. Although wool is traditionally known as an
uncomfortable fabric, certain types of wool (ie, Merino wool) are soft and comfortable enough to
wear as a base layer. The downside to wool is its weight and lack of compressibility, making it
one of the more heavy and bulky clothing materials.
Synthetic fibers have become very popular to outdoor enthusiasts. They are generally much
less absorptive and better at wicking, more comfortable, flexible, and can be processed to tailor
the garment to various activities. Nylon is an extremely adaptable compound used primarily in
outer layer garments, although it does require a water repelling treatment, as it is somewhat
absorptive. Polyester and polypropylene are lightweight and retain very little water. They are
both breathable and lightweight, and often used in base layer garments; however, they are well
known to retain body odor. Elastic materials, such as spandex, are often combined with other
synthetic fibers to provide a degree of flexibility and improve movement for outdoor activities.21
Water resistant and waterproof garments vary from the basic plastic poncho to highly
technical fabrics such as Gore-Tex and eVent. Whereas almost any plastic material will keep rain
and weather out, it also traps moisture and heat, potentially leading to increased perspiration and
wet clothing. Gore-Tex and eVent fabrics are fused to the inside of a garment and have
microscopic pores that allow moisture to escape.22 These are the best overall options for rain and
snow garments, but are also the most expensive. Another option is to coat a garment with a
waterproof material. This can be as simple as a polyurethane layer; however, it allows for no
breathability. Durable water repellent (DWR) treatments allow for a micropore layer that works
very much like Gore-Tex and eVent to be applied to the outside of the garment.23 DWR tends to
be not very durable and requires repeat treatments; however, there are several spray on and wash
in options available and are easy to use. Regardless of the micropore layer used (internal or
external), it is important to keep the material clean to maximize functionality.
The insulating capacity of clothing, such as an insulating jacket, is primarily related to its
density and loft (thickness). The more air trapped in the garment, the better the insulating ability.
Other factors to consider are wind resistance of the outer layer and absorptive capacity of the
material. Wind resistance prevents convective movement of air through the garment, allowing
for a more stable insulating layer. Highly absorptive materials allow water to fill up the
insulating space and collapse, minimizing insulating capability.
The two most common insulating fillers are duck/goose feathers (down) and synthetic
polyester fibers. Down is extremely light and compressible, making it ideal for use in wilderness
conditions. The disadvantages are that it retains water and loses the majority of its loft when wet,
rendering it useless. Synthetic insulation is much less absorptive and is able to retain a portion of
its insulating properties when wet, although it is heavier and bulkier than down. Several
companies now offer down-filled garments where the feathers are coated with a hydrophobic
DWR, allowing for loft retention and faster drying.
When determining how to dress, a multilayered method is suggested, with the ability to
easily add or remove layers as needed, for both the torso and the legs. All layers of clothing
should be loose and elastic enough to allow for unrestricted movement. The base layer consists
of a breathable, comfortable wicking material to help move sweat away from the skin and remain
dry. Care should be taken to avoid rough or abrasive materials to prevent chafing. The middle
layer is the main insulating layer, and can range from a thin shirt to thicker fleece or filled
garment. It can also consist of several layers as needed for warmth, such as a mid-weight wool
shirt and down parka. Lastly, the outer layer consists of a breathable windproof and/or
waterproof garment. It should be non-insulating, as the shell layer is often needed even in
warmer weather.22
Headwear, gloves, and socks are an essential part of dressing appropriately, since much body
heat can be lost through the scalp. In hot, sunny climates, a well-ventilated brimmed hat can help
provide shade and keep sweat from accumulating and running onto the face. Thicker insulating
beanies help with heat retention. Balaclavas and tubular headwear offer versatility when it comes
to providing warmth and direct protection from the sun. Gloves can be worn for both protection
and warmth. A layered approach consisting of a thin inner layer, insulating middle layer, and
waterproof outer layer is ideal. Mittens offer additional warmth, as there is less surface area and
fingers are able to share warmth. Thick gloves and mittens can significantly decrease dexterity
and subsequently are often removed in the field. This is a bad practice and can lead to cold
fingers and difficulty with fine movements. A protective thin contact layer or medical gloves
should be worn at all times for finger protection from cold and freezing injuries.16 Many gloves
come with features such as fabric with increased grip on the palms and fingers, or a conductive
material over the fingerprints to allow for usage of a computerized touch screen with the gloves
on. Sock materials should be given the same considerations as other garments. Wicking,
nonabsorbent materials with low friction, such as wool and synthetic fibers, are the best choices,
with thickness depending on the environment and footwear. The wrong sock and shoe combo
can lead to blister formation, wet macerated feet, and cold injuries. If socks are too thick, they
can lead to tight shoes and poor circulation, increasing the chances of cold injury. An extra pair
of clean, dry socks should always be available. Make sure to train with the clothing that will be
worn during rescue to help prevent any unexpected issues.
There are several styles and materials to consider when purchasing footwear. Uppers are
generally made of fabric, leather, or a hybrid of both. Fabric uppers are lightweight and allow for
more breathability, but are less durable and offer very little protection against rocks and thorns.
Leather is durable, but heavy and can absorb a large amount of water if not treated properly. A
waterproof micropore fabric layer (eg, Gore-Tex) is available in both fabric and leather boots.
This helps to maintain breathability while providing water resistance, but adds weight to the
shoes. The upper can be cut anywhere from below the ankle to full height. The higher the upper,
the more support it gives to the ankle, but the heavier it is. Approach style shoes have a sole with
the same type of rubber used in climbing shoes, making them ideal for rocky terrain. Depending
on the terrain, gaiters can often be worn over shoes. A taller gaiter that reaches the upper calf and
made of waterproof material is more appropriate for maneuvering in snow. It is important to
evaluate both terrain and weather prior to choosing footwear for a rescue. Shoes should be well
broken in and paired with the appropriate socks. Wet, painful, or cold feet can easily make a
rescuer inoperable.

Backpacks
Proper fit is the most important aspect when choosing a pack. A poor fitting pack is
uncomfortable and inefficient, leading to pressure spots, shift load, and more rapid fatigue. Most
retailers can assist in determining pack fit. The pack should be loaded with weight when trying it
on to provide a more accurate fit. The head, neck, and arms should have full range of motion.
The pack should sit close and hug the body, and when properly strapped there should be no
excess movement of shift of the weight.
When looking at organization, more pocket storage compartments help with pack
organization, but add to the weight of the pack. It also introduces more zippers and hardware that
may fail. One strategy is to save weight by minimizing required pack complexity by packing
gear into stuff sacks to allow for organization. At minimum, there should be a way to have the
items that need to be rapidly or frequently accessed in a part of the pack. We discourage
extraneous items hanging from a pack unless necessary, because this can unbalance the rescuer,
lead to an exterior item catching on a natural feature, and if excessive, could portray a general
lack of experience or preparedness.
Thus, a pack should be comfortable, have adequate space for required gear, and well
organized. Gear packed into modular stuff sacks can allow for rapid packing of the appropriate
gear for a specific rescue mission. As with clothing, one should train with the weighted pack
prior to using it on a mission to ensure proper fit and function.

Sleeping Bag and Pad

Considerations for sleeping bags are similar to that of general clothing. Materials and insulation
vary, with down offering the most compressible and lightweight warmth. Many sleeping bags are
available in hydrophobic down, with external liners that have a DWR coating. Synthetic
insulation is bulkier and heavier, but maintains its warmth when wet. Sleeping bags usually are
marketed with a temperature rating; however, these ratings can vary significantly between
manufacturers. The temperature listed is subjective based on the manufacturer’s
recommendations, and different sleepers have varying comfort zones. The lower the temperature
rating, the more insulation, weight, and bulk, so choosing the rating based on the average
temperature of the environment it will be used is recommended. Both internal and external liners
can be added to increase sleeping warmth, permitting the rescuer to carry a smaller sleeping bag.
Sleeping bags should always be used with a sleeping pad. In addition to comfort, the role of
the pad is to provide insulation from the sleeping surface. The R value of a pad indicates its
insulating capacity, with higher values providing more insulation. Inflatable pads are light,
compressible, and offer good comfort, but prone to puncture and have lower R values.22 They
also have to be inflated, either by mouth or with a small pump. Open cell self-inflating pads are
comfortable, durable, and warm. They tend to be the heaviest option and can be punctured.
Closed cell foam pads are lightweight and offer good insulation, but bulky. They are durable and
can be placed on almost any surface without concern for puncture.

Essential Nonmedical Equipment

For the bare essentials, the “Ten Essentials” can be simplified to the rule of threes as explained
above—three sources for hypothermia prevention, water, food, navigation and signaling devices,
including navigation materials, and a knife. The knife should be sturdy, with at least a 7-inch
sturdy blade; small pocket knives are not very useful. Multi-tools add convenience, but the small
knife provided tends to add aggravation to a survival scenario. Headlamps make life nicer; we
recommend carrying three potential light sources. Extra batteries and light bulbs are also handy.
Special lighting considerations for caving or diving are outside the scope of this chapter. We also
recommend first aid supplies. Sunscreen and sunglasses are nice, and important in high altitudes
or maritime areas.
For hypothermia, fire craft skill is essential. Fire matches (“flint and steel”) that deliver spark
to dry tinder is dependable in adverse conditions. Storm matches and Vaseline-impregnated
cotton balls are nice alternatives. Grade 0000 non-impregnated steel wool and a battery, where
electrodes are close to each other (a 9-V battery, or a car battery with cables) also works well.
Road flares work well, and are also good for signaling. Lighting fires with magnifying lenses are
not as reliable, and we do not recommend friction techniques (such as a bow drill) for a rescuer.
Extra socks and gloves, a tarp, and cordage (for shelters) are recommended; we generally do not
use “space blankets” because they are minimally effective for rewarming, and tear easily. Three
means to purify water would be boiling, chemical (tablets), and filter or ultraviolet light. The
rescuer must know the strengths and weaknesses of each method. Note that hunting or foraging
for food expends much energy, especially for the inexperienced. High density and high caloric
foods are preferred carry items for the rescuer, and are dependable. With any of these tools listed
above, it is imperative that the rescuer has practiced with the materials, since the likelihood that
these materials will work for an inexperienced rescuer is minimal.
Pre-planning: Risk assessment and mitigation
In stark contrast to the somewhat controlled environment in which many EMS personnel conduct
daily operations, the wilderness setting is home to many innate risks. The ever-changing risks
and unpredictability that exist in many wilderness settings are often amplified when the
rescue/recovery team has failed to adequately preplan for the mission. Risk is often defined as a
situation or action that has the potential of causing harm to persons or equipment.24 A general
understanding of how risk is defined allows an individual to conduct pre-mission risk mitigation,
by breaking down the overall mission into phases.
To avoid becoming lost and enduring a survival situation, rescuers should pre-plan, and
mitigate risk. To begin this process, rescuers must first think of the mission in four phases. In the
ideal situation, planners would have time to think beyond the phases of the operation with
contingency plans that would address unforeseen circumstances. Developing three different
courses of action (COA), or options will allow the planners to utilize a risk matrix to analyze the
most appropriate actions. Table 12.1 lists examples of these phases and their corresponding
COAs (note these examples are not all encompassing).

Phase 1: How will the team approach the incident site?

Phase 2: What is the best way to get to the incident scene?
Phase 3: Once arrived on scene, what are the planned actions?
Phase 4: How will the team and survivor be extracted?

Each phase of an operation offers its own set of risks, which hopefully can be mitigated to a
low level of risk. When deciding how to execute each phase, the planners must balance safety
with speed. These decisions are often determined by a number of factors such as known survivor
status, rescue/recovery team training and disposition, and environmental conditions. In order to
ensure that no critical phases of movement have been overlooked, planners must examine each
phase individually. The risks and hazards of each movement phase should be divided into two
categories: risk facts and risk assumptions. The following are examples of potential risk/hazards
facts and assumptions

Facts: What are the known hazards of the actions and environment?
Loose and unstable rocks in areas
Known rip-tides
Avalanche zone hazard
Helicopter dangers
Known swiftwater
Technical rescue dangers
Assumptions: Worst-case scenarios
The survivors were not prepared for the environment (clothing/gear)
Inexperienced volunteer rescue teams
Operation will take longer than expected
Survivors have decreased mental/physical capabilities due to extended environment
exposure
The team will be physically exhausted post-mission

As with most SAR missions, the clock is ticking against the planners, and decisions normally
must be made quickly. At every level of a local SAR team, it is important to have a developed
set of guidelines, which can be deviated from and adjusted to each operation. These guidelines
should be developed with the worst-case scenario in mind. This will allow the planners to reduce
the excess, rather than having to add items with haste. Most SAR and WEMS teams are familiar
with the type of terrain in their locale, and should develop guidelines to fit their specific
environment.

Table 12.1 Sample Risk Matrix

COA 1 COA 2 COA 3
Phase 1 Helicopter Motor vehicle ATV
Phase 2 Short-haul Hike (overland) ATV
Phase 3 Package patient for haul Package patient in litter with Package on ATV
wheel
Phase 4 Short-haul Team litter carry Litter carry/ATV

COA, course of action; ATV, all-terrain vehicle.

Identifying the common places SAR missions have been conducted in the past can have
tremendous effects on the success of a SAR mission. It is crucial that the SAR team conducts
training at these locations, which will greatly increase the chances of success if a mission occurs
at these sites. It is important, especially on small volunteer teams, that there are members of the
SAR team who are highly trained to manage the more complex aspects of WEMS such as high
angle rescue (Chapter 25) and swiftwater rescue (Chapter 26). This will help mitigate the risk of
untrained persons operating unfamiliar systems and equipment, potentially causing more
casualties.

NAVIGATION BASICS

Definitions
Cardinal Direction: North, East, South, West
Azimuth: A chosen direction of travel or direction in degrees
Magnetic Variation: The difference between the compass, true north, and grid north, due to
the Earth’s magnetic field
True North: A line from any location on earth to the north pole
Magnetic North (MN): The compass reading, which points to the north magnetic pole
Grid North (GN): Utilizing the North-South lines on a map
G-M Angle: Angular difference between GN and MN
USGS: United States Geological Survey

One of the most important skills, both for systemic operations and for individual survival,
necessary for WEMS caregivers is the ability to communicate and understand location and
direction. The most basic means of telling one’s cardinal direction during the day is the location
of the sun. Simply stated, the morning sun will be in the east, in afternoon it will be generally
overhead, and during the evening, it will set in the west. This basic tool can allow the user to
estimate general direction; but what about actual navigation?
The ability to read a topographical map is a crucial skill in navigation, even with modern
technology that would otherwise appear to replace this skill. When conducting a search or just
traveling, it is important to verify that the map reference system or datum is the same as all maps
and global positioning system (GPS) units being used. Common datums are NAD 27, NAD 83,
and WGS 84, and the difference between the datum can be hundreds of meters. Commonly,
when choosing a map for land navigation, a 7.5-minute series map will be the best choice, which
provides a 1:24,000 scale.25 This information can normally be found at the bottom of the map in
what is known as the margin, or key of the map. The margin of the map will provide the user
with all of the important information related to the map such as:

Map scale: 1:24,000 is the most common large scale navigation map
The G-M Angle: the difference between MN and GN
The contour interval: the distance between contour lines (average 40 ft)25
Date of the map, and several other items

The colors on a USGS map have very specific means, which can aid the navigator in the
process of route planning. Below are listed the most common colors on a map, and their
meanings26:

Brown: Contour lines and elevation

Red: Main roads and boundaries
Blue: Water features such as rivers, lakes, and streams
Green: Vegetation. This may appear in various patterns to refine the type of vegetation
Black: Man-made features such as buildings, roads, and railroads

The Universal Transverse Mercator (UTM) coordinate system divides the earth in 60 zones,
of which numbers 10 through 19 span the continental United States. Overlaying these 60
longitudinal zones are 20 letter designated latitude bands that are 6 degrees in height (Figure
12.1).27,28
The combination of latitude and longitude lines gives the specific zone. For example, New
Mexico is mostly in 13S. A normal “10” digit grid coordinate would look like this: 12T 495056
m E 5045436 m N. Any following digits are used to refine the location:
the more digits you include, the closer you get to the exact location.29
4
95056 m E 5045436 m N (4 digit) 1,000 m × 1,000 m area.
4
95056 m E 5045436 m N (6 digit) 100 m × 100 m area.
4
95056 m E 5045436 m N (8 digit) 10 m × 10 m area.
4
95056 m E 5045436 m N (10 digit) 1 m × 1 m area

Reading contour lines provides the navigator with the ability to plan routes of travel that will
be advantageous to the group and provide ease of travel. The farther apart the contour lines are,
the less steep the slope is since the vertical distance (VD) between lines is always a set amount,
such as 40 ft Lines that are extremely close will often mean an almost vertical slope, and as such
should be avoided, unless a high angle operation is being considered.
When planning a route on the map, it is important to account for the VD as well as the
horizontal, as this can add unexpected and substantial distances to travel. Measuring horizontal
distance is fairly simple. Place one end of a string on your desired starting point, and traced the
desired route with the string (Figure 12.2). Place the string onto the scale in the margin and
measure the horizontal distance (Figure 12.3).29,30
Figuring out the VD in a route in not quite as simple; however, it can be a crucial step in
route planning. In the example below, it is showing that factoring in VD can add great distance
to planned travel and allows the planner to rethink routes as necessary.

FIGURE 12.1. The Universal Transverse Mercator (UTM) coordinate system. Data from National Geospatial-intelligence
Agency. Universal Transverse Mercator and the Military Grid Reference System. http://earth-
info.nga.mil/GandG/coordsys/grids/utm.html. Accessed November 8, 2016
FIGURE 12.2. Measuring the course of a route with a string.

FIGURE 12.3. Measuring route distance by laying on the length of string on a distance scale.

To calculate the changes in elevation or VD, the following formula should be used:

1. Let’s say you are at point X: the elevation is 2,180 ft

2. Your destination is Peak Y: elevation 3,240 ft
3. Calculate the VD by subtracting the lowest point of the slope (Point X) from the highest
point of the slope (Peak Y): 1,060 ft is the VD (Y − X = VD)
4. Now, measure the horizontal distance (HD) between X and Y: let us say it is 3,960 ft (0.75
miles) straight line

angle, or as a slope ratio, 0.268.

6. Finally, calculate the HD of the slope you would cover by hiking up the slope using the
following: HDslope = HD × slope ratio = 3,960 × 0.268 = 1,061.3 ft This means, as you hike
 the slope, you are actually covering 1,061.3 ft.31

An essential tool for the WEMS provider is a compass, and while there are various
configurations and capabilities, they all have the same basic functions.
The common components of a compass are the north-seeking arrow, capsule, and dial. It is
vital that the individual is comfortable and familiar with using their personal compass, as there
are hundreds of variations available. When operating a compass, the user must be cognizant of
the potential for interference in the readings. In general, any metal object near the compass will
interfere with the north-seeking arrow, including common items such as belt buckles and
jewelry. The WEMS provider should hold the compass centerline of the body and horizontal,
with a 90-degree bend in the elbow. This should provide a safe distance from most metal objects
on the body such as knives, binoculars, or cameras. One of the most common causes of
interference are power lines. Often power line routes provide an easy route of travel through
areas of thick vegetation; however, these can cause irregularities in compass readings up to 180
ft from the power lines.
An altimeter provides the user with the ability to determine current elevation, which can
refine the user’s location even greater when used in conjunction with a map and compass.
Consider this example:
On a routine search you have become disoriented, and are not sure of your exact location. Using a USGS map and your
knowledge of reading topographical maps, you are able to locate three known terrain features on the map, which correlate
with those in visual sight. You take a compass reading to each of these and draw a line in the reverse compass heading. These
three lines create a small triangle that you are in; this is called triangulation. To better refine your location, you can use an
altimeter to note your current altitude, which then lets you know which contour line you are near, within the triangle.

One of the most common tools in modern wilderness navigation is the GPS. A GPS works by
communicating with several satellites orbiting the earth to give a location. Like all technology,
the GPS has its limitations and can have signal interface from factors such as weather, forest
canopy, location, and jamming devices. GPS devices can be programed for the datum you would
like, and how you would like the coordinates to be displayed, that is, latitude/longitude
(“lat/long”), UTM, and military grid reference system (MGRS). This can come in very helpful
when coordinates are passed to you in another format such as lat/long, and you would like to
convert them to UTM. For those not wanting to purchase a special GPS device there is good
news, as most people already own a device with GPS capabilities: a cell phone. Most smart
phones have built-in GPS which can be further augmented with useful positioning applications
such as TopoMaps. This smartphone application allows the WEMS provider to view
topographical maps in real time, get up-to-date coordinates in a variety of formats, and plot
routes directly from their phones.32 This is of course if there is cellular phone reception in the
areas that you are working.

COMMUNICATION
The ability to communicate in a rescue or wilderness setting is vital. Cellular phones are the
easiest form of communication if there is reception; however, in many wilderness settings there
is no reception at all. The next most common means of communication is the use of handheld
radios. These are very common in SAR operations, yet often are found to be unhelpful. This can
be due to the limited range of these devices in mountainous and vegetated areas, the tyranny of
distance, or user error. So what happens when one is in the wilderness without a radio or cellular
phone? This is when being prepared can save your life and keeping an emergency signal kit is
extremely important when working in rural areas. The idea with a signal kit is to have two forms
of signaling for both daylight and nighttime. Below are examples of daytime and nighttime
signal devices. Many of the devices described are intended to signal aircraft. More details
regarding aircraft operations and interface with WEMS operations are described in Chapter 28.

Daytime
Signal mirror
Can be seen at great distances
Compass mirror or cell phone may work
VZ17 panel
Brightly colored (orange or pink)
Contrast with surroundings
Ground to Air Signal (GTAS)
Large, straight, unnatural
Arrows, letters, et cetera
Flares (Day or Night)
Small pen flares
Beware of fire danger
Fire/Smoke (Day or Night)
Burn item such as green pine needles for extra smoke
Sea Dye
Works well in open water situations
Nighttime
BuzzSaw
Attach a Chemlight to 3 ft of cord
When swung in a circle at night, it creates a 6 ft glowing ring
Laser
Lasers can be seen by police and sheriff service helicopters with night vision or
forward looking infrared (FLIR) devices
Can be used to mark helicopter landing zones
Do not aim directly at the aircraft, as it can cause eye damage

TRAVEL CONSIDERATIONS
As a WEMS professional, you may find yourself in a number of different biomes, and while
many people are familiar with the biome that they live in, traveling only short distances can
change the environment drastically. This chapter is not designed to make you feel comfortable
crossing swiftwater, trekking in steep mountainous areas, or traveling in avalanche zones.
Chapters 26, 30, and 31 cover these topics specifically in more detail, but not chapter adequately
replaces experience. The ability to conduct operations such as these takes specialized training
and practice. As a part of pre-planning, these dangerous areas should be avoided, or risks
mitigated unless the team has specialized training prior to entering them. When traveling in the
wilderness, one must be vigilant to the ever-changing surroundings. Although not all hazards can
be avoided, having a heightened sense of awareness can mean the difference between life and
death.
Aside from the obvious dangers when traveling in the wilderness, the EMS professional
should be aware of and prepared for the seasonal hardships that occur in most biomes. Planning
ahead and factoring in seasonal circumstances will help mitigate the risks associated with a given
season. Seasonal considerations include:

Summer
Heat and dehydration
Active dangerous wildlife
Drastic temperature changes at night in desert climates
Monsoons and dangerous weather
Fall
Shorter period of daytime
Cooler temperatures
Possible early winter storms
Winter
Short sunlight duration
Possible freezing temperatures
Bring extra clothing
Possible snow and ice travel
Skis, snowshoes, crampons possibly needed
People are less aware of dehydration in the cold
Avoiding cotton and using layers
Avalanche risk33
30% to 45% slopes
Convex slopes
Leeward slopes
Spring
Muddy conditions
Higher risk of swiftwater with snow melt
If crossing is required, avoid fast moving water in river bends
Do not tether people who are crossing without the ability to cut or bingo latch away
Be cautious of undercut rocks and strainers
Wildlife coming out of hibernation
Possible late winter storms

SUMMARY
It is important that the rescuer understand the psychological and physical aspects of survival, to
not only better understand the state of being a lost or injured patient might be in during the initial
encounter, but also that the rescuer would avoid similar circumstances. A good understanding of
the risks, risk mitigation, and situational awareness will help both patient and rescuer come out
of the wilderness in a safe manner.
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23. Restoring Water Repellency. Available at: https://www.gore-tex.com. Accessed January 5, 2017.
24. English Oxford Living Dictionaries sv,“risk.” Available at: https://en.oxforddictionaries.com/definition/risk. Accessed
November 8, 2016.
25. Navigation. In: Mountaineering: Freedom of the Hills. 9th ed. Seattle, WA: The Mountaineers; 2017:58-76.
26. Davidson R. 3-3. Topographical map symbols. Available at: http://www.map-reading.com/ch3-3.php. Accessed November
8, 2016.
27. New Mexico Bureau of Geology and Mineral Resources. Available at: http://geoinfo.nmt.edu/search/UTM. Accessed
November 8, 2016.
28. National Geospatial-intelligence Agency. Universal Transverse Mercator and the Military Grid Reference System.
Available at: http://earth-info.nga.mil/GandG/coordsys/grids/utm.html. Accessed November 8, 2016.
29. Biggsa S. Map guide. Available at: http://mapguide2016.blogspot.com/2015/08/topographic-map_18.html. Accessed
November 1, 2016.
30. Riesterer J. Map scales. Available at: http://geology.isu.edu/wapi/geostac/Field_Exercise/topomaps/map_scale.htm.
Accessed November 1, 2016.
31. Basics of slope calculations. Available at: https://web.viu.ca/corrin/FRST121/Help/SlopeHelp.htm. Accessed January 5,
2017.
32. Endecott P. USGS topographical maps on your iPhone/iPod touch. Available at: http://topomapsapp.com/. Accessed
November 1, 2016.
33. Wasatch National Forest. General rules for avoiding and surviving snow avalanches. Available at:
http://www.avalanche.org/moonstone/rescue. Accessed November 2, 2016.
INTRODUCTION TO COLD INJURIES
Wilderness emergency medical services (WEMS) providers are exposed to a wide range of
weather and environmental conditions. Extremes of cold, heat, rain, snow, humidity, wind, and
solar energy can impact provider safety and performance, as well as the capability to care for
team members and patients. For this reason, WEMS providers must have a keen awareness of the
risk factors that lead to cold injuries. Equally important is developing the knowledge base to
accurately discern clinical manifestations of the various cold injuries, so that appropriate medical
management can be planned and executed. Failure to consider the physiologic consequences of
cold injuries can lead to significant morbidity and mortality in a wilderness setting.
Having a fundamental understanding of the mechanisms and pathophysiology of cold
injuries enables WEMS providers to better prepare for outdoor deployment, as well as employ
best practice strategies for assuring personal safety and well-being. Scene safety is of significant
importance and begins with appropriate trip preparation. The objective is to remain an asset in a
rescue rather than become a casualty of the environment. Attention to weather forecasts,
avalanche danger, thin ice, dangerous road and trail conditions, and the potential for falling tree
limbs heavy with snow or ice are essential for planning risk mitigation strategies.

SCOPE OF DISCUSSION
Cold injuries encompass a spectrum of disorders from minor, superficial manifestations without
long-term consequences, to profound physiologic derangements that can ultimately lead to
permanent disability and death. This chapter covers commonly encountered conditions that stem
from exposure to cold and presents out-of-hospital treatment approaches that are pertinent to an
austere or wilderness environment. Perhaps most vital is information that will enable EMS
providers to plan and take the necessary actions to prevent these conditions from occurring in
themselves and others.

PRINCIPLES OF THERMOREGULATION AND

HOMEOSTATIC PHYSIOLOGY
The human body strives to maintain a narrow window of body temperature, at or near 37°C
(98.6°F), through a dynamic balance of heat production and heat loss. Enzymatic functions
required for normal human physiology are temperature dependent. If body temperature drops
below the normal set point, metabolism increases to generate more heat and peripheral blood
vessels constrict to reduce heat loss at the body surface and in the extremities. Shivering is a
highly effective involuntary mechanism for thermogenesis, or heat production, through muscular
activity. Cognitively intact humans also make conscious choices to promote warmth such as
adding clothing, increasing activity, seeking shelter and heat sources, and consuming food. When
cognition is impaired—which, ironically, is an early effect of cold illness itself—the risk of heat
loss due to maladaptive behaviors is significant.
Heat is lost from the body in four ways. The methods of heat transfer (loss) include
conduction, convection, radiation, and evaporation.
Conduction is the heat transfer between two objects through direct contact. Body heat will
move from a warmer object to a colder object. For example, sitting on a cold rock or lying on
snow will result in conductive heat loss from the areas of the body that are in contact with the
cold surface. Wet clothes or immersion in cold water exacerbates the heat transfer.
Convection is the process in which heat is carried away from the body by currents of air or
water movement. The body warms the air or water in contact with the skin; the heat is carried
away by the movement of the air or liquid and then is replaced by an unheated source. The heat
loss is related to the relative temperature and the speed of the air or water. This is the reason why
the outdoor temperature feels colder when the wind speed is high and is the basis for the concept
of wind chill. The use of appropriate insulating clothing and windproof outerwear can decrease
heat loss from convection.
Radiation is the loss of heat through infrared radiation. Heat from the warmer body radiates
to the surrounding cooler environment. Radiant heat loss is much more significant in a colder
environment because of the difference in temperature between the heat source and the
surrounding environment. Insulating clothing, including wearing a hat, reduces radiant heat loss.
Evaporation is the energy lost through the process of converting liquid on the surface of the
skin to a gas. Body heat is necessary to evaporate liquid (sweat) to a gas, thereby cooling the
body and releasing that heat to the air. This process is much more effective in a dry environment,
which is why it is so useful for cooling in the desert. Heat is also lost through warming and
humidifying air in the lungs during the process of breathing or respiration. This form of heat loss
can increase at high altitude because of the deeper and more rapid respiratory pattern that is
common at elevation.
The pathophysiologic effects of cold injury are important to recognize to enable timely
identification of cold-induced conditions. Cold that produces a lower than normal body
temperature (hypothermia) acts as a central nervous system depressant. Effects worsen because
body temperature continues to drop. Manifestations include impaired judgment, incoordination,
slurred speech, and a decreased level of consciousness. In a wilderness environment, these
pathophysiologic effects lead to maladaptive behaviors and a subsequent a high risk for injury.
 The respiratory system initially responds to the cold through an increased respiratory rate.
However, a progressive drop in body temperature leads to respiratory depression with a
corresponding decrease in carbon dioxide production.1 Cold-induced pulmonary edema can
develop. With severe cold, the thorax can become stiff and noncompliant, furthering respiratory
failure.
The cardiovascular system is initially stimulated via the autonomic nervous system and
responds with tachycardia, peripheral vasoconstriction to conserve heat, and blood pressure
elevation. However, as body temperature drops, cardiac conduction slows and contractility
decreases, producing bradycardia, decreased cardiac output, and hypotension. Because cold
induces cardiac conduction system impairment and irritability, all manner of atrial and
ventricular dysrhythmias can occur. A characteristic electrocardiographic finding is the
appearance of an Osborn or J wave at the junction of the QRS complex and the ST segment
when body temperature falls to 32.2°C (90°F) or below.1 These waves become more pronounced
as body temperature drops further and can mimic the appearance of a myocardial infarction.
Peripheral vasoconstriction is a heat conservation response to shunt peripheral blood from
the cold extremities to the core. Conversely, if an individual is rewarmed, particularly through
heat application to the skin, peripheral vasodilation occurs. When the cold peripheral blood
mixes with the warmer core blood as circulation is stimulated during active rewarming, core
temperature afterdrop ensues. In afterdrop, body temperature will continue to drop for a period
of time even after rewarming interventions because of this counter-current mixing effect of cold
peripheral blood and warm core blood. Keep in mind that cardiac irritability increases with this
drop in temperature.
The renal system is also impacted by peripheral vasoconstriction. Because vasoconstriction
in the extremities pushes more blood volume into the core, there is greater blood flow to the
kidneys. This increased volume load produces a significant diuresis of dilute urine, even in
dehydrated individuals. Consuming alcohol can double the volume of this diuresis.1
Cold also impacts the ability of blood to clot normally. Blood clotting is a temperature-
dependent process; the enzymes responsible for normal coagulation are able to function only
across a very narrow temperature range. A core body temperature less than 36°C (96.8°F)
produces a coagulopathy that is unresponsive to the administration of blood products.2 This
coagulopathy is especially detrimental to individuals with injuries because they will suffer
increased blood loss.
Cold can also affect the body at the tissue level, particularly in skin without adequate
protection from cold and wet environmental conditions. Skin that is exposed to cold can suffer
various forms of damage, including nonfreezing injuries as well as superficial to deep tissue
freezing with ice crystal formation. Adequate blood circulation plays a key role in maintaining
warmth. When the skin is exposed to temperatures below 15°C (59°F), vasoconstriction starts to
occur, which can promote a further drop in skin temperature from the reduction in circulation.3 If
the skin becomes numb, the individual can lose awareness of the cold sensation and fail to
recognize the early stages of tissue freezing. Without timely preventive measures at this stage,
blood circulation will be further reduced, the tissue temperature will continue to drop and,
ultimately, the skin can take on the temperature of the environment.
The pathophysiology of frostbite includes extracellular and intracellular ice crystal
formation, cellular dehydration and shrinkage, derangement of intracellular electrolyte
concentrations, endothelial damage, vasoconstriction, thrombosis, ischemia, and ultimately tissue
necrosis.4
 Inflammatory mediators such as thromboxane, arachidonic acid, and prostaglandins play a
significant role in tissue destruction. Both the degree of tissue damage and the prognosis for
recovery are related to the depth of the cold injury.

EPIDEMIOLOGY
Cold injuries occur when heat production by the body or heat conservation is inadequate to
compensate for heat loss. Freezing temperatures are not necessary for these conditions to
develop. Cold injuries are possible even in moderate temperature climates. Predisposing
environmental factors in a wilderness setting include an ambient temperature below 26.6°C
(80°F), wet conditions, altitude, and wind chill. Wind chill, a function of wind velocity and air
temperature, can exacerbate cold effects as a result of increased air movement across the body
surface.
Physical factors in the at-risk individual include fatigue or exhaustion, inadequate clothing,
wet clothing from perspiration, immersion, or weather conditions, poor conditioning, and
insufficient food or fluid intake. Alcohol consumption and intoxication, illicit drug use, and
certain medications (eg, antidepressants, opioids, and antianxiety agents) also promote cold
injuries. Other significant precipitating factors include trauma, burns, dehydration,
cardiovascular disease, infection, psychiatric illness, and any disease state that slows the
metabolic rate or impairs thermoregulation such as diabetes hypothyroidism, adrenal
insufficiency, and stroke. The use of nicotine products elevates the incidence of cold-induced
tissue injury because of its vasoconstriction effects.

PREVENTION
Cold injuries are best prevented through appropriate physical preparation and trip planning.
WEMS providers are in an ideal position to educate members of medical teams who provide
wilderness rescue services as well as outdoor enthusiasts about the important of personal cold
injury prevention.

Food
In order to function efficiently, the human body requires energy. Adequate food and fluid intake
are essential to meet physiologic demands for heat production, especially in a cold environment.
This is particularly important during EMS operations in a cold weather environment, where low
temperature, wind, rain, snow, and the physical and mental stresses involved in an extended
wilderness operation increase the body’s energy requirements. Although the WEMS provider
must maintain a high level of physical fitness and good nutrition at all times, consideration must
be given to providing supplemental nutrition for personal and patient consumption during field
operations that may go on for hours to days or weeks.
For short-term operations, WEMS providers should carry enough food to sustain them for 24
hours or more. This food should be carried in the provider’s personal pack in the event that the
rescue team is separated. Meal-type food that requires a fire, stove, or preparation is not
recommended because the opportunity to prepare full meals during a rescue operation is seldom
available, unless such meals are prepared at a command center during a truly extended operation
lasting a day or more, such as a wildland fire operation or prolonged search.
Excellent food choices include nonperishable energy bars, dried fruit, nuts, peanut butter,
chocolate, and other snack type foods that can be consumed easily while working or during brief
breaks. Some groups will carry military “Meals Ready to Eat” (MREs) for extended operations.
Food should be calorie/energy-dense, nutritionally sound, with an adequate mix of
carbohydrates, fats, and protein, and should be nonperishable.
Hydration is equally important in a cold weather environment because dehydration can
increase the risk of hypothermia and frostbite, and lead to poor physical and mental performance.
The perception of thirst can decrease when skin temperature falls, leading to lower fluid intake.
Exercise at high altitude and in cold dry air increases respiratory water loss. Increased diuresis
occurs due to peripheral vasoconstriction, pushing fluid to the central core. In addition, some
medications, such as acetazolamide (Diamox) for altitude illness prophylaxis, will increase
diuresis.
An adequate water supply must be carried or procured by the WEMS provider. Typical water
requirements for an adult are about 2.5 L/day but can increase to 4 to 5 L/day or more during
strenuous activity in a cold dry environment. Avoid eating snow as a hydration method. Snow
can cause freezing injuries to the mouth, lower body temperature, and provides very little usable
water. A means of melting snow such as a portable stove is essential in a snowy environment.
Alternatively, where water is available from a stream or other nonfrozen source, a means of
purifying water must be used, such as boiling, filtering, chemical, or UV methods. See Chapter 7
(WEMS Equipment) for further information on water purification equipment.

Clothing
Clothing choices for cold temperatures should allow wicking and evaporation of perspiration as
well as insulation. The old adage “cotton kills” is true in a cold environment: When cotton
clothing gets wet, it holds the moisture, takes a long time to dry, and loses its insulating ability.
Synthetic materials including technical fabrics that are breathable and enable wicking of
moisture should be sought for the base layer of clothing. For those who prefer natural fabrics,
wool is a good choice over cotton. It maintains its insulating ability even when wet.
Layering clothing is an excellent strategy to prevent the loss of body heat to the environment.
Heavier weight wool or synthetic fabric, including inexpensive polyester fleece, can be worn
over the base layer that is next to the skin to retain warmth. Colder temperatures call for more
layers. The outer layer should be a fabric that is both breathable and wind- and waterproof. This
layer prevents the heat that is close to the body from being lost to the environment, blocks the
chilling effects of the wind, and keeps the individual dry. During physical exertion, layers can be
removed to prevent overheating, and then added when the activity level decreases or stops.

Footwear
For those traveling on foot, it is vitally important to keep feet warm and dry to prevent cold
injuries such as trench foot. Select footwear that fits well and is nonconstricting. If vapor barrier
(eg, rubberized or impermeable) boots are used, special attention must be directed at preventing
the accumulation of sweat.5 Inspect the feet frequently and allow them to air dry.
Cotton socks are not good footwear choices for outdoor travel because they retain moisture
to a greater degree than socks made from synthetic material or wool. Avoid wearing multiple
layers of socks, which can actually decrease circulation to the feet and can increase the risk of
cold injury. More than two layers of socks are rarely necessary: a synthetic liner and a synthetic
or wool sock. Many individuals prefer a single sock layer made of synthetic knit or wool fabric.
Change wet socks 2 to 3 times/day as needed. If necessary, employ methods to decrease
perspiration of the feet such as applying antiperspirants.6 Maintain activity to preserve blood
circulation to the feet.

Skin Protection
Regularly applying a hydrating lotion or cream moisturizer to exposed areas of skin is beneficial
to keep skin supple and to prevent skin from becoming dry and forming cracks or fissures, which
can predispose individuals to pain, open wounds, and infection. Moisturizers are especially
recommended for those who are prone to chilblains or pernio as a possible prevention strategy.

Shelter
Shelter from the elements is a primary survival strategy, particularly in a cold environment.
Although the typical goal is rapid evacuation of sick in injured patients in most WEMS
operations, wilderness providers may wind up in a situation that requires them to shelter in place
for some period of time because of severe weather that makes travel even more treacherous.
Survival depends on the ability of WEMS providers to adequately protect themselves and their
patients from wind, rain, snow, and low temperatures. Staying dry and getting out of the wind
increases the insulating ability of clothing and the effectiveness of preserving body heat.
Shelters in a WEMS operation can range from very simple (heavy-walled plastic trash bag),
to commercial (a tarp or mountaineering tent), to an improvised structure (debris shelter, snow
cave). The choice of shelter may be mission-specific and depends on the scope of the operation,
expected time in the field, and the probability of needing to make a safe camp for 1 or more
days. Are rescuers expecting to care for a patient for an extended period of time, or will they
carry only a simple emergency shelter for the unexpected night out?
There are several types of shelters to consider: a heavy-duty 3- to-4-mm plastic trash bag
pulled over a person’s head makes an instant wind and waterproof emergency shelter. Cut a
small opening big enough to fit the face through near the bottom of the bag. A second bag can be
pulled up over the legs for a complete emergency shelter. Make sure that the upper bag overlaps
outside the bottom bag so precipitation will not run inside.
A space blanket is made of a lightweight Mylar material that reflects body heat. Although it
fits into a pocket, it is very prone to tearing and puncturing. A bivouac (bivy) sack is smaller and
lighter than a full tent, and is generally designed for one person. It can be used with a sleeping
bag inside and makes a good emergency shelter. Lightweight and inexpensive, tarpaulins (tarps)
come in a variety of sizes and have grommets to allow tying to trees and other natural features.
Tarps can be rigged in a number of ways such as an A-frame or diamond shape. Depending on
how they are set up, tarps can offer some protection from precipitation and wind. Tarps can also
be a useful addition to other shelters such as snow trenches, tree wells, and debris shelters.
Heavier, but offering more substantial protection than a tarp, mountaineering tents that are
easy to set-up make a superior choice for extended field operations. Many are designed for high
winds and adverse weather conditions. Tents come in a variety of sizes and features for
sheltering an overnight rescue group and patient.
In an emergency when other forms of shelter are limited or not available, natural shelters
such as caves and rock overhangs can provide limited protection from precipitation and wind.
They can be improved upon by using other natural materials (eg, tree branches and rocks) to
increase the windbreak and reflect the heat of a fire. Another option is to build a debris shelter.
These are constructed from natural materials, commonly using a fallen tree as a ridge pole, and
stacking branches against the ridgepole to create an A-frame shape, then covering it with tree
branches, leaves, grasses, and other debris to provide some insulation. Debris shelters can be
time-consuming and labor intensive to construct.
In a snow-covered landscape, snow caves can be excavated into deep snow on the side of a
hill, or into a large pile of snow (ie, a quinzee) as an emergency shelter. They are more durable
structures and are useful if a situation calls for sheltering in place for several days to wait out
severe weather conditions. Snow caves do take a considerable amount of time and energy to
construct; the builders will get wet in the process.
If a snow cave or quinzee is not feasible given the time and energy requirements, one of the
simplest and quickest snow shelters to construct is a snow trench. Excavate a trench in the snow
approximately 3 ft deep, 7 ft long and wide enough for the occupants. Place skis and ski poles
across the top and cover with a tarp. Weight the tarp edges with snow and throw snow onto of
the tarp for extra insulation. Simpler yet is the use of a tree well. Tree wells can be natural
emergency shelters that take advantage of the void space in the snow found beneath trees.
Enhanced with skis and a tarp and some insulating material on the ground, a tree well can
quickly offer considerable wind protection.
An important factor to consider in selection of an appropriate shelter includes the time it
takes to construct. An improvised tarp shelter can be rigged in minutes but may offer minimal
protection, whereas a snow cave or quinzee hut will provide much better protection from the
elements but requires several hours to build.
The number of people using the shelter will determine the size. Avoid the temptation to build
a huge shelter because it will take much more time and energy to construct, and the shelter will
not be warmed by body heat if it is too large. All shelters should include a means of insulating
the individual from the cold ground to reduce conductive heat loss. Foam sleeping pads,
backpacks, pine boughs, and dry leaves and grasses will offer additional insulation between the
body and a cold- or snow-covered surface. The use of portable stoves or fires inside a shelter is
not recommended because of the asphyxiation risk; however, if their use is unavoidable, make
sure to provide adequate ventilation.
Whether they are planned shelters or emergency shelters, locate the shelter to take advantage
of terrain features as natural wind blocks whenever possible. Ridges, stands of trees, and rock
outcrops may provide protection from prevailing wind. Warm air rises—hillsides may be
partially protected from the wind. Avoid the very bottom of a valley because cold air sinks, and
avoid the very top of the hill or ridge because they tend to be windiest. Avoid sheltering beneath
dead or unstable trees, loose rock, cliffs and steep drops, potential avalanche areas or other
hazardous locations, and avoid creek beds, where flash floods are possible. Whenever possible,
establish the shelter in daylight hours so hazards can be better identified.

HYPOTHERMIA

Definition
Hypothermia represents a core body temperature less than the normal range (centered at 37°C or
98.6°F and ranging down to 35°C or 95°F). The etiology can be medically induced or accidental.
The focus of this chapter is on accidental hypothermia that occurs in a wilderness environment
when there is a 2 degree or greater decrease in the normal core body temperature as a result of
exposure to the elements. Cold and wet conditions are the predominant precipitating factors.
Accidental hypothermia can occur during any season of the year, even in temperate climates
when environmental conditions pose risks. The Wilderness Medical Society defines hypothermia
as “an unintentional drop in core temperature to 35°C or below.”7
Accidental hypothermia may be primary or secondary in nature. Primary hypothermia can
arise as the principle clinical problem in a wilderness environment from an imbalance between
heat production and heat loss, or secondary to a medical disorder that predisposes an individual
to the condition, such as burn wounds, trauma, alcohol intoxication, or a systemic disease state.
Another subclassification of accidental hypothermia is immersion hypothermia, which results
when patients are immersed in cold water and subsequently experience a drop in body
temperature, as opposed to nonimmersion hypothermia that is unrelated to cold water exposure.

Identification
The medical literature varies widely in regard to the specific temperature ranges that characterize
the severity levels of hypothermia, with many sources listing subtle differences in the numeric
values. For the purpose of this chapter, hypothermia will be categorized as defined by the
Wilderness Medical Society: mild (35°C to 32°C [95°F to 89.6°F]), moderate (32°C to 28°C
[89.6°F to 82.4°F]), and severe or profound (less than 28°C [82.4°F]).7
Each severity level of hypothermia is typically associated with clinical manifestations that
correspond with the pathophysiologic changes that occur in the body due to cold injury. Not all
patients will exhibit these manifestations in a predictable manner, however. There may be
significant variation from person to person. It is also critical to recognize that there are multiple
disease and injury entities that may mimic the clinical presentation of hypothermia such as head
injury, stroke, alcoholism, hypothyroidism, and hypoglycemia. Any of these conditions can
occur together with hypothermia. For that reason, maintain a high index of suspicion that the
patient may be experiencing multiple disorders and require care beyond that which is indicated
for hypothermia alone.
Prior to the development of true accidental hypothermia at the threshold of 35°C (95°F), an
individual can experience cold stress from the effects of cold temperature on the skin and may
start to shiver. Of note, this person will have a body temperature of 35°C (95°F) to 37°C (98.6°F)
and a normal mental status.7 Early recognition is essential: If heat production remains inadequate
and heat loss continues, accidental hypothermia will ensue.
Mild hypothermia (35°C [95°F] to 32°C [89.6°F]) results in autonomic nervous system
stimulation along with depression of the central nervous system.1 Patients can often be identified
at this stage when their skin is cold and pale and they exhibit the “umbles”: They stumble,
mumble, fumble, and grumble. In a wilderness environment, these individuals are more likely to
lose their footing when walking or climbing, become difficult to understand when speaking
because of trouble forming words, be unable to perform fine motor functions with their hands
(such as closing a zipper), and show evidence of mental status changes. These behaviors include
becoming inappropriately argumentative, apathetic, moody, or flat in affect. The key take-away
point is that these individuals are at high risk of injury due to significantly impaired coordination
as well as the loss of intact judgment. As temperature continues to drop, the individual can
become incapacitated and unable to function.
Shivering is pronounced and uncontrollable in mild hypothermia; it serves as an important
compensatory mechanism that generates heat through muscle activity. Shivering requires calories
to burn for heat production. Inadequate nutrition will negatively impact this essential physiologic
response and will promote worsening of the hypothermic condition.
Vital signs in mild hypothermia reflect increased levels of circulating catecholamines, which
produce tachycardia, elevated blood pressure, and increased respiratory rate. Because cold-
induced peripheral vasoconstriction shunts blood to the core of the body, the kidneys respond by
producing large quantities of dilute urine. Patients subsequently experience a cold-induced
diuresis that will result in frequent urination, worsen any preexisting dehydration, and promote
further cold injury.
Moderate hypothermia (32°C [89.6°F] to 28°C [82.4°F]) is characterized by
cardiopulmonary depression and further central nervous system impairment. Cellular energy
stores are depleted. Patients develop hypotension, bradycardia, and have a slow respiratory rate.
Atrial and ventricular cardiac dysrhythmias are common and can be further exacerbated by rough
handling. Shivering may still occur, but ultimately stops altogether. Speech becomes slurred to
incomprehensible, and the level of consciousness declines to unresponsiveness as the condition
worsens.
It is at this stage of hypothermia that the unusual phenomenon of paradoxical undressing can
occur: Patients may shed their clothing in a profoundly cold environment because they suddenly
feel very hot. Although this action seems completely counter to what a hypothermic patient
should do, this phenomenon is best explained by understanding that the sensation of hot or cold
is related to the perception of temperature at the skin surface.8 Because cellular energy is
required to maintain peripheral vasoconstriction in hypothermia, when the body no longer has
enough energy to maintain peripheral vasoconstriction, widespread peripheral vasodilation
occurs.8 Therefore, the individual with an impaired mental status experiences a rush of warmth as
blood flows into the cold extremities. Because the person is unable to process what is happening
and respond in a logical way to this critical survival situation, he or she removes articles of
clothing and casts them aside in an attempt to cool down. The resulting clothing trail serves as an
ominous preterminal sign for rescue parties who are searching for a missing person in cold
weather. Rescuers have found such missing persons naked in the snow with a predictably poor
outcome for survival.
In severe hypothermia (less than 28°C [82.4°F]), patients deteriorate into complete
unresponsiveness and may appear dead. Cardiac activity, blood pressure, and respiratory
function are depressed to the point of becoming imperceptible or absent. Apnea ensues. The
muscles become rigid and areflexic. Pupils are unresponsive to light. Lethal cardiac
dysrhythmias, including ventricular fibrillation, can occur.

Clinical Management
The clinical management of hypothermia is based upon its severity. The importance of early
recognition and the prevention of further heat loss are foundational principles in treating
hypothermia patients in a wilderness or austere environment. A confounding factor may be the
inability to accurately measure core body temperature in the out-of-hospital setting. In these
cases, severity can be best determined by observing the individual for the associated
manifestations of mild, moderate, and severe hypothermia.
Mild hypothermia is typically responsive to treatment in the field with active rewarming
techniques when compared with moderate to severe hypothermia. Severe hypothermia carries a
high mortality even in a hospital environment that has the necessary advanced resources to
manage it. Rapid evacuation to a hospital that offers critical care and extracorporeal warming
capabilities is key.

First Aid and Basic Life Support

Consider scene safety for rescuers. For cold stress and all levels of hypothermia, move the
patient into a shelter because protection from the elements as soon as possible is necessary to
prevent further heat loss. A heated building or ambulance is the best choice, but may not be
available in a wilderness setting. Instead, shelter is likely to take the form of a lean-to, a tent,
snow cave, debris shelter, or another type of improvised structure as previously described. Aid
the cold-stressed individual as needed in removing damp or wet clothing and dry the skin to
prevent further heat loss. Remove the clothing of persons with mild, moderate, and severe
hypothermia. An oral thermometer can be used to rule-out the presence of hypothermia, but
cannot accurately determine body temperature in a person who is actually hypothermic.7
Immediately wrap the individual in warm blankets or sleeping bags. After assessing the
person and determining that he or she is suffering from hypothermia, manage the individual’s
ABCs as appropriate, provide supportive care, dress open wounds, and splint any fractures.
MILD HYPOTHERMIA
In most cases, individuals with mild hypothermia should respond well to basic passive and active
rewarming interventions and will be able to participate to some degree in self-care. Of primary
importance is assisting the person to change into warm, dry clothing. If his or her own clothes
are wet or otherwise insufficient for the weather conditions, collect extra clothing items from
other members of the party or from the rescue team (however, do not put the rescuers at risk by
taking crucial protection from them). Layer the clothing to offer thermal insulation as well as an
outer wind and waterproof barrier. Make sure to place a wool or fleece cap on the person’s head.
Offer hot, sweetened beverages, and high carbohydrate food to rebuild caloric energy stores to
support activities like shivering and movement.
Initially, the person with mild hypothermia should not stand or walk and remain horizontal
until after rewarming for at least 30 minutes to prevent a drop in blood pressure.7 The individual
may experience core temperature afterdrop with active rewarming because of the counter-current
effects of cold peripheral blood moving into the core as vasodilation occurs. As body
temperature drops further during the initial phase of rewarming, assure gentle handling to guard
against the development of cardiac dysrhythmias. Do not rewarm even a mildly hypothermic
person in a shower or heated bath because circulatory collapse can occur.7
If not already present, build a fire if possible to provide radiant warmth and to heat food and
beverages. Place commercial heat packs or water bottles with heated liquid in the core areas of
the body such as the neck, axilla, chest, and groin as an active rewarming measure. Assure that
the heated items are very well wrapped in clothing such as a pair of socks or mittens to prevent
burns from direct contact with the skin. Consider oxygen administration on an as-needed basis.
For individuals who have mild hypothermia, but are too ill or injured to participate in
hypothermia self-care, consider using a hypothermia wrap to best facilitate passive rewarming
by preventing further heat loss and retaining heat generated by the body. A hypothermia wrap,
sometimes called a “burrito,” is a field technique that employs items typically found in a
backcountry or wilderness/austere environment. Begin with a waterproof ground cloth such as a
heavy-duty plastic sheet or poly tarp, generally 8 × 10 ft in size. On this tarp, place an insulating
layer such as one or more foam sleeping pads, followed by an insulated sleeping bag or several
wool or synthetic (eg, fleece) blankets. Place the patient in the sleeping bag. Enhance the
effectiveness by adding active rewarming interventions: Place large chemical heat packs or hot
water bottles around the patient’s body in areas of maximum blood flow such as the axilla, neck,
abdomen, and groin. (Note that Wilderness Medical Society consensus guidelines discourage the
use of the more common small chemical heat packs for this purpose, citing risk of burns and
inadequate overall heating benefit.)7 Wrap the heat packs in clothing, towels, or other insulating
materials to prevent accidental skin burns. Then, wrap the tarp around the patient, overlapping
the edges to prevent wind and water from penetrating the burrito. Make sure to leave access to
the patient’s face for breathing and for monitoring vital signs. Absorbent materials can be placed
under the patient’s buttocks and over the genitals to capture urine if the person voids while in the
wrap. Secure the wrap with rope or nylon webbing. If it is necessary to carry the patient a
significant distance while in the wrap, the wrap can be placed on a coil of rope laid out on the
ground and laced back and forth to securely hold it together (a “rope litter,” described in Chapter
7 [WEMS Equipment] and Chapter 24 [Technical Rescue Introduction]).
An alternative technique is skin-to-skin rewarming if other heat sources are unavailable. This
method of active heat transfer is best accomplished by one or two rescuers stripping down to a
point that enables large areas of the rescuer’s skin to be in direct contact with the patient’s bare
skin while positioned against one another in a sleeping bag. This should be done in a relatively
controlled environment with assurance of dry materials and minimal risk of creating two patients
by making the rescuer hypothermic via the intervention.
MODERATE
Moderate hypothermia is much more serious and requires active rewarming techniques. This
individual will require total care and is at a much higher risk of continued deterioration,
particularly during the initial period of active rewarming when core temperature afterdrop
occurs. He or she should be maintained in a horizontal position to prevent a further drop in blood
pressure, which would result from an upright posture.7 Apply commercial heat packs or heated
water bottles wrapped in socks or clothing to the patient’s head, neck, axilla, chest, and groin.
Administer warm, humidified oxygen if available. Rapid evacuation to a heated building, tent, or
ambulance is necessary. However, if evacuation will be delayed or prolonged, consider the need
for shelter and active rewarming measures as previously described.
Avoid giving food or fluids by mouth in moderate hypothermia until the person’s level of
consciousness returns to a point that he or she is fully conscious and no longer at high risk for
aspiration. Gentle handling is key to prevent cardiac dysrhythmias that can become lethal. A cold
heart is an irritable heart.
SEVERE
Severely hypothermic patients often appear dead with fixed and dilated pupils and stiff
extremities, but may survive after core rewarming and resuscitative efforts. Remember the often-
repeated adage, “no one is dead until warm and dead,” but with the caveat that if trauma or a
medical condition caused the severe physiologic instability or cardiac arrest, rewarming is not
likely to result in survival even in the best of circumstances. Table 13.1 lists some common
WEMS criteria for obvious death in the context of cold environments.
Severe hypothermia requires the resources of a health care facility that ideally can provide
high-level clinical resources, including critical care and extracorporeal rewarming methods, for
active core rewarming. However, if these resources are not accessible in the austere or
wilderness environment and evacuation will be delayed, place the patient in a prewarmed
sleeping bag and utilize skin-to-skin contact for rewarming with two rescuers as described earlier
for moderate hypothermia, taking care not to create a second patient (cold rescuer) rather than
improving the condition of the patient.8 Administer warm, humidified oxygen if available.
Be prepared to administer cardiopulmonary resuscitation (CPR) at the standard rate for the
severely hypothermic person who loses a palpable carotid pulse for at least 1 minute; giving CPR
to a profoundly bradycardic individual can precipitate ventricular fibrillation.7 If the patient’s
chest wall is rigid, however, chest compressions will not be effective. This finding is indicative
of death as previously described. For severely hypothermic individuals, CPR can be intermittent
or delayed if necessary during the evacuation.7 In addition, if an AED advises a shock, only one
shock should be attempted as long as the person’s temperature is below 30°C (86°F). Note that
there is no lowest temperature limit for performing or withholding CPR; successful resuscitations
have occurred even in individuals who were profoundly hypothermic.7

Advanced Life Support

For moderate to severe hypothermia, attach a cardiac monitor, if available, to monitor heart rate
as well as for the development of cardiac rhythm disturbances. The monitor is extremely useful
in cases where pulses cannot be easily palpated due to vasoconstriction. As body temperature
rises due to active rewarming interventions, heart rate should increase if the cause of the
bradycardia was hypothermia.

Table 13.1 Criteria by Which Hypothermic Patients Can Be Considered Dead Without
Rewarming
• Patient’s chest is too stiff to perform CPR
• Patient’s airway is occluded with ice
• Patient has a traumatic injury incompatible with life, such as decapitation (head removed from neck) or thoracic transection
(chest separated longitudinally into two body parts)
• Patient has been buried in an avalanche with known airway blockage from snow for prolonged period

Because dehydration is common and can hinder the effective management of hypothermia,
initiate intravenous (IV) or intraosseous (IO) access and administer modest amounts of
crystalloid solutions (warmed if possible) as fluid boluses to avoid pulmonary edema for persons
with moderate and severe hypothermia. An initial fluid bolus of 250 to 500 mL of normal saline
with dextrose is recommended over using lactated Ringers solution, because the hypothermic
liver cannot metabolize lactate.1,7,8 Use IV fluid warming devices, including insulating the IV
tubing itself, if available. These devices will likely not help to actively rewarm a patient in the
field, but may prevent a further decrease in body temperature secondary to the infusion of cold
fluids. Heating the fluids to a temperature of 40°C to 42°C (104°F to 107.6°F) is recommended if
possible in the austere environment.7
In severe hypothermia, intubation with an endotracheal tube or use of a supraglottic airway is
indicated if the person is unconscious and there is organized electrical activity on the cardiac
monitor with evidence of a pulse and respiration after assessing for 1 minute. Provide ventilation
at half the normal rate.7 Use an end-tidal CO2 (ETCO2) monitor if available. Confirmed absence
of a waveform on the ETCO2 monitor indicates the absence of circulation and the need for
initiation of CPR.9 Administer heated, humidified oxygen if available. Insert a nasogastric tube to
decompress the stomach after intubation if available. Avoid administering any vasoactive drug
until the body temperature is 30°C (86°F) or greater, and then at only half the standard dosing
intervals until the core temperature is 35°C (95°F) or greater.7 If ventricular fibrillation ensues,
one shock at maximum power should be given. If unsuccessful, rewarm the person to greater
than 30°C (86°F) and attempt defibrillation again.7

Clinician
The clinician may elect to insert an esophageal probe in the intubated person to continuously
measure core body temperature if available. Rectal temperatures are contraindicated in the field
because of the potential for further heat loss during measurement.7 The best choices for advanced
temperature monitoring devices include an epitympanic thermometer with an ear cap for a
nonintubated person and an esophageal probe for an intubated patient; a bladder temperature via
a urinary catheter with a thermistor may lag behind true core temperature of the heart.7
If a portable blood analyzer is available, consider drawing a blood sample to measure the
serum potassium level for the patient of severe hypothermia. If potassium is greater than 12 and
the individual shows no sign of life, resuscitation efforts can be terminated.7 A portable
ultrasound device may also be useful in monitoring for the presence or absence of cardiac
activity if available, and may guide decision regarding when CPR should be initiated in the
person with profound bradycardia.

Disposition
Individuals with mild hypothermia may recover enough that transport to the hospital is
unnecessary if there are no other conditions present that require further medical evaluation or
intervention.
Persons with moderate hypothermia who are hemodynamically stable should be transported
to the closest available hospital, ideally with intensive care capabilities.7 Unstable patients with
moderate to severe hypothermia are best transported, if possible, to a medical facility that has the
resources to provide both critical care and extracorporeal rewarming.7
Also consider the need for transport to a specialty center whenever possible for hypothermic
individuals who have concurrent trauma, cardiac, or neurologic (stroke) disorders. For all
persons with hypothermia, careful, gentle handling is essential to prevent the onset of
dysrhythmias, including ventricular fibrillation from cardiac irritability. Maintain the person in a
horizontal position during the duration of the transport to prevent hemodynamic instability. In
addition, prewarm and maintain the transport vehicle cabin at least to a temperature of 24°C
(75.2°F) if possible.7 The WMS consensus guidelines note that ideal temperature for patient care
is 28°C (82.4°F, the temperature at which healthy humans neither gain nor lose heat), but may be
excessively hot for crew. Around 24°C (75.2°F) is the compromise temperature derived by the
guidelines, which give this recommendation a recommendation grade of 1C (“strong
recommendation, low grade evidence”).7

FROSTBITE

Definition
Frostbite is defined as a freezing injury to the tissues. It occurs at temperatures below 0°C
(32°F). The highest incidence of frostbite involves the extremities, but can affect any part of the
body, particularly those areas that may be directly exposed to the cold such as the ears, nose, and
face. The feet are affected more frequently than the hands. In very cold temperatures, frostbite
can also affect areas that are covered with clothing. In addition to the usual precipitating factors
for cold injuries described earlier in this chapter, below freezing temperatures, wind chill, wet
conditions, poor circulation, bare skin against metal, alcohol intoxication, cigarette or nicotine
use, dehydration, a prior history of frostbite, and lack of adequate shelter pose particularly
notable risks. Tight boots or clothing that impairs blood circulation also increases susceptibility.
The severity of frostbite is related to the depth of the tissue freezing. There may be
superficial to deep involvement, including muscle and bone. At the far end of the severity
spectrum is a condition known as frostnip, which is the mildest form of cold injury and involves
only vasoconstriction and ice crystal formation in the most superficial layers of the skin. Frostnip
is not considered a form of frostbite because actual tissue freezing does not occur, but will be
defined here for completeness because it can progress to tissue freezing if not properly
addressed.

Identification
Frostbite is categorized in first through fourth degrees based on the depth of freezing and tissue
destruction. The challenge in identifying the degree of frostbite severity is that all degrees may
yield a similar appearance while the part is frozen. The degree of frostbite can only be
determined after the tissue has been thawed.

Frostnip
Relevant to the discussion of frostbite severity is the early identification of frostnip. The
individual’s skin may appear blanched or white, but unlike true frostbite, it maintains its softness
and pliability. Frostnip is easily reversed within minutes by seeking shelter and applying local
warmth to the area. Discomfort with warming is common. Although it is a very minor condition,
it is important to note that frost nip may be a precursor to frostbite. Its presence heralds a
significant potential for a more serious cold injury if precautions are not immediately taken to
reduce cold exposure.

First-Degree Frostbite
First-degree frostbite involves only superficial layers of the skin. It is best recognized as a pale
white or yellow plaque on the skin that feels firm to the touch. The part is also numb while
frozen. After thawing, redness or hyperemia occurs, along with pain and edema. First-degree
frostbite is not associated with tissue loss.

Second-Degree Frostbite
Second-degree frostbite affects the deeper skin layers. It appears as a hard pale or white area that
is numb and firm to the touch. After thawing, the skin becomes red or hyperemic with edema as
well as the formation of blisters filled with clear or milky fluid. Tissue loss, if it occurs, is
minimal.

Third-Degree Frostbite
Third-degree frostbite is considered severe and involves complete freezing of the deeper layers
of the skin. Although frozen, the area appears pale or white and feels numb and hard to the
touch. After thawing, the part becomes red, edematous, and forms blisters that are filled with
hemorrhagic fluid (Figure 13.1). Tissue loss can occur.

FIGURE 13.1. Edema from frostbite involving the fingers. From Sherman SC. Atlas of Clinical Emergency Medicine.
Philadelphia, PA: Wolters Kluwer; 2016.

Fourth-Degree Frostbite
In fourth-degree frostbite, deep tissue freezing is present that may include muscle and bone. The
part will have what is classically described as a “chunk of wood” consistency. After thawing,
some parts may be red and swollen with hemorrhagic blisters in areas that may recover, or will
be dark and dusky with no blisters, absent sensation, and no capillary refill in areas that will
ultimately become necrotic or gangrenous (Figure 13.2). Tissue viability may not be able to be
determined for several weeks.
FIGURE 13.2. Fourth-degree frostbite of the toes with lines of demarcation forming 8 days after injury. From McCarthy JJ,
Drennan JC. Drennan’s The Child’s Foot and Ankle. 2nd ed. Philadelphia, PA: Wolters Kluwer Health Lippincott Williams and
Wilkins; 2010.

Clinical Management
First Aid and Basic Life Support
Move the patient into a shelter to prevent further exposure to the elements and subsequent heat
loss. Evaluate for the presence of hypothermia and apply the clinical management principles
described in the previous section of this chapter. The treatment of moderate to severe
hypothermia takes priority over the treatment of frostbite. Frostbite treatment should not be
initiated until an individual’s core body temperature is greater than 35°C (95°F).3 Remove any
wet clothing as well as clothing overlying the affected areas. In anticipation of edema formation,
remove rings, jewelry, and other constricting items. Consider placing the individual in a warm
sleeping bag if available. Provide warm fluids by mouth if consciousness is not impaired.
Alcohol intake and smoking are not advised because both can worsen the outcome in frostbite.
Assess the involved areas for clinical evidence of frostbite and note the appearance. If
possible, take a digital photo of the body parts to establish the baseline for comparison after the
freezing injury thaws and further evolves. If available, administer over-the-counter ibuprofen 400
mg by mouth twice a day.10 The ibuprofen may improve tissue viability in frostbite by decreasing
cellular damage. In addition, ibuprofen provides an analgesic or pain-relieving effect during
frostbite treatment. If the individual is in a high altitude environment or is hypoxemic for any
reason, also administer supplemental oxygen by nasal cannula or facemask if it is available.10
The standard frostbite treatment associated with the best chance of tissue recovery is rapid
rewarming in a gently swirling water bath (described in detail later). However, whether or not to
initiate rapid rewarming is a judgment call in an austere environment when rescue or evacuation
will be prolonged. If it will be necessary for the patient to hike out or risk further freezing injury
during the rescue operation, then do not attempt to rapidly rewarm a frostbitten body part.
Refreezing will worsen the overall tissue damage. In any case, it is not necessary to attempt to
keep the injured parts frozen. The injured part(s) should be well padded and splinted for
protection if the patient must ambulate or use his or her extremities as the only available option
during the rescue.
If there is no capability to provide a water bath in the wilderness environment, then the body
parts should be allowed to thaw slowly and spontaneously once in a sheltered area because the
longer tissue stays frozen, the worse the outcome.10 The injured parts may be placed against the
individual’s or a rescuer’s warm skin (particularly under the armpits or on the abdomen). Do not
rub with snow or massage the affected parts, or use fire or other types of external heat sources to
achieve thawing, because these actions will further injure the frostbitten tissue.
For individuals with frostbite who ultimately will be carried out (if the feet are involved) or
have a low risk of refreezing during the rescue, rapidly rewarm the affected areas by preparing a
warm water bath by using a stove or a camp fire. The optimal water temperature for rapid
rewarming is 37°C (98.6°F) to 39°C (102.2°F).10,11 Use a thermometer if available to accurately
measure the water temperature. If no thermometer is available in an austere environment, the
common wisdom is to heat the water to the temperature of a hot tub. Water that feels
uncomfortably hot to nonfrostbitten skin or to the rescuer’s own hand is too hot and will increase
the severity of injury. At the same time, although cooler water may produce less pain with
thawing, prolonging the thawing process by using cooler temperatures may decrease tissue
viability and lead to a poorer outcome. Once the optimal temperature has been reached, remove
the water bath from the heat source.
Immerse the individual’s affected body part in the water bath and gently swirl the water.
Note that rewarming a frostbitten part is extremely painful. If not already given and available,
administer ibuprofen by mouth as a pain reliever. Use the water bath for approximately 30
minutes or longer, adding additional warm water carefully to maintain the desired temperature
range of 37°C (98.6°F) to 39°C (102.2°F). For cases of frostbite to the nose and ears, apply
warm, moist compresses frequently in order to maintain a consistent temperature.12
When the part is adequately thawed, the skin will become fully red or purple in color as well
as soft and pliable.10 Allow the part to air dry; rubbing the skin to dry it will produce tissue
damage. If the body part has pain and intact sensation after thawing, there is a much better
chance of tissue recovery. If available, apply aloe vera cream or gel to the affected areas to
promote wound healing.10,12 Dress the frostbitten areas loosely with clean, dry sterile bandages
and apply padding between the affected fingers and toes. Elevate the frostbitten areas to decrease
swelling.

Advanced Life Support

In addition to the treatment described earlier, assure that ibuprofen is administered to decrease
the production of inflammatory mediators, including thromboxane. An ibuprofen regimen of 12
to 24 mg/kg/day in divided doses is recommended.10 The higher dose range is also beneficial for
pain management. To manage severe pain during the rewarming of frostbite, administer opioid
pain relievers when available. Monitor for evidence of respiratory depression whenever an
opioid is used.

Clinician
Consider administering systemic antibiotics for Grades III and IV frostbite.11 Because frostbite
produces a tetanus-prone wound, administer tetanus prophylaxis if available. Debridement of
blisters secondary to frostbite is not recommended in the field setting. However, if the blister is
at risk of rupturing, fluid may be drained from clear blisters, but hemorrhagic blisters should be
well padded and left intact.10
There are several advanced interventions currently under investigation for their utility and
efficacy in the field management of frostbite. These include nerve blocks, anticoagulants, and
even the use of recombinant tissue plasminogen activator and iloprost in austere settings, but the
evidence is insufficient to recommend them as part of the frostbite treatment regimen at this
time.11

Disposition
Individuals with frostbite of all severity levels except frost nip require evacuation. Individuals
who have undergone frostbite treatment with subsequent thawing should not be allowed to bear
weight upon or use the injured body parts during their field treatment and evacuation, including
walking or using the hands for climbing, unless there is no other option during the rescue. In
these cases, a carryout is indicated. Care in a hospital setting for wound evaluation and
management is necessary.

CHILBLAIN

Definition
Chilblain, also known as pernio, is a localized abnormal tissue response following exposure to
cold, damp environments, including immersion in cold water. The underlying pathophysiology
appears to involve cold-induced vasoconstriction, inflammation, and tissue hypoxemia. The cold
exposure itself does not have to be prolonged; chilblains may occur in as little as 30 minutes in a
cold environment.13 Chilblains fully develop 12 to 24 hours after exposure to predisposing
conditions. It affects school-age children and females to a greater degree than males, as well as
people with poor circulation. The incidence is seasonal in nature, usually corresponding to
environmental temperatures between 0°C (32°F) and 15°C (59°F).8,13

Identification
Chilblain manifests as bluish red lesions that may appear on the ears, nose, hands, thighs, lower
legs, and feet after exposure to cold. Single or multiple lesions can develop, accompanied by
intense itching, burning, paresthesias, and sometimes pain (Figure 13.3).13 The lesions usually
present as discolored patches on the skin, but can form nodules, ulcers, or blisters. These lesions
generally resolve over a period of days to weeks. Areas of hyperpigmentation may persist after
the lesions have resolved. Even short exposure to cold can trigger a recurrence. The affected
areas may become painful even with light touch. The condition can become chronic in some
individuals and produce permanent skin changes.

FIGURE 13.3. Chilblains or pernio occurs due to exposure to cold. The tissue does not freeze, but appears reddened with itching
and burning. From Anderson MK. Foundations of Athletic Training: Prevention, Assessment, and Management. 6th ed.
Philadelphia, PA: Wolters Kluwer; 2017.

Clinical Management
First Aid and Basic Life Support
The initial management of chilblains entails warming and drying the affected areas as well as
providing gentle massage. Active warming that involves the use of heat over 30°C (86°F) should
be avoided because it can increase pain.3 Elevate the affected parts to minimize edema and
protect them from further cold exposure. Apply dry, sterile dressings to the nodules and open
lesions to both protect the areas from injury and to prevent infection.
FIGURE 13.4. Trench foot from exposure to cold, wet conditions involving the toes and the entire soles of the feet. From
Sherman SC. Atlas of Clinical Emergency Medicine. Philadelphia, PA: Wolters Kluwer; 2016.

Advanced Life Support

In addition to the interventions listed earlier, consider administering ibuprofen 400 to 600 mg by
mouth for pain 2 to 3 times/day. Ibuprofen may also be preventative for this condition.3 To treat
the severe itching associated with this condition, diphenhydramine may be helpful.8

Clinician
Nifedipine 20 mg by mouth administered 3 times/day may promote more timely resolution of the
skin lesions as well as minimize symptoms. If evidence of a wound infection develops,
antibiotics can be considered.

Disposition
Chilblains or pernio does not require field evacuation. If individuals are extremely uncomfortable
or if their mobility is impaired, they may wish to terminate their outdoor activities and return to a
warm, temperature-controlled environment. Advise follow-up with a health care provider for
further evaluation and management as necessary.

TRENCH FOOT
Definition
Trench foot, otherwise known as immersion foot, is a nonfreezing cold injury that occurs when
feet are continuously exposed to wet conditions for an extended period of time, which can range
from hours to several days.3 This cold injury produces vasoconstriction, which can lead to deep
tissue damage and nerve injury. The temperature ranges that produce this condition are 0°C
(32°F) to 15°C (59°F).3 Precipitating factors include wet socks from perspiration, particularly
when footwear is not breathable, and boots or socks that have not dried after immersion in water.
This ailment has been well-described in foot soldiers during wartime, but can occur in anyone in
a wilderness setting who spends a prolonged time in conditions that lead to cold, wet feet.
Individuals with African ethnicity may be at higher risk.5

Identification
It is important to note that there is no tissue freezing in trench foot. Initially, the skin may appear
pale or yellowish white and then becomes bluish and mottled.3 The most important diagnostic
feature is the presence of sensory deficits in the affected area, including the loss of
proprioception or position sense, with a progression to complete anesthesia.14 As this nonfreezing
cold injury worsens, the individual will experience numbness, tingling, and pain, including
cramping, and motor deficits due to deep tissue injury and nerve damage. Gait abnormalities
occur at this stage. After warming, the skin appears red (hyperemic), hot and edematous with
delayed capillary refill.
Over the course of hours to days, the individual will have skin discoloration or mottling,
blistering, ulcerations, tissue loss, painful paresthesias, muscle cramping, and edema (Figure
13.4). Gangrene is possible in severe cases. Neurologic deficits in the affected areas can persist
for a prolonged period of time.3,14

Clinical Management
First Aid and Basic Life Support
Remove wet boots and socks and carefully inspect the patient’s feet for evidence of injury and
infection. It is very important to accurately differentiate trench foot from frostbite. The
combination of wet socks and an environmental temperature range of 0°C to 15°C (32°F to
59°F), along with injury pattern of trench foot, are consistent with the trench foot diagnosis.
Cleanse the feet and allow them to fully air dry. Maintain overall body warmth to facilitate
core rewarming, but allow the feet to remain cool (not cold) to decrease pain and inflammation.3
Both rubbing the skin and rapid rewarming are contraindicated in trench foot because they can
lead to increased tissue injury and pain. Apply dressings over open wounds and change the
dressings on a daily basis.

Advanced Life Support

In addition to the first aid and basic life support interventions listed earlier, administer analgesic
agents as necessary for pain management. Apply topical antiseptic and antimicrobial agents to
open wounds to prevent infection.

Clinician
If there is evidence of infection, administer antibiotics as indicated. Advise the patient to seek
follow-up care with his or her health care provider. Ultimately, surgical intervention for wound
management may be indicated. In severe or complex cases, long-term disability due to nerve and
tissue damage is possible.

Disposition
Although trench foot is not a life- or limb-threatening cold injury and does not require immediate
field evacuation, an individual with pain, sensory abnormalities, open wounds, or gait
disturbances may be unable to continue participation in a planned wilderness activity. In those
cases, the injured individual should be assisted out of the cold environment and referred to his or
her health care provider for follow-up. Cases involving evidence of infection or severe
impairment may warrant transport from the field to a health care facility for management.
Individuals with early or mild forms of trench foot may be able to continue the planned activity
if the condition is addressed rapidly and effectively as previously described.

EQUIPMENT SUMMARY
WEMS providers will not always have all the equipment that is readily available and accessible
in an urban EMS environment. During a wilderness operation, especially in the early stages,
patient care equipment may be limited to what is contained in a personal backpack, a designated
medical kit, or carried by members of the team. See Chapter 7 (WEMS Equipment) and Chapter
12 (Personal Safety/Survival) for discussions of general equipment likely to be needed on a
WEMS operation.
Other items to consider in cold weather include location- or environment-specific equipment
such as an avalanche beacon, an ice axe, a shovel, probe poles, climbing rope and harness,
crampons, a climbing helmet, snowshoes, and mountaineering skis as appropriate to the
situation.
For WEMS responses involving patients with cold injuries, equipment to have available
include gear to make a hypothermia wrap. This gear may consist of combinations of the
following types of items: a large 8 × 10 ft poly tarp or plastic sheet, one or more foam sleeping
pads, one or more cold weather sleeping bags or several wool or synthetic blankets, commercial
hypothermia bags, reflective space blankets, plastic trash bags (for use as vapor barriers),
chemical heat packs, water bottles, dry clothes and a wool or synthetic cap for the patient, a rope
to tie the hypothermia wrap together, and nylon webbing. In some cases, commercial survival
bivy sacks or emergency hypothermia blankets made of heat reflective material may be available
and can be included in the treatment wrap.
In a backcountry operation, a stove and fuel will allow the warming of water to fill hot water
bottles. A stove will also allow the preparation of warm, sweet liquids if the patient is capable of
taking liquids by mouth. Keep in mind that hot drinks are a real boost for members of the rescue
team in the field as well.
If immediate evacuation from the cold environment is not possible and other shelter is not
available, then be prepared to provide appropriate shelter for the patient and rescuers using tents,
tarps, snow caves, and improvised options such as debris shelters as appropriate to the situation.
Consider carrying nonperishable energy bars, dried fruit, nuts, peanut butter, chocolate, and
other snack type foods that can be consumed easily while working or during brief breaks, or
MREs.
Depending on the capabilities of the team, consider the following cold-injury-specific items
in addition to standard basic and advanced life support medical equipment and supplies:
ibuprofen, an opioid pain reliever (IV, intramuscular, and/or oral forms), a metal pot for
rewarming a frostbitten extremity, and an esophageal probe or epitympanic or oral (not rectal)
hypothermia thermometer.

SUMMARY
Cold injuries are best prevented through knowledge of risk factors and adequate preparation for
the wilderness environment. WEMS providers must protect themselves from the consequences of
environmental exposure and recognize the spectrum of cold injury manifestations in the persons
they are treating. On this injury spectrum are the nonlife-threatening, but mobility-limiting
conditions of chilblains, trench foot, to the limb-threatening freezing degrees of frostbite,
through life-threatening levels of hypothermia. Scene safety, rescuer capabilities, the dynamic
nature of the environment, and the terrain itself dictate whether or not prompt evacuation is
feasible or if a shelter is required prior to evacuation. These factors also drive treatment decisions
in the wilderness setting. In all cases, rescuer safety is of paramount importance and provides the
best opportunity for successful outcomes.

References
1. Danzl DF. Accidental hypothermia. In: Auerbach PS, ed. Wilderness Medicine. 6th ed. Philadelphia, PA: Mosby Elsevier;
2012:116-142.
2. Hill JG, Hardekopf SJ, Chen JW, et al. Successful resuscitation after multiple injuries in the wilderness. J Emerg Med.
2013;44(2):440-443.
3. Auerbach PS. Medicine for the Outdoors. 6th ed. Philadelphia, PA: Elsevier; 2016.
4. Freer L, Handford C, Imray CHE. Frostbite. In: Auerbach PS, ed. Auerbach’s Wilderness Medicine. 7th ed. Philadelphia,
PA: Mosby Elsevier; 2017:197-221.
5. Johnson C, Anderson SR, Dallimore J, et al., eds. Oxford Handbook of Expedition and Wilderness Medicine. 2nd ed. New
York, NY: Oxford University Press; 2015.
6. Kamler K. Environmental Injuries. In: Bledsoe GH, Manyak MJ, Townes DA, eds. Expedition & Wilderness Medicine.
New York, NY: Cambridge University Press; 2009:479-491.
7. Zafren K, Giesbrecht GG, Danzl DF, et al. Wilderness Medical Society Practice guidelines for the out-of-hospital
evaluation and treatment of accidental hypothermia: 2014 update. Wilderness Environ Med. 2014;25:S66-S85.
8. Della-Giustina D, Ingebretsen R, eds. Advanced Wilderness Life Support. 8th ed. Salt Lake City, UT: AdventureMed; 2013.
9. Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010. Cardiac arrest in
special circumstances: electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma,
anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation. 2010;81:1400-1433.
10. McIntosh SE, Opacic M, Freer L, et al. Wilderness Medical Society Practice guidelines for the prevention and treatment of
frostbite: 2014 update. Wilderness Environ Med. 2014;25(4):S43-S54.
11. Cauchy E, Davis CB, Pasquier M, et al. A new proposal for management of severe frostbite in the austere environment.
Wilderness Environ Med. 2016;27:92-99.
12. Backer HD, Bowman WD, Paton BC, et al. Wilderness First Aid: Emergency Care in Remote Locations. 4th ed.
Burlington, NJ: Jones & Bartlett Learning; 2015.
13. Imray CHE, Handford C, Thomas OD, Castellani JW. Nonfreezing cold-induced injuries. In: Auerbach PS, ed. Auerbach’s
Wilderness Medicine. 7th ed. Philadelphia, PA: Mosby Elsevier; 2017:222-233.
14. Imray CHE, Castellani JW. Nonfreezing cold-induced injuries. In: Auerbach PS, ed. Wilderness Medicine. 6th ed.
Philadelphia, PA: Mosby Elsevier; 2012:171-180.
INTRODUCTION
The wilderness emergency medical services (WEMS) provider will assess and treat overt heat
illness, as well as underlying illness that is affected by the stress of heat, for patients in many
environments. Such environments include those recreating outdoors,1 during large events such as
endurance races,2 and in people working outdoors3 or serving as emergency responders for fire,4
search, rescue and EMS. In the context of a natural disaster—an event that changes the familiar
urban environment into a wilderness—the WEMS provider may manage heat stress in people
unable to seek shelter from heat, who have inadequate access to water, or who may be confined
to residences and institutions without the electricity to power air-conditioning.5
The WEMS provider also has an important role in prevention of heat illness through
education of participants, teammates and the public, and through practice of the field techniques
that promote temperature homeostasis and hydration and enable response in adverse
environmental conditions.
Heat-related illness is a spectrum from mild to severe; from the discomforts of exercise-
associated muscle cramps, heat syncope, and heat exhaustion to the life threat of heat stroke.
This chapter will review the pathophysiology and presentation of these illnesses, including the
associated issues of fluid balance, dehydration and exercise-associated hyponatremia, and the
range of medical care from field first aid through advanced wilderness practices and hospital-
based care.

Definitions
Cramps, syncope, exhaustion, and hyperthermia have multiple causes. This chapter specifically
addresses these problems, as well as hydration, dehydration, and hyponatremia, in the context of
exposure to environmental heat stress.
Exercise-associated muscle cramps are muscle spasms, which can be intense and debilitating
and occur typically in the legs, arms, and abdomen. Heat cramps is the traditional and popular
term. The term exercise-associated muscle cramps reflects the understanding that these cramps
are not directly related to an elevated body temperature.
Heat syncope is dizziness, weakness, and fainting during heat exposure and after prolonged
standing or rapidly standing from a lying or sitting position.
Heat exhaustion is a generic term referring to an inability to cope with heat stress. It is
characterized by minor changes in mental status, nausea, headache, fatigue and lassitude, rapid
heart rate, and diaphoresis.
Heat Stroke is a life-threatening illness characterized by confusion, disorientation, impaired
judgment—central nervous system dysfunction—usually accompanied by a temperature of more
than 40°C (104°F).* Classic heat stroke occurs with passive exposure to heat stress. Exertional
heat stroke occurs during strenuous exercise and is the presentation most often associated with
wilderness activities.6
Dehydration occurs when water loss exceeds water intake and there is an overall fluid
deficit. It makes us more susceptible to the effects of heat, cold, and altitude, worsens fatigue,
decreases the ability to exercise efficiently, and reduces mental alertness. In extreme cases,
dehydration can be a life-threatening medical problem.
Exercise-associated hyponatremia is a physiologic state where blood sodium concentration
is lower than normal. In the context of this chapter it is most often due to overhydration during
exertion in the heat using fluids without supplemental electrolytes, like water. Signs and
symptoms include confusion, disorientation, loss of faculties, headache, nausea, vomiting,
aphasia, loss of coordination, and muscle weakness. Severe hyponatremia can lead to brain
swelling and death.

Scope of Discussion
Physiology of Humans in the Heat
Humans, as homeotherms, strive to maintain body temperature within acceptable limits—35° to
37°C (95° to 98.6°F) and do so in the face of wide variations in temperature, humidity, solar
radiation, and other environmental parameters and with a variety of physiologic and behavioral
adaptations.
There are two main avenues of heat production in the human body—basal metabolism and
exercise. Basal metabolism produces an average of 65 to 85 kcal of heat per hour. This output
increases 13% per degree Celsius rise in body temperature.7 Muscular activity produces heat at a
range of 300 to 1,000 kcal/h and can dramatically raise body temperature at a rate that well-
conditioned athletes can sustain for hours. Even at rest, humans can produce enough heat that the
excess must be dissipated. The addition of exercise, warm temperatures, humidity, solar
radiation, and other environmental, physiologic (eg, underlying health, medications) and human-
created (eg, excess clothing) parameters can greatly increase this challenge.
There are four main avenues of heat exchange with the environment: conduction, convection,
radiation, and evaporation. These are discussed here in the context of heat illness.
Conductive heat transfer occurs when there is direct contact between two bodies of differing
temperatures. Energy in the form of heat moves from the warmer to the cooler object. Human
tissues are generally poor conductors of heat, especially areas with subcutaneous fat. In general,
behavior limits the effect of conduction as a heat exchange mechanism; we insulate ourselves
from both cold and warm surfaces.
Convective heat transfer occurs when two surfaces, in direct contact, are moving relative to
each other; moving air and water are the obvious examples. Convection transfers heat within the
body between blood and tissues and between blood vessels via counter current heat exchanges.
This effect varies based on the temperature gradient, the thermal conductivity of the medium (air
or water), surface exposure and protective clothing. In a cold environment wind chill occurs
when a cool wind moves over warm skin. Moving cold water combines the increased
conductivity of water with the convective mechanism to increase heat loss. In a warm
environment a hot wind can theoretically add heat to the body, but its effect would be low due to
the small thermal gradient. Hot wind is mostly an agent of overall heat stress.
Radiation heat transfer occurs from the emission of electromagnetic energy. The gradient of
energy transfer is from a warmer to a colder object. In a cold environment humans are often the
warmer objects in the environment (normal body temperature of 37°C [98.6°F]) and lose heat by
emitting radiation from exposed skin. In a warm environment an increase in skin temperature
facilitates heat loss from radiation as long as the surrounding environment is cooler than the skin.
We receive radiation heat input from fires, from the sun or from warm objects in our
surroundings such as concrete or rock walls. Bare skin is receptive to radiation heat input;
clothing diminishes this response.
Evaporation is our most important means of heat dissipation. When perspiration evaporates
from the skin’s surface the change in state from liquid to gas consumes energy from the surface
of the skin—approximately 580 kcal/L of evaporated sweat. Evaporative heat loss accounts for
20% of the body’s total heat loss in normal conditions—much more when we are under heat
stress or working hard. We use evaporation to our advantage to cool ourselves in hot
environments.
For conceptual understanding the regulation of body temperature is often sketched as a
negative feedback system consisting of central and peripheral sensors that signal to the anterior
hypothalamus in the brain and a set of return signals that induce physiologic and behavioral
responses for body temperature regulation. In homeostasis, body temperature fluctuates around a
thermal set point, a homeostatic thermostat. Environmental heat exposure and exercise may raise
the skin and core temperature above the set point, evoking autonomic responses (peripheral
vasodilation, increased cardiac output, increased respirations, increased sweating) and behavioral
responses (adjusting clothing, seeking shelter, fanning) to lower the temperature. Environmental
cold exposure may lower the temperature below the set point, evoking autonomic (peripheral
vasoconstriction, increased metabolic rate, cardiac output) and behavioral responses (adjusting
clothing, seeking shelter, consuming food and warm fluids, exercise) to elevate the temperature
back to the set point. Fever is a protective response, an increase in the set point to assist immune
responses to infection, inflammation, or trauma. Protective hypothermia is used by some species
to decrease metabolic demands.

Hydration
For the WEMS provider, hydration impacts personal and team homeostasis and the ability of the
responder to perform. It requires constant attention while in the field. Wilderness providers care
for patients whose primary medical condition may be dehydration and for patients where
dehydration underlies and complicates other injuries and illnesses.
Humans are bags of water: 50% to 70% of the body mass of an average young adult male is
water. We hear through a medium of water. The brain is cushioned by fluid, and the joints are
lubricated by fluid. Blood is 90% water, and every biochemical reaction takes place in a medium
of water. The inability to maintain fluid balance through a lack of fluid availability or exposure
to extreme environments affects health, the ability to think clearly, and to perform physical work.
WATER LOSS
There is an inevitable daily turnover of water from respiratory, gastrointestinal, renal, and sweat
losses and there is gain from consumption of liquid, food, and water released as a metabolic
byproduct. When combined with unlimited access to food and beverages net body water balance
is regulated remarkably well day-to-day as a result of thirst. In ideal environmental and
physiologic conditions water gain and loss are balanced and keep total body water within 0.2%
to 0.5% of baseline.8
The kidneys are a key player in the systems that regulate fluid balance. Urine output is
normally 1 to 2 L/day and will fluctuate over a wide range in response to fluid consumption,
activity, and total body water. Minimum outputs of approximately 20 mL/hour and maximal
volumes of approximately 1,000 mL/hour are possible.8
SWEAT AND SWEAT PRODUCTION
As body temperature rises, increased skin blood flow and sweat secretion drive the evaporative
heat loss process. When the air temperature is greater than or equal to skin temperature,
evaporative heat loss accounts for most body cooling.
Air movement and the water vapor pressure gradient between the skin and environment
affect the rate of sweat evaporation; for example, in still or humid air, sweat does not evaporate
readily. Thick or impermeable clothing or protective garments create high vapor pressure next to
the skin and also reduce sweating. When sweat drips from the skin without the change of phase
from liquid to gas it only dehydrates, it does not cool. The loss of water and electrolytes from the
skin contributes to dehydration and makes less fluid available for evaporation.9
Sweat is typically one-half of plasma osmolality and is hypotonic relative to plasma. The
electrolyte loss in sweat depends on the duration of sweating and the concentration of
electrolytes in the sweat. Sodium is the major electrolyte in sweat and varies in concentration
depending on genetic predisposition, diet, sweating rate, and heat acclimatization state. One of
the benefits of acclimatization to heat is a higher and more sustained sweating rate. Heat
acclimatization also improves the ability to reabsorb sodium and chloride. Heat-acclimatized
individuals usually have lower sweat sodium concentrations, up to a reduction of 50% or more,
for any given sweating rate.6
Imbalances of fluid loss and gain may occur due to illness, environmental exposure, exercise,
or physical work. Illnesses, such as diarrhea and hyperglycemia, can lead to loss of large
amounts of fluid and electrolytes. Physical activity in a hot environment can result in water
balance deficits even with unlimited access to food and fluids.10
Fluid requirements vary based on an individual’s body size, activity level, and the
environment. The range for sedentary adults is from 1.2 to 2.5 L/day. For adults performing
modest physical activity in a mild environment this range expands to 3.2 L and in a hot, dry
environment will reach 6.0 L or more.11 In wildland firefighting, water loss of 0.5 L/hour is
common and 2 L/hour can be expected in extreme conditions.12 Females tend to have slightly
lower fluid requirements than males, presumably due to lower average total body water.
To calculate water needs, an individual must predict sweat loss in a given environment and
activity. There are tables available that predict fluid requirements by environmental conditions
and activity (Table 14.1). These may be helpful to those supervising and providing logistic
support to wilderness rescue teams. Practically, water needs are often based on the individual’s
experience and self-awareness of fluid needs.
Pathophysiology of Humans in the Heat—Heat Illness, Dehydration, and
Exercise-Associated Hyponatremia
Exercise-Associated Muscle Cramps
The term exercise-associated muscle cramps reflects the understanding that these cramps are not
directly related to an elevated body temperature. They can happen in any exercise, in warm and
cold temperature, during warm-up, during the exercise, or after exercise. The cause of exercise-
associated muscle cramps remains a topic of debate. Discussions focus on exercise-associated
muscle cramps as a result of local fluid and electrolyte deficits, (eg, increased intracellular
calcium stimulating muscle contraction), or as a result of central neuromuscular fatigue, or any
combination of these factors.13 Exercise-associated muscle cramps are associated with other
forms of heat illness, but they do not predispose a person to other forms of heat illness.

Table 14.1 Work, Rest and Fluid Needs in Warm-Weather

Moderate Work Hard Work
Flag Color Work/Rest (min) Water qt/h Work/Rest (min) Water qt/h
Green 50/10 0.75 30/30 1
Yellow 40/20 0.75 30/30 1
Red 30/30 0.75 20/40 1
Black 20/40 1 10/50 1

From Montain SJ, Latzka WA, Sawka MN: Fluid replacement recommendations for training in hot weather. Mil Med. 164:502-
508, 1999.

Lack of fitness, lack of acclimatization to exercise in the heat, and profuse sweating
associated with sodium loss are characteristics of people who suffer from exercise-associated
muscle cramps.14

Heat Syncope
Syncope is a sudden, transient loss of consciousness and postural tone. Heat syncope is
commonly a limited period of altered mental status or loss of consciousness in the context of heat
exposure. It is similar to vasovagal syncope and results from orthostatic blood pooling,
peripheral vasodilation, and the absence of a robust vascular response to positional change.
There is no evidence of severe, life-threatening causes in heat syncope and either no loss of
consciousness or rapid return of normal mental status once the patient is in a supine position and
removed from heat stress. Dehydration, a lack of heat acclimatization, prolonged standing, and
underlying cardiovascular health are presumed contributing factors. It usually resolves promptly
with rest, removal from heat stress, and hydration.15
Heat-associated postural hypotension, a term that can be used interchangeably with heat
syncope, often refers to syncope from inadequate hydration and alterations in lower extremity
vascular tone when exercise stops. For example, when a runner stops and the leg muscles are no
longer contracting in the constant rhythmic manner of running, blood may pool in the legs. The
stress of dehydration and the sudden cessation of movement may cause a sudden drop in blood
pressure that triggers fainting.

Heat Exhaustion
Heat exhaustion, also known as heat prostration or heat collapse, is just what the term says,
fatigue from the stress of coping with a hot environment. The work of heat dissipation along with
the stress from coping with sunlight and heat exhaust the patient. Heat exhaustion is not low
fluid volume from dehydration, although dehydration can occur alongside heat exhaustion.
Heat exhaustion is considered to be on the mild to moderate spectrum of heat illness,
although for some patients it is debilitating. It may remain an entity by itself or progress to
exertional heat stroke. It may occur with or without dehydration and elevated core temperature.16
It is usually seen in the context of exercise in the heat but can occur without exercise in
people with underlying medical conditions and associated heat stress (cardiovascular
insufficiency limiting robust response to the heat stress, medications that predispose to
dehydration or drive metabolic rate, cumulative stress over multiple days).

Exertional Heat Stroke

In the spectrum of heat illness, heat stroke is the life-threatening emergency. Patients have
exaggerated heat production and an inability to cool themselves due to extreme heat challenge
and underlying health issues (classic heat stroke) or heat challenge and exertion (exertional heat
stroke). Core temperature is usually above 40°C (104°F).
Current understanding of the pathophysiology of heat stroke, which is still incomplete, is that
the need to dissipate heat from exertion or chronic heat stress results in an increase in blood flow
to the skin and a decrease in blood flow to the gut. This triggers gut ischemia, increased
epithelial membrane permeability, and leakage of endotoxin into the systemic circulation causing
a systemic inflammatory response. Multi-organ system failure is the ultimate cause of heat stroke
death.17
Classic heat stroke occurs in an at-risk population of the very young, the elderly, and the
chronically ill, often accompanied by social and economic factors such as inability to access air-
conditioning or cool surroundings during periods of heat stress.
High temperature and humidity that impair heat dissipation, often for several days, can
precede classic heat stroke. Infants are vulnerable due to their high surface area to body mass
ratio, which can increase heat gain and dehydration, poorly developed thermoregulation
mechanisms, and inadequate behavioral responses. The elderly can have comorbidities such as
mental illness, use of prescription medications that influence thermoregulation (diuretics,
anticholinergics, antipsychotics, tranquilizers), diabetes, and cardiovascular disease.
Exertional heat stroke is typically seen in athletes unacclimatized to exercise in the heat.
During exercise, excess heat must be dissipated from the body to avoid hyperthermia. The
burden of the heat load can be slow to develop and accompanied by nausea, dizziness, feeling of
heat oppression, and perceived high exertion. These may be overlooked as normal side effects of
exertion or ignored from motivation to train, compete, work, or rescue. The presentation may
also be acute with sudden collapse and altered mental status.

Dehydration
People vary in their tolerance for dehydration. A body mass water deficit of greater than 2% is
often cited as a threshold for symptomatic dehydration, although trained athletes can tolerate
greater deficits during competition. Dehydration causes increased body core temperature,
increased cardiovascular strain, increased glycogen utilization, and altered central nervous
system function. The impact of dehydration on prolonged work efforts is magnified by hot
environments, and probably worsens as the level of dehydration increases.
 The 2% dehydration threshold has been reported to affect cognitive performance. Outdoor
people are aware of the irritability and dullness of intellect from dehydration. Studies of
performance when dehydrated have documented reduced visual motor tracking, impaired short-
term memory, reduced attention span, reduced ability to do arithmetic calculations, and higher
levels of perceived effort and concentration. This has clear implications for the quality of
decisions and the effect on risk management in wilderness activities.18

Exercise-Associated Hyponatremia
Exercise-associated hyponatremia has been observed during marathon and ultramarathon
competition, military training, and recreational activities. Hyponatremia describes a state of
lower than normal blood sodium concentration, typically lower than 135 mEq/L. Exercise-
associated hyponatremia tends to be more common in long-duration activities and most often
occurs when individuals consume low-sodium drinks or sodium-free water in excess of sweat
losses (typified by body mass gains), either during or shortly after completing exercise.
The primary cause of hyponatremia in the context of exercise in the heat is drinking fluids
without electrolyte supplements in excess of fluid loss. In an effort to reduce heat stroke
emergencies, Grand Canyon National Park emphasized “drink water, drink water, drink water” to
its visitors. Pure water does not have electrolyte supplementation, and consequently, the
incidence of hyponatremia increased. The same phenomenon was seen in marathon running
where hyponatremia was virtually unknown before the modern advice to drink water to excess.
Contributing factors can include inappropriate increased antidiuretic hormone (vasopressin)
secretion that causes fluid retention and a hypertonic urine. Sodium loss in sweat is not a cause
of exercise-associated hyponatremia, although it may exacerbate the problem in some people.
Most sports drinks are not protective as they tend to have insufficient sodium to compensate for
excessive fluid intake.
At risk is anyone consuming excessive fluids, as well as smaller people, females, those
exercising for longer than 4 hours, or those taking high doses of nonsteroidal antiinflammatories
(NSAIDs), which slow kidney function.19

Predisposing Factors
WEMS providers have an important role in prevention of heat illness. They should be aware of
the factors which influence the incidence of heat illness in order to anticipate and prevent these
problems in themselves, their teammates, and their patients.
Environmental heat is the obvious source of stress. Heat waves (three or more days of
temperatures greater than 32.2°C [90°F]) are commonly associated with an increase in both
direct mortality and morbidity from heat illness and with increased overall mortality.20
There are several metrics that describe and attempt to quantify environmental heat stress that
may be useful to those supervising field operations. These metrics often incorporate
environmental factors such as ambient temperature, humidity, wind, dew point, and cloud cover.
The U.S. National Weather Service (NWS) uses a heat index that combines ambient
temperature in the shade and relative humidity with presumed clothing, body activity, and other
parameters (Figure 14.1). The resulting number is expressed as “effective” or “perceived”
temperature in degrees Fahrenheit.21
The wet-bulb globe temperature is used to express environmental heat load. This metric
accounts for means to gain and dissipate heat by combining air temperature in the shade, effects
of wind, evaporation, and sun radiation, thus accounting for the various methods by which a
resting body can gain and dissipate excess heat. However, this is difficult for both the lay public
and EMS to calculate or use and currently appears to have little clinical or operational efficacy.
The military has developed a flag system to communicate risk regarding activity in heat (Table
14.2).22

FIGURE 14.1. NWS heat index. NWS, U.S. National Weather Service. Adapted from
http://www.nws.noaa.gov/om/heat/heat_index.shtml. Downloaded 29 April 2016.

Table 14.2 Wet Bulb Globe Temperature

Category WBGT°F WBGT°C Flag Color
1 <=79.9 <=26.6 White
2 80–84.9 26.7–29.3 Green
3 85–87.9 29.4–31.0 Yellow
4 88–89.9 31.1–32.1 Red
5 <=90 <=32.2 Black

Adapted from Why Use WBGT VS a Heat Stress Indicator. Kestrel Weather & Enviorment Meter website.
http://www.weathermeters-direct.com/content/wbgt-vs-heat-stress. Accessed April 29, 2016.

Cumulative exposure is a known risk factor in both the military and in firefighting. The risk
of heat illness increases on the second and subsequent days of exposure without relief.23
Additionally, fatigue and sleep deprivation adversely affect the ability to respond to heat stress.
Wildland firefighters can be deployed for multiple days of extended physical work hours.
Evidence suggests that individually, physical work and sleep restriction can elicit an acute
inflammatory response that may have implications for the individual’s ability to tolerate heat
stress.24–26
Protective clothing is a significant microclimate factor in the development of heat illness.
Clothing intended to protect against chemical or infectious disease exposure, search and rescue
(SAR) responders with loads of protective clothing, harnesses and packs, or clothing to protect
during firefighting or fire-protective flight suits insulate the skin from heat exchange and often
include the head and neck in the clothing ensemble thus further reducing the ability to dissipate
heat load.27,28
Exercise is another obvious source of heat stress. Core temperature rise is common in
strenuous activity. In the presence of an environment unfavorable to heat dissipation, or
excessive or improper clothing, or other factors that impair heat dissipation, the threat of heat
illness rises. Numerous guidelines, previously noted, exist for decision-making in the context of
activity in warm environments.15,29
Underlying health status influences the ability to tolerate heat stress. In studies from the
Grand Canyon National Park, at least a quarter of the nonfatal cases had cardiovascular and
endocrine conditions.30,31 The cardiovascular system is fully engaged in dissipating heat load as
blood is shunted from the core organs to the skin. An impaired cardiovascular system may be
unable to maintain cardiac output in the face of heat stress, resulting in cardiovascular collapse.
The elderly may have lower sweat rates, longer time to onset of sweating, and impaired
responses to vasodilation and blood pressure changes. A number of studies document the
influence of cardiovascular fitness on ability to respond to heat stress and the role of
cardiovascular disease on the incidence of heat illness.32–34
Obesity places an individual at risk as a result of reduced cardiac output, the increased
energy cost of moving extra mass, increased thermal insulation, and altered distribution of heat-
activated sweat glands.35 Age is a factor as older adults and younger individuals show decreased
efficiency of thermoregulatory functions and increased risk for heat illness. However, due to the
demographics of the hiking population, heat illness patients in the Grand Canyon National Park
tend to be middle-aged. Note that this is a good example of the discussion in our introductory
chapter about the importance of considering the population studied in a research study, and how
they compare to populations actually receiving care, when examining evidence.1
The skin, the largest organ of the body, has a critical role in heat dissipation. Skin disorders
that block sweat ducts such as miliaria rubra (prickly heat, sweat rash, or heat rash) prevent
dissipation of heat. Sunburn can cause inflammation and fever and impair sweating.
Many drugs can affect the body’s response to heat stress. Drugs that increase heat production
include thyroid hormones, amphetamines, tricyclic antidepressants, lithium, and lysergic acid
diethylamide. Haloperidol deceases thirst. Antihistamines, anticholinergics, and phenothiazines
decrease sweating.36–38
Acclimatization to heat is as important a prevention strategy as acclimatization to altitude.
Lack of acclimatization is associated with increased incidence of heat illness. Unfortunately,
there is poor public awareness of this factor. Wildland firefighters are aware of the importance of
training in the heat to prepare for the fire line environment. Outdoor programs or guided trips can
take unacclimatized people into hot environments.
Acclimatizing to heat entails increasing the rate of sweating, decreasing the sweating
threshold, improving vasodilation, and decreasing electrolyte loss in the sweat. When
acclimatized, sweating happens faster and sooner and with the loss of fewer electrolytes in the
sweat, and with improved physical and mental tolerance to heat.39
To become acclimatized to a hot environment requires 1 to 2 hours of exercise in the heat
daily for approximately 10 to 14 days. The exercise ideally mimics the anticipated activity and
has to be sufficiently strenuous to generate sweating and should be matched to the anticipated
environment. If the heat exposure is anticipated to be in a hot, humid environment, then training
should occur in a hot, humid environment, and likewise for a hot and dry environment. As with
altitude acclimatization, in the absence of environmental exposure the training effect wanes over
time. Continued exposure, at least 1 to 2 hours of exercise a week, is required to maintain
acclimatization.40

EPIDEMIOLOGY
An understanding of the incidence of heat illness in the wilderness is elusive. There are discrete
studies from the perspective of SAR and from outdoor programs, and surveys of groups such as
trekkers and adventure athletes, but this literature is clouded by the context of the study and the
incident inclusion thresholds. For example, heat stress and hydration are daily challenges in
many environments, yet they appear infrequently in the literature describing incidents in outdoor
programs. This probably reflects a focus on prevention on these trips and it probably
underreports the impact of heat stress and hydration on participants. Confounding the
understanding is the overlapping of signs and symptoms of heat illness and dehydration with
fatigue, altitude illness, flu-like illness, and other maladies. Selection bias in reporting may be
causing a distorted incidence picture. We are also unable to understand the exacerbation of
underlying health issues, such as cardiac or diabetes, by heat and hydration stress or the impact
of heat and hydration stress as an overt cause of a traumatic accident. For example, dizziness
from heat might trigger a fall, or the stress from heat and dehydration may influence poor
decision-making or judgment, navigation errors, or the other subtle prodromal events that lead to
accidents.
That said, the data do paint a picture where the mild forms of heat illness—heat exhaustion
and dehydration—are common and the life threat of heat stroke is rare.
Heat illness is only 0.5% of reported illness on NOLS multi-week field expeditions, a theme
echoed in other reviews of organized outdoor programs. Heat exhaustion requiring evacuation is
uncommon; heat stroke is nonexistent in these data.41–44 Yet the wilderness therapy industry,
taking young people on extended hikes in hot environments, has a number of media-reported
fatalities attributed to the combination of heat, dehydration, fatigue, lack of acclimatization, and
forced activity without rest.45
As expected, heat and dehydration were prominently reported in a survey of canyoneers, but
the seriousness of these incidents and the number of patients requiring field medical intervention
is not available.46 Heat exposure was a cause of 4% of illness in a survey of hikers in Adirondack
Park47 and 3.7% in expedition length adventure racers.48 Heat exhaustion was 5% of illness
reported on organized guided treks.49
Data from the National Park System show similar figures. Heat exhaustion was 3.5% of
illness reported in Shenandoah National Park,50 5% in a survey of incidents in western parks.51 A
study of eight National Parks in California found “dehydration or heat stroke” to be the fifth
most common illness among visitors overall.52 Heat exposure was a cause in 7% of medically
related deaths in a Pima County Arizona wilderness SAR report.53 Environmental heat exposure
was the cause of 61% of migrant deaths on the U.S. and Mexico border.54
We have no data on incidence in wilderness responders. This and the lack of clarity in the
overall available data on heat illness argues for more WEMS research with consistent reporting
definitions and thresholds to allow for comparison between populations.

CLINICAL MANAGEMENT
Identification
Cramps, syncope, and exhaustion are all abnormal conditions that occur in settings other than
exposure to heat stress. These presentations have multiple physiologic causes. Since numerous
other medical conditions may lead to sudden loss of consciousness and postural tone, syncope,
and heat exhaustion are a diagnosis of exclusion, meaning that more serious conditions must be
considered first, particularly if the person does not regain consciousness rapidly once in a
horizontal position or if they exhibit evidence of another, more serious medical or traumatic
condition.
The signs and symptoms of heat exhaustion are vague and overlap with a range of illnesses
including dehydration and altitude illness. Symptoms of heat illness, like those of hypothermia
and altitude illness, may be subtle and remain unrecognized until a sudden collapse occurs. The
provider must be suspicious and diligent in their assessment because the subtle signs of heat
stress may be a warning of the life threat of heat stroke.
Influencing the variability in presentation is the concept that heat illness can be a culmination
of stress over hours or days, a time period of ongoing heat stress the responder may not
appreciate unless they do a thorough medical history. Also vexing is that exertional heat illness
can conversely evolve quickly, especially in the context of an unacclimatized patient and
strenuous exercise in extreme heat.55

Exercise-Associated Muscle Cramps

Descriptions of muscular cramps in the heat or with exercise range from isolated spasms,
twinges, or tremors in working muscles to widespread involvement of abdominal and facial
muscles. Calf, abdominal, and thigh muscles can cramp. Spasms in the abdominal muscles can
be severe and painful.56

Heat Exhaustion
Signs and symptoms of heat exhaustion are the vague nondistinctive set of the unwell patient;
fatigue, nausea and/or vomiting, loss of appetite, dizziness with fainting possible, an elevated
heart and respiratory rate, skin that is pale, cool and clammy, or slightly flushed. Exercise-
associated muscle cramps may be present. Temperature may be normal or moderately elevated.

Exertional Heat Stroke

Heat illness can be viewed clinically as a continuum between mild and moderate forms; from
exercise-associated muscle cramps, syncope and heat exhaustion, to the severe form, heat stroke.
This clinical presentation continuum, the spectrum of signs and symptoms that seem to lead from
one problem to another, can falsely imply that there is also a pathophysiological continuum. The
answer to this question is elusive. Heat exhaustion and heat stroke may be linked by heat stress
as an environmental factor, but a link through a pathophysiological process has not been
determined. Until a unifying pathological process is identified, a clinical progression among
these disorders is speculative. A recent review reported no evidence that heat stroke is preceded
by less severe heat-associated disorders. Indeed, one of the challenges of heat stroke is its sudden
appearance without obvious prodromal signs and symptoms.57
The primary task for a rescuer responding in the context of elevated heat stress is to rule out
heat stroke. Heat stroke has no distinct warning symptom such as pain. The classic heat stroke
presentation triad of altered mental status, elevated temperature, and dry skin is enticing as a
memory aid but fails in the reality of the field. Several case studies describe athletes who tolerate
high temperatures without illness. Dry, hot skin has been described as distinctive for heat stroke;
however, at the moment of collapse, sweating may still be present. Dry skin may be the result of
a dry climate and a brisk evaporation of sweat, not heat stroke. The most reliable method to rule
out incipient heat stroke is to measure core temperature, but this is most often not available or
practical in the field. And there are several case studies describing athletes who tolerate high
temperatures without illness. The practical and key field assessment is to recognize altered
mental status in the context of heat stress.
Signs and symptoms of heat stroke include an elevated heart and respiratory rate and skin
that is usually warm and which can be either dry or moist depending on whether the patient is
still sweating. Nausea, vomiting, and diarrhea may be present. The temperature threshold is
commonly defined as 40°C (104°F). This temperature threshold is expert opinion and a common
reference point. It is not absolutely correlated with symptoms. Reliance on temperature as a
diagnostic anchor is discouraged due to individual variation in presentation and the difficulty of
obtaining a reliable temperature in the field.
The provider needs to be alert to central nervous system abnormalities that accompany heat
stroke and include delirium, agitation, stupor, seizures, or coma. Altered mental status in the
context of heat exposure is an important distinguishing feature between heat stroke and heat
exhaustion.

Dehydration
The signs and symptoms of dehydration are nonspecific and insidious. They mimic a variety of
illnesses from heat exhaustion through acute mountain sickness and may only reveal themselves
to the nonobservant when fluid losses are significant. On one end of a spectrum dehydration can
present with thirst, weakness, headache, fatigue, lightheadedness, irritability, dark smelly urine,
and diminished urine output. A seriously dehydrated patient may appear to have signs of shock:
rapid pulse; pale, sweaty skin; weakness; and nausea. Mental deterioration presents itself as loss
of balance and changes in mental awareness. Tenting—in which the skin forms a tent shape
when pinched—is a sign of serious dehydration.
FIGURE 14.2. Weight, Urine, Thirst (WUT). Likelihood of dehydration. Adapted from Chevront SN, Sawka MN: Hydration
Assessment of Athletes, Sports Sci Exchange 18:1, 2005.

A key part of the assessment is to carefully explore fluid intake and output, not just today,
but over the past several days. Dehydration can be cumulative.
The scientific and sports medicine communities have not reached consensus for field
assessment of hydration. Cheuvront and Sawka present a Venn diagram decision tool (see
Figure 14.2) that combines three markers of hydration—body mass (weight), urine, and thirst.58
This system does require the ability to monitor weight, which may be impractical in the field. No
marker by itself provides enough evidence of dehydration, but the combination of any two
simple self-assessment markers means dehydration is likely. The presence of all three makes
dehydration very likely.

Urine Concentration
In a clinical setting, urine volume, specific gravity osmolality, and color can be used to assess
fluid status. In the field, only urine color is practical. Urine volume varies widely based on fluid
status and intake. Changes in urine volume in response to fluid intake lag behind consumption
because the kidneys do not respond immediately to changes in plasma osmolality. Drinking large
volumes of hypotonic fluids can result in copious urine production long before hydration is
achieved.59
 The most reliable means to use urine color is the first morning void. Under ideal
circumstances, the first morning urine should be in a clean, clear container with the color
assessed against a white background. Paler color urine (similar to lemonade) suggests adequate
hydration and darker yellow/brown urine color (similar to apple juice) suggests dehydration;
however, urine color is not a precise or useful diagnostic tool. There are too many variables in
urine color; medications and foods can change urine color, and diuretics (as common as coffee)
can make color more clear and urine more dilute despite actual under-hydration or even
dehydration. Water intake history is more important than urine color.

Weight
Pre- and post-exercise weights can be used to monitor changes in hydration but are not
commonly available in field operations. In a field setting, where a scale may not be available for
body weight measures, the combination of first morning urine color and thirst being present may
suggest the presence of dehydration.

Thirst
Thirst is a reliable subjective sensation in response to fluid depletion. There is a misconception
that the thirst sensation lags behind actual fluid needs and is satiated before hydration is restored.
However, there is no published scientific evidence to show that drinking to stay ahead of thirst
during exercise is more beneficial than drinking to match the thirst sensation. There are several
recent reviews of hydration and the thirst mechanism supporting the concept that fluid intake to
match the thirst sensation—sometimes known as ad libitum drinking—is an effective
strategy.60,61

Exercise-Associated Hyponatremia
Signs and symptoms of hyponatremia can mimic those of heat exhaustion and dehydration and
include confusion, disorientation, loss of faculties, headache, nausea, vomiting, aphasia, loss of
coordination, and muscle weakness. They often do not correlate with blood sodium levels,
reducing the utility of this tool as a field assessment. A patient with hyponatremia may feel
worse when supine. This sensation is speculatively attributed to increased intracranial pressure
aggravated when lying flat. On-site serum sodium concentration measurement can be valuable
and these tools are used by some rescue services, but in general are not widely available. The
WMS Practice Guidelines for Treatment of Exercise-Associated Hyponatremia provide
guidelines for evaluation of these data.19

Dehydration versus Hyponatremia

Fluid intake history is vital to an accurate assessment. When deciding between hyponatremia or
dehydration in the field, consider the population and the circumstances. An endurance athlete on
a race with access to water has the opportunity to overhydrate. A desert backpacker with limited
water has less of an opportunity. If you are unsure if your patient has hyponatremia or
dehydration, assume hyponatremia. The body can tolerate dehydration better than acute
hyponatremia.

Prevention
Heat illness is a leadership challenge long before it becomes a medical problem. In all aspects of
medicine, and clearly in the wilderness with its challenges of timely access to definitive care,
prevention is a powerful personal and public health strategy.
Self-awareness of health status while in the wilderness and diligent self-care are a mark of a
competent wilderness practitioner. A study in a Hawaiian National Park, in which only a small
percentage of hikers took the time to read the warning signs at the trailhead providing
information on the importance of carrying water to prevent dehydration and heat exhaustion,
illustrates a common unawareness of the risk inherent in outdoor activities.62 Likewise,
inadequate preparation and poor travel decisions influence the incidence of heat illness and heat
aggravated medical conditions in our desert national parks.1
The hiker who thinks about how much water they may need for the planned activity, who
considers sources of sun protection and work-rest cycles as well as acclimatization to heat, is
practicing preventive health care and wilderness competence. The outdoor trip or SAR leader
who coaches, educates, supervises, and models prevention of heat illness in themselves and their
team members is also practicing preventive SAR. While not a recognized member of the EMS
system they are, from one perspective, imbedded pre-responders acting to prevent unneeded
EMS system response.
The WEMS provider has an important and expanded role beyond simply medical and rescue
response, that of prevention through public education. WEMS providers often take on a public
education role and are recognized in their community as a source of knowledge on health and
safety while in the wilderness. Heat illness prevention strategies follow directly from an
understanding of predisposing and risk factors. A study of the Israeli Defense Forces showed that
soldiers with heat illness all had at least one clear risk factor.63
The following are principles for prevention of heat illness.

Reduce exposure to heat

Exercise early and late in the day. Rest during the heat of midday.
Utilize shade and cooler surroundings to lessen the environmental heat load.
As a route is planned, look for areas of relentless sun exposure, and islands of shade and
water. Plan work-rest cycles to best use these terrain features.
Carry personal shade in the form of broad brimmed hats.
Wear loose, well-ventilated long sleeved garments.
When possible, shed personal protective gear to facilitate dissipation of heat load.
Exercise cautiously in conditions of high heat and humidity. Air temperatures exceeding
32°C (90°F) and humidity levels above 70% severely impair the body’s ability to lose heat
through radiation and evaporation.
Stay alert to the effect of accumulated heat stress.

Rest

Use scheduled rest periods to manage cumulative heat load.

Use planned maximum exposure schedules when forced to work in hot environments (eg,
rotate off the fire line or off the hot sun blasted rock face).

Underlying health
 Be alert to vulnerable populations (the unacclimatized, the very young, the old).
Avoid heat exposure if there is ongoing illness, especially illness with fever, extensive skin
lesions that interfere with sweating, or a medication that increases heat production or
interferes with heat dissipation.

Hydration

During exercise, the objective is to drink enough fluid to sustain performance and the ability
to dissipate heat. Fluid needs vary based upon the individual, the environment, and the
activity. Ideally, the individual has access to fluids before exercise and begins with normal
fluid and electrolyte levels. Ideally, the individual is familiar with their response to exercise
and environment and has a sense of their fluid needs. If not, the American College of Sports
Medicine (ACSM) provides helpful guidelines. The ACSM Position Statement on Nutrition
and Exercise 2009 summarizes current knowledge regarding fluid and electrolyte needs
during exercise. The paper provides recommendations for fluid and electrolyte intake
before, during, and after exercise.64
Recovery after exercise is important, especially if the responder is engaged in a multi-day
response. Deficits are common in prolonged work in heat. Cumulative deficits influence
heat illness. Eating normal meals and snacks with sufficient sodium and drinking plain
water is often sufficient to restore hydration. The sodium helps to retain ingested fluids and
stimulates thirst. Sodium losses are more difficult to assess than are water losses and it is
well known that individuals lose sweat electrolytes at vastly different rates. Drinks
containing sodium, such as sports beverages, may be helpful and many foods can supply the
needed electrolytes. A little extra salt may be added to meals and recovery fluids when
sweat sodium losses are high.
Hyponatremia can be prevented by not drinking in excess of sweat rate. Consuming salt-
containing fluids or foods when participating in exercise events that result in many hours of
continuous or near-continuous sweating helps maintain salt balance, but will not by itself
compensate for overhydration.

Acclimatize to heat

Acclimatization usually takes 10 to 14 days of hard exercise (sufficient to induce sweating)

in similar environmental conditions to the anticipated exposure and requires periodic
reexposure to maintain the acclimatization response.42

Treatment and Disposition

Much of the literature from the past 20 years regarding out-of-hospital treatment of what is
termed exertional heat illness has come from the sports medicine literature. For several reasons,
such as relatively low incidence of severe disorders, there are no well-constructed clinical trials
of treatments.
The principles for treatment of heat illness apply to all levels of care: remove the patient
from the heat stress, restore fluid balance, and aggressively lower temperature in the heat stroke
patient (Table 14.3).

Exercise-Associated Muscle Cramps

All Levels of Care
Anecdotal reports from Grand Canyon National Park rangers and one small study support gentle
stretching to interrupt muscle cramping in heat.65 The empirical experience of most persons is
that stretching and massaging help to relieve cramps. These two interventions seem to be
reasonable first aid for isolated heat or exercise-associated muscle cramps.
Although the only available evidence is case reports, it is also reasonable to use electrolyte
solutions in the heat or exercise cramp patient.

Heat Exhaustion and Syncope

All Levels of Care
A lay first aid responder can be expected to identify a patient suffering from heat stress but not to
distinguish between heat exhaustion and dehydration. In the absence of supporting clinical trials
it is reasonable first aid—potential benefit, low risk of harm—to remove the patient from the
heat stress: move into the shade, indoors, or another cool place sheltered from the sun and
insulated from hot ground. Lay the patient prone. Loosen or remove excess clothing. Allow the
patient to drink if thirsty.66,67

Table 14.3 Treatment Approaches for Heat Illness

Exercise-associated muscle cramps
All levels of care
• Gentle stretching and massaging.
• Hydration and electrolyte support as needed.
Heat exhaustion and syncope
All levels of care
• Remove the patient from heat stress: move into the shade, indoors, or another cool place sheltered from the sun and insulated
from hot ground. Loosen or remove excess clothing.
Basic life support
Advanced life support
Clinician
• If dehydration is also suspected, oral or intravenous (IV) fluid therapy (see below) can be considered.
Exertional heat stroke
All levels of care
• Rapid reduction of core body temperature. This should not be delayed with attempts to measure temperature.
• Immersion in cool water. Protect the airway.
• Spray with water, fan the patient to drive evaporative heat loss.
Basic life support
• Cold water immersion on-site is necessary, although it may not be practical during transport. The BLS provider should
consider ice packs or ice sheets as well as use of any available air-conditioning during transport.
Advanced life support
Clinician
• Consider cool IV fluids (4°C [39°F]).
• There are no known pharmacological treatments for environmental heat stroke.
 Dehydration
First aid
• Oral rehydration for a thirsty patient who is alert and able to hold a cup and drink. Plain water is fine as are electrolyte-
replacement beverages.
Basic life support
Advanced life support
Clinician
• Advanced providers need to use caution when administering IV fluids in the context of heat illness. If exercise-associated
hyponatremia is present, improper fluid management can greatly exacerbate the problem with potentially disastrous
consequences. An IV saline lock should be placed for access during transport but hypotonic IV fluids should be avoided.
Exercise-associated hyponatremia
First aid
• If able to tolerate oral intake, a hypertonic (approximately 9% saline) solution of concentrated broth (3–4 bouillon cubes in
125 mL [½ cup] of water) would be an appropriate initial oral treatment for suspected hyponatremia.
Basic life support
Advanced life support
Clinician
• Hypotonic or isotonic IV fluids should be restricted when on-site serum sodium measurements are not available. Consider
with caution the risk from IV normal saline.
• If measured serum sodium levels are available and are below 130 mmol/L with a symptomatic patient, consider an IV bolus
of 100 mL 3% saline every 10 min up to three doses or until neurologic symptoms abate.

If the patient does not improve, evaluation from an advanced provider should be sought or
the patient should be evacuated. The first aid provider should be aware that recovery can take
hours, and a bout of heat illness can leave the patient exhausted and vulnerable for days.13

Basic Life Support/Advanced Life Support/Clinician

The basic life support (BLS) and advanced life support (ALS) provider would apply the same
treatment principles and approach to exercise-associated muscle cramps and heat exhaustion as
the lay first aid provider. If dehydration is also suspected, oral or intravenous (IV) fluid therapy
(see below) can be considered.

Exertional Heat Stroke

All Levels of Care
Rapid reduction of core body temperature, restoration of fluid and electrolyte balance, control of
seizures, and prompt evacuation to an emergency medical facility can result in a survival rate for
heat stroke patients exceeding 95%. Morbidity is directly related to the duration of hyperthermia.
Early recognition, early and aggressive temperature lowering, and rapid evacuation are
important. In the context of a patient with a heat illness and altered mental status the first aider
should presume heat stroke and initiate treatment.68
Studies of cooling of heat stroke patients have focused on using conduction with cold water
immersion or evaporation with fanning and sprayed water on exposed skin. Immersion in cold
water is the most effective field treatment for heat stroke. It is the fastest method to reduce
temperature (twice as fast as spraying water on the patient and fanning).68–71 The thermal
conductivity of water is higher than air and a high thermal gradient can be achieved between the
skin and the water. There is a perception that cold water immersion can trigger shivering, which
may inhibit cooling, but this has not been observed as a problem.72 Assuming a cold water bath is
available, the patient should have clothing removed and should be placed in the water up to the
shoulders with common sense protection of both the rescuer and the patient from drowning—
constant hands-on supervision.
If a cold water bath is not available, removing clothing and spraying the patient with water
while fanning to induce evaporative cooling may be the only practical field method. If water
supplies are limited, a tarp under the patient can capture non-evaporated fluid for reuse in
cooling. Isolated ice packs are less effective in reducing treatment in heat stroke. If cold water
immersion or cold water on the skin combined with fanning are not available, rotating wet cold
sheets/towels or multiple ice packs may be applied to the axilla and groin areas.69,73

Basic Life Support

Cold water immersion may not be practical during transport, and the BLS provider should
consider ice packs or ice sheets as well as use of any available air-conditioning during transport.
The BLS provider may have access to temperature measurement. Rectal temperatures are
seldom measured in the field. Tympanic thermometry, which is more common in the field, is
likely lower than the actual core or rectal temperature.74 Rapid reduction in temperature is the
emergency treatment goal. This should not be delayed with attempts to measure temperature.

Advanced Life Support/Clinician

In addition to the BLS interventions above, an advanced provider may consider cool IV fluids
(4°C [39°F]). These have not been shown to be effective as an isolated treatment for heat stroke,
but as an adjunctive treatment may be helpful.75
There are no known pharmacological treatments for exertional heat stroke. Antipyretics
(used for fever) are inappropriate for heat stroke.
National Athletic Trainer’s Associations (NATA’s) Position Statement on Exertional Heat
illness recommends that if a physician is on-scene and cooling systems are available, treatment
should occur on-site with transport delayed until temperature is stabilized.16

Dehydration
Dehydration may occur separately from, or concurrently with, heat exhaustion. Without
laboratory analysis, pre- and post-event weights, or a reliable history of fluid intake and output, it
is impossible to accurately determine whether dehydration or electrolyte imbalance is
contributing to the heat illness. It is reasonable to treat for both simultaneously.
The provider must be alert to the possibility of overhydration. The overlap of signs and
symptoms between heat exhaustion, dehydration, and overhydration makes this a challenging
assessment.

All Levels of Care

Dehydrated patients who can manage their airway, who can drink from a cup without assistance,
should be allowed to hydrate orally. The guideline is to drink water until the patient is no longer
thirsty. Plain water works fine. The patient should be encouraged to sip water rather than gulping
large volumes quickly. Sugar may treat depleted energy reserves, but is not needed for
rehydration. The addition of electrolytes (1 tsp of salt per liter) is acceptable, as are electrolyte
containing sports or hydration solutions, but these are usually not needed. Cool water is absorbed
faster than warm water. While the diuretic and vasoconstrictive effects of coffee, tea, and alcohol
are often exaggerated, they have no therapeutic value over simple water and electrolyte solutions
and should be avoided when rehydrating.
Dehydration usually takes time to develop and time to treat. A severely dehydrated patient
may have electrolyte imbalances as well as a fluid deficit. Such a patient cannot be rehydrated in
the field and must be evacuated to a hospital for IV fluid therapy.
Significant body water deficits associated with physical work or heat stress may need hours
of rehydration and electrolyte consumption to reestablish body water balance. It may take more
than 24 hours to fully rehydrate from a deficit of 4% of total body mass via water and electrolyte
replacement.

Basic Life Support/Advanced Life Support/Clinician

Advanced providers need to use caution when administering IV fluids in the context of heat
illness. If exercise-associated hyponatremia is present, improper fluid management can greatly
exacerbate the problem with potentially disastrous consequences. An IV saline lock should be
placed for access during transport. Hypotonic IV fluids should be avoided. There should be clear
indications of a need for fluid support such as low or unstable blood pressure or low serum
sodium concentration measured on-site. If there is a suspicion of the presence of hyponatremia
and no clear evidence supporting IV fluid need, the IV fluids should be restricted during
transport to a receiving facility.

Exercise-Associated Hyponatremia
All Levels of Care
The first aid provider should be cautious when it is unclear whether the patient is dehydrated or
hyponatremic. The risk of causing harm is greater through hydration of the hyponatremic patient
than it is in delaying fluid in the dehydrated patient. “When in doubt, sit it out until they pee it
out” is a maxim used in the Grand Canyon. If the patient is not showing neurologic signs and
symptoms in the context of presumed exercise-associated hyponatremia, use patience until
spontaneous diuresis occurs.
If able to tolerate oral intake, a hypertonic (approximately 9% saline) solution of
concentrated broth (3–4 bouillon cubes in 125 mL [½ cup] of water) would be an appropriate
initial oral treatment for suspected hyponatremia. Use caution, as some people find this salty
broth nauseating. If there is any doubt, there should be little to no fluid intake while the kidneys
reestablish a sodium balance.

Basic Life Support/Advanced Life Support/Clinician

Hypotonic or isotonic IV fluids should be restricted when on-site serum sodium measurements
are not available. In the scenario where no blood electrolyte measurement is available consider
oral hypertonic solutions (approximately 9% saline). Consider, with caution, the risk from IV
normal saline.
If measured serum sodium levels are available and are below 130 mmol/L with a
symptomatic patient, consider an IV bolus of 100 mL 3% saline every 10 minutes up to three
doses or until neurologic symptoms abate.
Equipment Summary
Portable Blood Analyzer
The iStat is a portable blood analyzer used by some WEMS responders to measure electrolytes,
specifically blood sodium, in the field in the context of heat illness, dehydration, and
hyponatremia. The equipment has improved over the years and is not nearly as sensitive to
ambient temperature and rough handling as it once was.

Temperature Measurement
An accurate core body temperature is an ideal diagnostic measurement to differentiate heat
stroke from milder forms of heat illness. A rectal temperature is the standard measurement of
core temperature, considered more reliable than temporal, axillary, oral, or aural measurements.
Esophageal and ingestible thermistors are impractical in the wilderness setting. Rectal
measurements are invasive and patient privacy and hygiene are reasons why providers are
reluctant to use this route in the field. As stated earlier, aggressive cooling for presumed heat
stroke is begun based on the presence of altered mental status in the context of heat stress, and
should not be delayed for temperature measurement.76

SUMMARY
The WEMS provider plays two key roles in the management of heat illness: prevention and field
treatment. In all aspects of medicine, and clearly in the wilderness with its challenges of timely
access to definitive care, prevention is a powerful personal and public health strategy. Education
of the public brings the outdoor leader, educator, or guide, along with the WEMS provider, into
the traditional EMS system through the critical role of prevention, a public health function.
Education and supervision of fellow responders protect the health and safety of the rescuers,
keeping this vital link in the system “in the game.”
Assessment of the spectrum of heat illness, with its often vague and overlapping
presentations, can be challenging. Patient history of length and degree of exposure, hydration
status, fitness, and acclimatization play important roles in diagnosis. Yet while assessment may
be a challenge, the underlying treatment principles are simple and can be used by all levels of
providers: remove the patient from heat stress, restore fluid balance, and aggressively lower
temperature in the heat stroke patient. In the case of heat illness complicated by significant
dehydration and hyponatremia, the advanced provider can bring more resources to bear,
primarily transport and judicious use of IV fluids.

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J Athl Train. 2007;42:333-342.

*This is the threshold defined by the Wilderness Medical Society (WMS) Consensus Guideline.6 The National Athletic Trainers’
Association 2015 Position Statement uses 40.5°C (105ºF).16 The clinical relevance of this difference is probably nil. As by
definition WEMS operational activities will be wilderness environments, and we find the even 40°C/104°F threshold easier to
remember, we use the WMS definition in this text.
INTRODUCTION
Acute high altitude illnesses range from acute mountain sickness (AMS), which is merely
unpleasant, to high altitude cerebral edema (HACE) and high altitude pulmonary edema (HAPE),
which can be fatal. Acute high altitude illnesses can be prevented, primarily by gradual ascent
and can be treated, usually by rapid descent. Patients who survive acute altitude illness generally
make a complete clinical recovery. Wilderness EMS (WEMS) providers who are involved in
operations at high altitude need to know how to prevent and treat high altitude illness for their
own safety as well as for the benefit of their patients.
People living in areas at or near sea level, who travel to areas above 2,400 m (7,874 ft), are at
risk of acute high altitude illness. Tens of millions of people visit high altitude areas worldwide
every year. There are an estimated 40 million visitors annually to areas above 2,400 m (7,874 ft)
in the western United States alone.1 Many subjects of high altitude illness are visitors to
wilderness areas or other remote areas with little or no medical infrastructure. There are millions
of cases of AMS and an unknown number of fatal cases of HACE and HAPE every year.

Definitions
Acclimatization
Acclimatization is the process of physiologic changes by which people adapt to high altitude. A
person who lives at sea level taken suddenly to the altitude of the summit of Mt. Everest (8,848
m or 29,029 ft) would become unconscious in a few minutes. The same person, acclimatizing for
a few weeks on an expedition to Mt. Everest, might be able to climb to the summit breathing
ambient air. Altitude illness is caused by decreased availability of oxygen due to low
atmospheric pressure (hypobaric hypoxia). The percentage of oxygen in air is 21% at all
altitudes, but atmospheric pressure decreases as altitude increases, causing hypoxia.
Acclimatization enables people to live and work at high altitude without suffering from high
altitude illness.

High Altitude—1,500 to 3,500 m (4,921 to 11,483 ft)

The physiologic effects of low atmospheric partial pressure of oxygen become evident above
about 1,500 m (4,921 ft). These effects include decreased exercise performance and increased
resting ventilation. Oxygen saturation (SaO2) at rest remains above 90% until about 3,500 m
(11,483 ft), although the arterial partial pressure of oxygen (PaO2) is markedly lower than at sea
level. The abbreviation SaO2 refers to oxygen saturation measured by co-oximetry (blood gas
analysis), while SpO2 refers to oxygen saturation measured by pulse oximetry. SpO2 readings are
usually lower than measured SaO2 when SaO2 is below 85% to 90%. “High Altitude” is the most
common range for acute altitude illness, because so many people ascend rapidly to altitudes
between 2,500 m (8,202 ft) and 3,500 m (11,483 ft).

Very High Altitude—3,500 to 5,500 m (11,483 to 18,045 ft)

Above 3,500 m (11,483 ft), resting SaO2 is less than 90% and resting PaO2 is below 50 mm Hg.
Severe hypoxemia may occur during exercise, during sleep, or with HAPE. The risk and severity
of altitude illness tend to increase with increasing altitude. “Very high altitude” is the most
common range for severe altitude illness, because relatively few people ascend to altitudes above
5,500 m (18,045 ft).

Extreme Altitude—above 5,500 m (18,045 ft)

“Extreme altitude” is associated with severe hypocapnemia, hypocapnia, and alkalemia at rest as
well as with exercise. Rapid ascent without a period of acclimatization or use of supplemental
oxygen carries a very high risk of severe altitude illness. At extreme altitude, progressive
deterioration of physiologic function eventually overwhelms acclimatization,2,3 causing
weakness, lethargy, weight loss, sleep disturbances, and severe polycythemia. For this reason,
there is no permanent human habitation above 5,500 m (18,045 ft). The highest permanent
settlement in the world is at Aconquilcha, Chile, at 5,340 m (17,520 ft).

Scope of Discussion
The emphasis in this chapter is prevention, recognition, and treatment of acute high altitude
illnesses, primarily AMS, HAPE, and HACE in wilderness and in other remote settings where
there are limited medical resources. Other high altitude conditions include high altitude
headaches, high altitude syncope, neurologic conditions, retinopathies, visual problems, high
altitude pharyngitis and bronchitis, high altitude peripheral edema, high altitude flatus expulsion
(HAFE), disturbed sleep, and periodic breathing.
WEMS responders who are based at altitudes lower than that of the rescue scene are
themselves at risk of high altitude illnesses, especially if they are able to reach the scene but are
unable to descend immediately. WEMS responders also run risks due to limitations of human
and machine performance at high altitudes.

EPIDEMIOLOGY
AMS and HACE affect the brain, while HAPE affects the lungs. AMS or HACE may occur
alone or in combination with HAPE. HAPE may also occur alone or in combination with AMS
or HACE. HACE and HAPE frequently occur together.
AMS is rare below 2,400 m (7,874 ft). HACE is rare below 3,000 m (9,843 ft) and, in most
settings, is uncommon, even above 3,000 m. HACE most frequently occurs in very high
mountains, such as the Himalayas. HAPE is more common than HACE in most settings,
especially in areas below 4,000 m (13,123 ft). The incidence of HAPE is increased by colder
conditions.4 HAPE is common above 3,000 m (9,843 ft), but may be seen well below 2,400 m
(7,874 ft) in occasional patients with congenital absence of a pulmonary artery.5,6
In most high altitude areas, the incidence of high altitude illness can only be roughly
estimated. This is especially true in wilderness and remote areas where the number of people at
risk is often unknown. Many travelers who suffer from altitude illness, especially AMS, do not
seek medical attention. Medical care is often unavailable in wilderness and remote areas. Visitors
to high altitude may blame the symptoms of acute altitude illness on other causes.
Risk is increased primarily with rapid ascent. The higher the altitude, the higher are the risks
of both HACE and HAPE. At a given location, AMS and HACE are more common during
periods of low barometric pressure, which causes a higher effective altitude.4 HAPE is more
common during periods of cold weather.4 HAPE also seems to be more common in travelers
such as trekkers and climbers who are exerting themselves and seems to be less common in those
who reach high altitude by passive means and who do not participate in strenuous activities once
they arrive.
In the western United States, where tens of millions of visitors from lowland locations sleep
above 2,400 m (7,874 ft), the estimated incidence of AMS is about 22% for those sleeping at
2,500 m (8,202 ft) and 17% to 42% for those sleeping above 3,000 m (9,843 ft).7 The overall
incidence of HAPE or HACE is about 0.01%. Trekkers in the Khumbu (Mt. Everest) region of
Nepal typically sleep at altitudes from 3,400 m (11,155 ft) to 5,100 m (16,732 ft) and reach
altitudes of 5,400 to 5,700 m (17,717 to 18,701 ft). In a classic study, almost half of the trekkers
who flew to 2,800 m (9,186 ft) and ascended in several days to 4,300 m (14,108 ft) developed
AMS, compared to about a quarter of those who spent an extra week or so walking from the
lowlands.8 The incidence of HACE or HAPE was 1% to 2% of those who flew to 2,800 m (9,186
ft) and about 0.05% of those who walked from the lowlands.
Climbers and hikers attempting summits of high mountains are at risk of altitude illness. On
Mt. Rainier (4,392 m or 14,410 ft), in the Cascade Mountains of Washington State, most
climbers live near sea level and sleep one night at about 3,048 m (10,000 ft) on the way to the
summit. The incidence of AMS is estimated to be about 67%, with a negligible incidence of
HACE and HAPE.9 On Mt. Kilimanjaro (5,895 m or 19,341 ft), hikers typically sleep at altitudes
ranging from 2,700 to 4,700 m (8,858 to 15,420 ft), taking 2 to 6 days to reach the summit. The
incidence of AMS is estimated to be 50% to 83%.10,11 Although the incidence of HACE and
HAPE is not known, deaths from altitude illness are common. On Denali in Alaska, climbers
typically take 3 days to a week or more to reach the summit (6,190 m or 20,310 ft) after reaching
3,000 m (9,843 ft), sleeping at 3,000 to 5,300 m (17,388 ft). The incidence of AMS is about
30%.12 The incidence of HACE and HAPE is about 2% to 3%.
The highest incidences of AMS are found in situations with very rapid ascents, especially in
travelers who fly to places like Lhasa, Tibet (3,656 m or 11,995 ft), and La Paz, Bolivia, where
the airport is at about 4,000 m (13,123 ft) and most travelers sleep at about 3,500 m (11,483 ft).
These are neither wilderness nor remote locations and are low enough that HACE and HAPE are
rare. The combined incidence of HACE and HAPE is below 1% in most settings, but the
incidence of HACE has been reported in an amazing 31% of pilgrims ascending to Gosainkund
Lake (4,380 m or 14,370 ft) in Nepal.13 Most of the pilgrims live at about 1,340 m (4,400 ft).
They ascend to the lake in 1 to 2 days. The incidence of HAPE was estimated to be about 5%.

CLINICAL MANAGEMENT
In contrast to the management of many types of illnesses and injuries, management of high
altitude illnesses by WEMS providers is relatively straightforward and seldom requires
sophisticated equipment for diagnosis or treatment.

Identification
Acute Mountain Sickness
CLINICAL FEATURES
AMS is at the mild end of the spectrum of high altitude illness that affects the brain. The severe
end of the spectrum is HACE. AMS is a syndrome of cerebral symptoms that can occur after
recent ascent to high altitude. For practical purposes, as well as for research, AMS is defined by
the Lake Louise Score (LLS) (Table 15.1) as the presence of a headache and at least one other
symptom on a specific list of brain-mediated symptoms. The LLS symptoms are gastrointestinal
disturbance (anorexia, nausea, and vomiting), “fatigue and/or weakness,”
14
dizziness/lightheadedness, and poor sleep. Poor sleep has long been recognized as being normal
at high altitude rather than a symptom of AMS.15,16 The symptom of “poor sleep” is in the
process of being eliminated from the LLS. This will likely occur in 2017.
AMS usually starts 6 to 12 hours after arrival at a new, higher altitude,17 but may begin as
early as 2 hours and as late as 4 days.18 Symptoms may range from mild to severe. The headache
is classically described as throbbing, bitemporal, or occipital. It tends to be worse at night and
even worse on awakening in the morning. Bending over or Valsalva maneuvers worsen the
headache. Gastrointestinal symptoms can include poor appetite alone, nausea, or vomiting.
“Fatigue and/or weakness” is a subjective term that, if present, may be reported as mild,
moderate, or severe. “Dizziness/lightheadedness” is another term that has purposely been left
vague to allow for individual and cultural variation. The term dizziness can include vertigo.
Respiratory symptoms are common at high altitude, even in the absence of AMS and are not
related to AMS. Dyspnea on exertion is normal after arrival at altitude. Dyspnea at rest may be a
symptom of HAPE.
The presence of abnormal physical findings is not a feature of AMS. Resting heart rate
generally rises with ascent to altitude. In AMS, the resting heart rate is usually normal or slightly
high, but may also be low. Blood pressure usually rises with acute ascent to altitude even in the
absence of AMS. Low blood pressure would be concerning for conditions other than AMS.
Fever suggests HAPE or an infectious process. Peripheral edema is a common finding after
ascent to altitude. Although AMS is associated with decreased urine output, peripheral edema is
usually not a sign of AMS. Resolution of AMS is often associated with markedly increased
diuresis.
Table 15.1 The Lake Louise Acute Mountain Sickness Scoring System (LLS)
AMS SELF-REPORT SCORE
Headache
No headache 0
Mild headache 1
Moderate headache 2
Severe headache, incapacitating 3
Gastrointestinal Symptoms
None 0
Poor appetite or nausea 1
Moderate nausea or vomiting 2
Severe nausea and vomiting 3
Fatigue and/or Weakness
Not tired or weak 0
Mild fatigue/weakness 1
Moderate fatigue/weakness 2
Severe fatigue/weakness 3
Dizziness/Lightheadedness
Not dizzy 0
Mild dizziness 1
Moderate dizziness 2
Severe dizziness, incapacitating 3
Difficulty Sleeping
Slept as well as usual 0
Did not sleep as well as usual 1
Woke many times, poor sleep 2
Could not sleep at all 3

A diagnosis of acute mountain sickness (AMS) is based on a recent gain in altitude, at least several hours at the new altitude and
the presence of a headache and at least one of the following symptoms: gastrointestinal upset (anorexia, nausea, or vomiting),
fatigue or weakness, dizziness or lightheadedness, and difficulty sleeping. Add together the individual scores for each symptom
to get the total score. A score of 3 points or greater on the AMS self-report questionnaire alone, or in combination with the
Clinical Assessment score, constitutes AMS.
Note: Symptoms of “Difficulty Sleeping” will be eliminated from the LLS in the future.
Adapted from Roach R, P B, Oelz O, et al. The Lake Louise acute mountain sickness scoring system. In: Wood S, Roach R,
editors. Hypoxia and Molecular Medicine. Burlington, VT: Queen City Printers; 1993. p. 272-4.

SpO2* decreases with altitude. In AMS, SpO2 is usually normal for the altitude although it
may be slightly low. SpO2 cannot be used to diagnose AMS or predict whether AMS will occur
with further ascent, in spite of several studies that assert its utility for these purposes.19
DIFFERENTIAL DIAGNOSIS
AMS is a nonspecific syndrome. Many other conditions can mimic AMS, but the diagnosis is
usually clear in the setting of recent ascent to an altitude above 2,500 m (8,202 ft). Fever and
muscle aches suggest a viral syndrome. A hangover can cause symptoms of AMS and may be
found in association with AMS. The diagnosis of hangover in the morning is based on a history
of drinking alcohol the night before. Exhaustion may mimic AMS. Volume depletion can also
cause symptoms consistent with AMS, but, unlike AMS, dehydration is rapidly relieved by
drinking fluids. Carbon monoxide (CO) poisoning can closely mimic AMS. CO poisoning
should be considered if multiple patients are affected in the presence of combustion in a closed
space such as a tent or snow cave. Cooking stoves are the most likely source of CO in the
wilderness.

High Altitude Cerebral Edema

CLINICAL FEATURES

HACE is the severe end of the spectrum of high altitude illness that affects the brain. It is an
encephalopathy characterized by ataxia or altered mental status.20,21 Although it is the severe
form of AMS, HACE may occur without antecedent symptoms of AMS. When HACE occurs
without preceding AMS, it is often rapidly progressive. Ataxia is tested by having a patient walk
heel-to-toe (tandem gait). Inability to walk heel-to-toe in a straight line on level ground or any
unsteadiness is abnormal. The initial symptom of HACE may be inability to keep up with a
group. Another early symptom may be extreme lassitude. Focal neurologic signs are said to be
possible, but they are rare.20,22 The presence of focal neurologic signs suggests a diagnosis other
than HACE. HACE often presents with extreme lassitude and drowsiness that may progress to
stupor and coma. When HACE is associated with HAPE, the diagnosis of HACE may be missed.
Untreated HACE is fatal. Coma usually develops in 1 to 3 days, but may occur in less than 12
hours to as long as 9 days.20,22 Comatose patients with HACE have 60% mortality.23
DIFFERENTIAL DIAGNOSIS
Usually HACE occurs as a progression of AMS. In such cases, the diagnosis is usually clear.
When HACE occurs without a preceding headache or other symptoms of AMS, it can be difficult
to make the diagnosis. Encephalopathy due to any cause can mimic HACE. Fever is usually
absent in HACE, unless HAPE is also present. Heat stroke or hypothermia can cause altered
mental status or ataxia, but touching the skin should be sufficient to make a diagnosis of heat
illness or hypothermia. The effects of sedative/hypnotics, including alcohol, can mimic HACE.
A clinical history is usually sufficient to make the distinction. Neurologic causes of altered
mental status that can occur at high altitude include subarachnoid hemorrhage,24 cerebral venous
thrombosis, mass lesion,25 migraine, or delirium.26 A patient with altered mental status with or
without headache, in the absence of other causes, should be considered to have HACE until
proven otherwise.
If an apparent case of HACE does not resolve with descent, further investigation is
necessary. In severe cases of HACE, ataxia may persist for months after descent. In such cases
the ataxia may be so pronounced that the patient seems to have muscle weakness. A case of
sagittal sinus thrombosis causing a headache that persisted after descent has been reported.27 The
patient was misdiagnosed as having HACE.

High Altitude Pulmonary Edema

CLINICAL FEATURES
HAPE is a noncardiogenic form of pulmonary edema. It is the most common severe high altitude
illness and the most common cause of death from high altitude illness.28 HAPE begins with
fatigue, weakness, shortness of breath on exertion, and a nonproductive cough. HAPE can occur
in the absence of AMS, but AMS or HACE are commonly found in association with HAPE.
Coexisting severe HACE with altered mental status or coma may complicate the diagnosis. The
onset of HAPE is usually described as sudden, after the second night at altitude, but HAPE may
occur earlier or later.29,30 It is not clear if the onset is truly sudden or if the apparent abruptness is
due to worsening of HAPE while the patient is sleeping followed by a sudden awareness of
dyspnea on awakening.
HAPE causes shortness of breath at rest and also when lying flat (orthopnea). Vital signs are
abnormal, with tachycardia, tachypnea and a low-grade fever.31,32 The earliest physical exam
finding is usually crackles in the right middle lobe. These are best heard in the right axilla.1 As
HAPE progresses, crackles may occur throughout both lungs. HAPE may also occur with clear
lungs. A cough with frothy pink sputum is a late and ominous sign. SpO2 in HAPE is usually
much lower than expected at a given altitude. HAPE can be diagnosed solely on clinical
presentation, but pulse oximetry can be helpful to confirm the diagnosis. A pulse oximeter will
markedly underestimate the SpO2 at lower saturations. SpO2 readings, even in the 50s and 60s,
should not unduly alarm a WEMS provider, because the true value is much higher. WEMS
providers should use the clinical appearance of a patient, rather than a number, to guide
treatment.
Risk factors for HAPE include cold exposure and physical exertion.33–36 These factors are
thought to increase the risk of HAPE by increasing pulmonary artery pressure. Males are more
likely to develop HAPE than females.37 This may be due to increased exertion after ascent to
high altitude. Children who live at high altitude are at risk of developing HAPE when they return
home after a stay of at least 10 to 14 days at low altitude.30,38,39 This has been called “reascent”
pulmonary edema. The etiology is unclear and may differ from that of HAPE in travelers to high
altitude.
Pulmonary hypertension is a risk factor for HAPE. Patients have been found to develop
HAPE below 2,000 m (6,562 ft) due to congenital absence of one pulmonary artery.5,6 These
patients were asymptomatic near sea level.
A person who has had HAPE is at risk of recurrence with further ascents to altitude. Most of
the research into the prevention and treatment of HAPE has been carried out on subjects who
have had HAPE multiple times after rapid ascent.40,41 These individuals are termed HAPE-
susceptible (HAPE-S). Research involving HAPE-S subjects may not be applicable to the
majority of presumably non–HAPE-S individuals.
DIFFERENTIAL DIAGNOSIS
Before HAPE was described, most cases were diagnosed as pneumonia.42 Although fever and
cough are present in both HAPE and pneumonia, the fever in HAPE is usually low grade and the
cough does not produce purulent sputum. Like HAPE, pulmonary embolism (PE) can cause
shortness of breath, tachycardia, tachypnea, and low-grade fever. Both HAPE and PE benefit
from descent and oxygen, but only HAPE resolves quickly with treatment. Congestive heart
failure (CHF) can cause cardiogenic pulmonary edema, which may be mistaken for HAPE. In
CHF, unlike in HAPE, there may be jugular venous distension and crackles confined to the lower
lung fields.

Conditions at High Altitude Other Than AMS, HACE, and HAPE

HIGH ALTITUDE HEADACHE
Headache is usually the first symptom of AMS, but a headache may occur at high altitude
without the later development of AMS. Any type of headache, including migraine, can occur at
high altitude. Treatment of a headache at high altitude does not differ from treatment at low
altitude except that supplemental low-flow oxygen (typically 2 L/min) often provides complete
relief in 10 to 15 minutes.43 There is no accepted definition of high altitude headache. For
practical purposes, high altitude headache could be defined as a headache occurring without
other symptoms of AMS, or with symptoms of AMS that do not reach a total of 3 points on the
LLS, that is relieved by supplemental oxygen.
NEUROLOGIC CONDITIONS OTHER THAN AMS OR HACE
Any neurologic condition, including stroke, can occur at high altitude.44,45 Thrombotic strokes
have been reported in climbers46 and soldiers47 at extreme altitude. Other neurologic syndromes
that have been described at high altitude include isolated cranial nerve palsies,48 transient
monocular blindness,49 and cortical blindness.50 Cerebral sinus thrombosis can cause neurologic
signs such as ataxia and speech difficulties.51 Transient global amnesia has also been reported at
high altitude,52 although it may be a psychiatric rather than a neurologic condition.
Many apparent transient ischemic attacks (TIAs) have been reported at altitudes above 5,500
m (18,045 ft), usually in young healthy climbers. Several participants in a simulated “climb of
Mt. Everest” in a high-altitude chamber also experienced apparent TIAs.53 These episodes have
resolved completely without descent. It is possible that some solo climbers have fallen to their
deaths on difficult terrain due to hemiplegia. The etiology of apparent TIAs at altitude is unclear,
but may represent vascular spasm or atypical migraines. Subsequent magnetic resonance images
of the brain have been normal.
HIGH ALTITUDE SYNCOPE
Syncope can occur at high altitude. Near syncope due to acute hypoxemia is frequent after rapid
transport to altitudes above 4,000 m (13,123 ft). A benign condition, “high altitude syncope,” is
common in the first 2 to 3 days at moderate altitude,54 especially at night and after large meals
and alcohol consumption. Syncope at high altitude may be related to vasomotor instability and
cerebral hypoperfusion due to hypocapnemia.55 It is not clear whether “high altitude syncope”
differs from syncope at low altitude.
HIGH ALTITUDE RETINOPATHY
The most common form of retinal pathology (retinopathy) at high altitude is high altitude retinal
hemorrhage (HARH).56,57 HARH is common above 5,000 m (16,404 ft). Above 5,000 m HARH
is not related to AMS,58 although retinal hemorrhage may be correlated with AMS at 4,300 m
(14,108 ft). The location of the hemorrhage seems to be random, but blindness may result if the
hemorrhage occurs over the macula. Otherwise, HARH does not cause any symptoms.
Additional hemorrhages may occur with further ascent,59 but resolve with descent. In the case of
HARH over the macula, blindness usually resolves with descent, but a blind spot may persist for
years or may be permanent.60
HIGH ALTITUDE VISUAL PROBLEMS
Drying of the eye is the most common cause of blurred vision at high altitude.61 Drying is caused
by dry air exacerbated by wind. Blurred vision is often unilateral, especially in windy conditions.
Blurring resolves when the affected person gets out of the wind. Saline eye drops may also help.
Blurred vision in one eye may also be the result of a person touching a transdermal scopolamine
patch and then touching the eye. A unilateral dilated pupil without neurologic signs is the usual
presentation. Transient monocular blindness can also occur at high altitude.44
Corneal surgery to improve refraction can cause visual problems at high altitude.61 Persons
who have had radial keratotomy can undergo severe changes in refraction at high altitude that
may be disabling. Photorefractive keratotomy does not lead to refractive changes at altitude.
Laser in situ keratomileusis (LASIK) can cause refractive changes above 5,500 m (18,045 ft),
but some climbers have ascended above 8,000 m (26,247 ft) without problems after LASIK.
HIGH ALTITUDE PHARYNGITIS AND BRONCHITIS
Sore throat and cough are common above 4,000 m (13,123 ft) and affect almost everyone after 2
weeks above 5,500 m (18,045 ft).62 In the Everest region, the cough is called “Khumbu cough.”
Elsewhere in Nepal, a common term is “Himalayan Hack.” The cough is paroxysmal and
frequently is worst just after exertion. High altitude cough can be debilitating and can cause rib
fractures.63 The cough is most often dry, but can be purulent.
Antibiotics are of no use in treating high altitude pharyngitis or bronchitis. The most
effective methods of prevention or treatment are lozenges or hard candies, water vapor, and
breathing through a “buff” or a face mask during the day and at night. Breathing through a “buff”
works by moistening inspired air. The symptoms typically resolve rapidly and completely after
descent.
PERIPHERAL EDEMA
Swelling of the face and extremities is common at high altitude. Peripheral edema is thought to
be more frequent in women. In severe cases, edema can distort facial features and can make it
difficult to use the hands. Peripheral edema seems to be more common in people with AMS, but
is often found in individuals without other signs or symptoms.64 In severe cases, when edema is
not associated with AMS, it can be treated with furosemide, a diuretic. Peripheral edema usually
resolves rapidly and completely after descent.
HIGH ALTITUDE FLATUS EXPULSION
HAFE is “the unwelcome spontaneous passage of colonic gas.”65 Increased flatulence may be
due to expansion of bowel gas due to lowering of atmospheric pressure with ascent, intestinal
hypermotility, incomplete digestion, or a high carbohydrate diet. Theoretically, HAFE may lead
to hypothermia when the affected individual is forced to sleep outside by tentmates. Social rifts
on treks or expeditions are another potential consequence. HAFE usually resolves promptly after
descent.
SLEEP DISTURBANCE AND PERIODIC BREATHING
Poor sleep, with disordered sleep stages, is normal during acclimatization to high altitude.15
Periodic breathing of high altitude is a form of central sleep apnea, as opposed to obstructive
sleep apnea, that can occur during ascent and often persists after acclimatization.16,66 Apneic
periods are usually 8 to 12 seconds long and terminate with a large gasping breath. The total
cycle lasts about 18 to 20 seconds. Periodic breathing of high altitude is sometimes mistakenly
referred to as Cheyne-Stokes breathing, a form of periodic breathing due to head injury. During
pauses in breathing, oxygen saturation can drop precipitously. Poor sleep and desaturations
overnight may cause fatigue the next day. The preferred treatment of insomnia at high altitude is
acetazolamide 62.5 to 125 mg orally, taken in the early evening. Acetazolamide decreases or
abolishes periodic breathing and improves sleep.67–69 Zolpidem and related drugs are also safe
and effective for insomnia70,71 and are preferred to benzodiazepines which suppress ventilation.
Temazepam, a benzodiazepine, appears to be safe and effective for insomnia at high altitude,72,73
but should be used only if acetazolamide and zolpidem or a related drug do not work.

Prevention
Prevention of high altitude illness is critically important for WEMS personnel who provide care
at high altitude. Ideally, WEMS providers who are not acclimatized to high altitude should
ascend gradually to a high altitude base of operations and be acclimatized prior to providing care
at high altitude. This is not always possible. In some circumstances, non-acclimatized WEMS
providers may have to provide care at high altitude.

Gradual Ascent
High altitude illnesses are caused by decreased availability of oxygen due to low atmospheric
pressure at altitude. The percentage of oxygen is 21% at all terrestrial altitudes, but decreased
pressure at high altitudes causes hypoxia. Acclimatization is the process of human physiologic
adaptation to high altitude over days to weeks. There is great variation among individuals in the
rate of acclimatization. Rare individuals are unable to acclimatize, even after days or weeks at
high altitude. AMS, HACE, and HAPE result from ascending to high altitude more rapidly than
the rate of acclimatization.
The most effective method of preventing AMS, HACE, and HAPE is gradual ascent. The
importance of gradual ascent for preventing AMS and HACE is well established by
observational data and a few prospective studies.74,75 There are no prospective studies of gradual
ascent for the prevention of HAPE, but there is a strong epidemiologic correlation between rapid
ascent and increased incidence of HAPE.
It is important that WEMS providers be aware of safe rates of ascent in order to prevent high
altitude illness in the populations they serve as well as for their own safety. Ideally, WEMS
responders who respond to calls at high altitude locations should be based at high altitude, but
this is not always possible. WEMS personnel who are based at lower altitudes may need to
exceed safe rates of ascent in order to accomplish a high altitude mission. When this occurs,
personnel should have a plan for rapid descent to avoid becoming ill. Because AMS takes several
hours to develop, there is a period during which personnel can ascend to altitude and accomplish
a rescue with minimal risk of high altitude illness. Personnel should have safety plans that
include descent before high altitude illness has a chance to develop.
For the development of altitude illness, the most important altitude is the altitude at which a
person sleeps each night (sleeping altitude). This is likely due to relative hypoxia during sleep
compared to oxygen levels while awake. The safe rate of ascent varies widely among
individuals. Some are fast acclimatizers and some are slower.

Table 15.2 Recommendations for Gradual Ascent

Recommendation HRA77 WMS78
Daily ascent (sleeping altitude) 300 m 500 m
Rest day Every 600–900 m Every 3–4 d
Maximum single day gain 800 m No recommendation

Intended for individuals going from altitude <1,200 m directly to altitudes >2,500 m
Optional: Spend one or more nights at an intermediate altitude (1,500 to 2,200 m)
Optional: Spend two to three nights at 2,800 to 3,000 m before further ascent

Non-acclimatized individuals who go from altitudes below 1,200 m to altitudes above 2,500
m (3,937 to 8,202 ft) can decrease the risk of high altitude illness by spending at least one night
at an intermediate elevation, usually 1,500 to 2,200 m (4,921 to 7,218 ft).76 Non-acclimatized
individuals who ascend above 3,000 m (9,843 ft) should spend two or three nights at 2,800 to
3,000 m (9,186 to 9,843 ft) before further ascent. Different guidelines suggest different rates of
ascent (Table 15.2). The Himalayan Rescue Association (HRA) guidelines recommend daily
ascent of up to 300 m (984 ft) with a “rest day” during which there is no ascent of sleeping
altitude, for every 600 to 900 m (1,969 to 2,953 ft) of ascent.77 Because there may be no good
place to sleep at intermediate altitudes, the HRA suggests a maximum one-day altitude gain of
no more than 800 m (2625 ft). A one-day gain of greater than 300 m (984 ft) should follow a rest
day. The Wilderness Medical Society (WMS) guidelines recommend that daily ascent be limited
to 500 m (1,500 ft) with a rest day every 3 to 4 days.78 There is a large variation among
individuals in the rate of acclimatization. Individuals with experience at high altitude ascend
faster or more slowly based on previous experience. Neither the HRA nor the WMS guidelines
are meant to offer complete protection against altitude illness. Following the more conservative
HRA guidelines would be expected to result in a lower rate of AMS than will following the
WMS guidelines. Individuals who suffer from AMS while following the HRA guidelines are
likely to have milder symptoms than if they had followed the WMS guidelines. Following either
set of guidelines is likely to provide nearly complete protection from HACE. Some HAPE-S
individuals will still be at risk of HAPE, even with a very conservative ascent profile.

Other Non-Pharmacologic Methods of Prevention

Spending days to weeks at a moderate altitude, usually 2,200 to 3,000 m (7218 to 9843 ft), is a
variant of gradual ascent. Although clearly effective, most people do not have time to use this
strategy. Pre-acclimatization in hypobaric or hypoxic (nitrogen-enriched) chambers that simulate
high altitude, especially while sleeping, can be effective, but only if the length of exposure is
adequate. Long periods of time are required, making this strategy impractical for most people.
Because the likelihood of altitude illness depends mostly on sleeping altitude, individuals can
follow the “mountaineers rule—climb high, sleep low.” This strategy takes advantage of the fact
that altitude illness usually takes many hours to develop. It is not clear whether going higher
during the day speeds acclimatization. Other measures that are thought to protect against altitude
illness include moderate exercise, adequate fluid intake, a high carbohydrate diet,79 and
avoidance of sedative or hypnotic drugs, including alcohol. Aerobic fitness confers no benefit for
acclimatization, but is clearly advisable for hikers, climbers, and WEMS providers at all altitudes
in order to meet the physical demands of their activities. Very physically fit individuals may be
unable to resist ascending too rapidly, sometimes with fatal consequences.

Pharmacologic Prevention of AMS and HACE

RISK STRATIFICATION
WMS divides the risk of AMS into low, moderate, and high categories based on ascent profile
and past medical history78 (Table 15.3). Prophylactic medication is not advised for low-risk
ascents. Prophylactic medication may be advised for moderate or high-risk ascents. Anyone with
a history of HACE or HAPE should take medication to prevent high altitude illness for an ascent
above 2,500 m (8,202 ft) (Table 15.4).
Table 15.3 Risk Stratification for Altitude Illness
Risk Category Criteria
Low No previous history of altitude illness, ascending to ≤2,800 m
Taking ≥2 d to reach 2,800 m with subsequent increases in sleeping altitude <500 m/d
Moderate Previous history of AMS, ascending to 2,500–2,800 m in 1 d
No history of AMS and ascending to 2,800–3,500 m in 1 d
Increase in sleeping altitude >500 m/d starting between 3,000 and 3,500 m
High History of AMS, ascending to ≥2,800 m in 1 d
Previous history of HAPE or HACE
Ascending to >3,500 m in 1 d
Increase in sleeping altitude >500 m/d starting above 3,500 m
Member of a group with individual moderate or high risk
Very rapid ascent (eg, Mt. Kilimanjaro)

Intended for non-acclimatized individuals going from altitude <1,200 m to altitudes >2,500 m. Altitudes are sleeping altitudes.
AMS, acute mountain sickness.
Modified from Luks AM, McIntosh SE, Grissom CK, et al. Wilderness Medical Society practice guidelines for the prevention
and treatment of acute altitude illness: 2014 update. Wilderness Environ Med. 2014;25(4 suppl):S4-S14, with permission from
Elsevier.

Table 15.4 Recommended Medications for Prevention of Altitude Illness

Medication Dose Start/Stop
AMS/HACE
Acetazolamide 125 mg by mouth twice daily Start: day before ascent
Pediatric: 2.5 mg/kg by mouth twice Stop: after 2 d at highest sleeping altitude
daily or when starting descent
Dexamethasone 4 mg by mouth every 12 h for passive Start: day of ascent
ascent and no physical exertion Stop: after 2–3 d at highest sleeping
anticipated at altitude altitude or when starting descent
4 mg by mouth every 6 h for active Do not use for >10 days
ascent or physical exertion anticipated at
altitude
Pediatric: not recommended
Acetazolamide + Dexamethasone Same as individual medications Same as individual medications
Use in emergency situations only
HAPE
Nifedipine 60 mg (slow release) by mouth daily in Start: day before ascent
2–3 divided doses Stop: after 5 days at highest sleeping
altitude or when starting descent
Salmeterol 125 µg inhaled twice daily Start and stop at the same time as
Use only with nifedipine in very high-risk nifedipine
individuals

AMS, acute mountain sickness; HACE, high altitude cerebral edema; HAPE, high altitude pulmonary edema.

ACETAZOLAMIDE
Acetazolamide is the preferred medication to prevent AMS.78 The adult dose for prevention of
AMS is 125 mg twice daily.80–82 Higher doses cause increased side effects without an increase in
efficacy. Because acetazolamide works by speeding acclimatization, it does not “mask”
symptoms. No other available medication works by speeding acclimatization.
DEXAMETHASONE
Dexamethasone at a dose of 4 mg twice daily is effective in preventing AMS in sedentary
subjects.83 A dose of 2 mg four times daily is equivalent, but is unnecessarily complicated. For
WEMS providers who are stationed at low altitude and must ascend rapidly to altitudes over
3,500 m (11483 ft) to perform a rescue, the dose should be increased to 4 mg every 6 hours.84,85
Unlike acetazolamide, dexamethasone does not speed acclimatization. Dexamethasone should
not be used for over 10 days due to the risk of toxicity, including adrenal suppression.
POSSIBLY EFFECTIVE DRUGS—IBUPROFEN, GINKGO, AND GABAPENTIN
Based on a few trials, ibuprofen at a dose of 600 mg three times daily may be effective in
preventing AMS.86,87 Unlike acetazolamide, ibuprofen does not seem to speed acclimatization.
Until more data become available, ibuprofen should not be recommended instead of
acetazolamide for prevention of AMS.88 Ginkgo biloba is a herbal medication that has been
found to be effective in prevention of AMS in some trials89–91 and has had no benefit92,93 in other
trials. Because Ginkgo is a herbal medication, the composition varies widely, even among
batches of the “same” product from a given manufacturer, which may explain some of the
variation in efficacy.94 Ginkgo should not be recommended for prevention of AMS.95
Sumatriptan reduced the incidence of AMS from 45% to 23% in one small trial.96 Gabapentin
slightly reduced the incidence of AMS in one trial.97 Neither sumatriptan nor gabapentin should
be recommended for prevention of AMS.
INEFFECTIVE DRUGS
Naproxen,98 spironolactone,99–101 antacids,102 magnesium,103 calcium channel blockers,104
medroxyprogesterone,105 and antioxidants106 have all been studied and found to have no benefit
for the prevention of AMS. Coca tea or coca leaves have been used, primarily in South America,
to prevent AMS. There are no studies to support the use of coca for AMS prophylaxis.107
Sorojchi pills are marketed in Peru and Bolivia for prevention and treatment of AMS. Soroche
(or sorojchi) is a South American word for altitude illness. The active ingredients of Sorojchi
pills are acetylsalicylic acid (ASA), salophen (which decomposes to ASA and paracetamol), and
caffeine.107 None of the ingredients have any known efficacy against AMS.

Prevention of High Altitude Pulmonary Edema

Non-pharmacologic methods of preventing AMS and HACE, especially gradual ascent, are also
important for the prevention of HAPE. Because the pathophysiology of HAPE differs from that
of AMS and HACE, pharmacologic prevention of HAPE differs from the pharmacologic
prevention of AMS and HACE. All studies of medications for the prevention of HAPE were
conducted using HAPE-S subjects.40,108,109 It is not known whether the results also apply to the
general population. It is not advisable for a person who has never had HAPE to take medication
to prevent HAPE.78
Nifedipine is the best-established medication for the prevention of HAPE (Table 15.4).
Nifedipine is a calcium channel blocker that is thought to prevent HAPE by blunting the rise in
pulmonary artery pressure that occurs at altitude and that is especially pronounced in HAPE-S
individuals. Although the use of nifedipine to prevent HAPE is supported by just one small
randomized placebo-controlled study of HAPE-S individuals,40 extensive clinical experience
supports the use of oral nifedipine (slow-release) to prevent as well as to treat HAPE. The
recommended dose is 60 mg/day in divided doses. The available dose of slow-release nifedipine
is 30 mg in North America and 20 mg in Europe. Nifedipine should be started the day before
ascent, if possible, continued during ascent.78
A small study of HAPE-S subjects found that inhaled salmeterol was mildly effective in
preventing HAPE, at high doses that are known to lead to a significant incidence of side
effects.108 A very small trial studied tadalafil and dexamethasone for the prevention of HAPE in
HAPE-S individuals.109 Tadalafil increased the incidence of severe AMS. Dexamethasone at a
dose of 16 mg daily in divided doses seemed to prevent both HAPE and AMS. Unless further
studies are carried out, only nifedipine should be used to prevent HAPE in HAPE-S
individuals.78

Strategy for prevention of High Altitude Illness

WEMS personnel who reside below 1,200 m (3937 ft) should ascend gradually and acclimatize
prior to providing care at high altitude. This is not always possible. When WEMS providers do
not have time to make a low-risk ascent prior to providing care at high altitude, they should take
prophylactic medication in order not to jeopardize the success of the mission. As an example, the
HRA runs an annual health camp for pilgrims at Gosainkund Lake (4,380 m or 14,370 ft). Most
of the WEMS providers who participate live at about 1,340 m (4,400 ft). For logistical reasons,
they ascend to 4,380 m in 4 days. While some of the providers would likely not have AMS with
this profile, most teams elect to have all their members take acetazolamide in order to minimize
the chance of having a member unable to work due to AMS.

The “Golden Rules” of Altitude Illness

Rescuers should follow the “Golden Rules” of altitude illness, both for their own safety and to
help their potential patients. The “Golden Rules” were developed and popularized by the HRA77
(Box 15.1).

Operations at High Altitude and Very Rapid Ascent Involving Unacclimatized Rescuers
On occasion, it may be necessary for WEMS personnel who reside at low altitudes and are not
acclimatized to high altitude to perform rescues at high altitude. For safety, non-acclimatized
rescuers should use supplemental oxygen throughout the rescue whenever they are above 3,000
m (9,843 ft).

Box 15.1 The “Golden Rules” of Altitude Illness

Golden Rule 1: If you are ill at altitude, your symptoms are due to altitude illness until proven otherwise.
Golden Rule 2: If you have symptoms due to altitude illness, don’t go any higher until the symptoms have resolved.
Golden Rule 3: If you are feeling very ill or getting worse or if you cannot walk heel-to-toe in a straight line, descend
immediately.
Golden Rule 4: Never send anyone with altitude illness down alone.
Golden Rule 5: It is okay to get mild altitude illness.
Golden Rule 6: Even doctors and other WEMS providers can get altitude illness.

When in Doubt, Descend!

Modified from Zafren K, Honigman B. High-altitude medicine. Emerg Med Clin North Am. 1997;15(1):191-222.
A major concern in helicopter rescue is the possibility that a rescuer will be stranded above
3,000 m (9,843 ft) and develop altitude illness. The Denali National Park Mountaineering
Rangers maintain a camp with acclimatized rescuers at 4,300 m (14,108 ft) during the
mountaineering season. Occasionally a technical rescue, usually involving helicopter short-haul
operations, will require the use of a non-acclimatized rescuer who is based below 1,500 m (4,921
ft). There is also the possibility that the helicopter crew (who are based below 1,500 m) may be
stranded above 3,000 m by helicopter malfunction or by weather conditions. Rescues are
commonly performed above 5,000 m (16,404 ft). Because high altitude illness usually takes
several hours to develop, there may be time to intervene with acetazolamide in the event that a
rescuer is stranded. In 1997, the medical director for the Denali National Park Mountaineering
Rangers developed emergency guidelines for non-acclimatized rescuers performing rescues
above 3,000 m (Box 15.2). The guidelines noted that, when possible, rescuers should be flown to
3,000 m and allowed to acclimatize for 1 to 2 days before operating at higher elevations. Non-
acclimatized rescuers who were known to be at increased risk of any form of altitude illness were
excluded from high altitude operations. The main strategy in the emergency guidelines was to
limit ground operations above 3,000 m involving non-acclimatized rescuers to a few hours. A
non-acclimatized rescuer who was stranded would begin taking acetazolamide 125 mg twice
daily and make every effort to descend to 3,000 m as soon as possible.
Although not included in the original guidelines, non-acclimatized rescuers who must ascend
rapidly and perform work above 3,500 m (11,483 ft) should consider taking acetazolamide and
dexamethasone concurrently.78 Because of the potential euphoric effects of dexamethasone, it
should be used with caution. It would not be advisable to use dexamethasone routinely during
technical rescue operations.

Guidelines for Operations at High Altitude Involving Non-

Box 15.2
Acclimatized Rescuers
These are Emergency Guidelines only for Operations in which there is no Alternative to Using Non-Acclimatized
Rescuers
These guidelines apply to rescuers residing at elevations below 1,500 m (5,000 ft) and not acclimatized to higher altitudes.
They may be modified for rescuers acclimatized to high altitudes.
Whenever possible, rescuers should be flown (or transported rapidly by other means) to 2,500 to 3,000 m (8,200 to
10,000 ft) and allowed to acclimatize for 1 or 2 days before operating at higher elevations. Rescuers who are known to be at
increased risk of any form of altitude illness should be excluded from these operations.

Category 0: Operations conducted entirely below 3,000 m (10,000 ft) or commencing below 3,000 m and not expected to
exceed a rate of ascent of 300 m (1,000 ft) per day. No medications are recommended.
Category 1: Operations commencing below 3,000 m (10,000 ft) but expected to exceed a rate of ascent of 300 m (1,000
ft) per day above 3,000 m. Rescuers should take acetazolamide 125 mg twice daily for one day before ascent and for 2
days after reaching the highest sleeping altitude on ascent.
Category 2: Operations commencing at 3,000 to 4,000 m (10,000 to 13,000 ft). Rescuers should not remain on the ground
longer than a few hours. Supplemental oxygen, if available, should be used throughout the rescue. If rescuers are
stranded, they should take acetazolamide 125 mg twice daily unless they anticipate being able to descend below 3,000
m within a few hours.
Category 3: Operations commencing above 4,000 m (13,000 ft). Rescuers should not remain on the ground longer than
1–2 hours. They should use supplemental oxygen throughout the operation. If rescuers are stranded, they should take
acetazolamide 125 mg twice daily and dexamethasone 4 mg every 6 hours unless they anticipate being able to descend
below 3,000 m within a few hours.

Rescuers who develop high altitude illness should follow treatment guidelines.

Modified from Zafren K, Honigman B. High-altitude medicine. Emerg Med Clin North Am. 1997;15(1):191-222.

Screening of WEMS Providers

WEMS providers should be physically fit. Non-acclimatized WEMS providers who are known to
be susceptible to high altitude illness, including HAPE-S individuals, should be excluded from
operations at high altitude until they can acclimatize safely and should not be allowed to
participate in rapid ascents. A WEMS provider who has had a radial keratotomy should not
participate in operations at extreme altitude.

Treatment and Disposition

The mainstay of treatment for acute high altitude illnesses is descent. Descent can be actual
descent to lower altitude or virtual descent in a portable hyperbaric chamber. Use of oxygen and
pharmacologic treatment can be useful as temporizing measures and to augment the effects of
descent.

Treatment of Acute Mountain Sickness and High Altitude Cerebral Edema

SYMPTOMATIC TREATMENT OF AMS AND HACE
Mild or moderate AMS does not usually require descent. Resolution of symptoms after a day or
two at the same altitude is the rule.78 Patients with severe AMS are usually miserable enough that
they prefer descent to staying at the same altitude and hoping to acclimatize. It is acceptable to
treat symptoms. Headaches can be treated with acetaminophen (paracetamol in most countries
other than the United States and Canada) or nonsteroidal antiinflammatory medications such as
ibuprofen. Vomiting can be treated with prochlorperazine or ondansetron. Prochlorperazine was
once the preferred agent because it was the only antiemetic that increased hypoxic ventilatory
response. Prochlorperazine has largely been supplanted by ondansetron. Ondansetron has fewer
side effects and has the advantage in that it can be given as an oral dissolving tablet.
Symptomatic treatment does not hasten acclimatization.
SPECIFIC NON-PHARMACOLOGIC TREATMENT OF AMS AND HACE
Specific treatment of AMS starts with descent. HACE is a life-threatening illness. It is
imperative that a patient with severe AMS or HACE descend immediately if possible, and
continue descent until symptoms improve markedly or resolve. Nobody with AMS or HACE
should be allowed to descend alone. An individual with HACE may be ataxic enough to need
significant assistance or may need to be carried. Descent is usually very effective. AMS often
resolves rapidly and completely after a relatively modest descent of 300 to 1,000 m (984 to 3,281
ft). HACE should improve markedly, although ataxia often persists after treatment. As with all
aspects of altitude illness, there is great individual variation.
If immediate descent is not possible, a practical initial step is to simulate descent with the use
of a portable hyperbaric chamber (Figure 15.1). Portable hyperbaric chambers are usually
effective for treating AMS110–113 and HACE but are not intended as a substitute for descent if
descent is possible. During treatment in a chamber, a health care provider should monitor the
patient continuously. One or more assistants will need to pump air into the chamber without
interruption, usually at a rate of 12 compressions/min. Claustrophobic patients may require
sedation or may be unable to tolerate treatment in a hyperbaric chamber. Vomiting is a relative
contraindication to chamber treatment. A patient with vomiting who is not fully conscious and
able to lie on one side should not be placed in a portable hyperbaric chamber. Symptoms of AMS
sometimes recur after a patient is taken out of the chamber. In that case, the patient should be
placed in the chamber again. Multiple sessions may be necessary. A typical protocol is to keep
the patient in the chamber for an hour at a time, as tolerated,114 with a short rest period in
between sessions.
FIGURE 15.1. Portable fabric hyperbaric chamber (Gamow Bag). The head of the bag was elevated because the patient, who
had HAPE, was unable to tolerate the supine position while the bag was lying flat. Courtesy of Ken Zafren, MD.

SPECIFIC PHARMACOLOGIC TREATMENT OF AMS AND HACE

Administration of oxygen (usually at 0.5 to 1 L/min by nasal cannula), simulating descent, is
effective in relieving the symptoms of AMS (Table 15.5).20,115 The usual target SpO2 is greater
than 90%. In most wilderness settings, use of oxygen is limited by the supply of bottled oxygen.
Oxygen concentrators are now available in many remote locations, but require an adequate
supply of electricity. Small wearable oxygen concentrators that operate on batteries are now
available. For reasons that are not clear, some patients with rapidly progressive HACE will
continue to deteriorate with use of oxygen or a hyperbaric chamber.
ACETAZOLAMIDE
Based on a single study and extensive clinical experience, acetazolamide is effective in the
treatment of AMS.116 The only dose that has been studied is 250 mg twice daily. The lower
prophylactic dose—125 mg twice daily—might be effective for treatment, but cannot be
recommended without further study. Acetazolamide seems to be safe and effective in pediatric
patients at a dose of 2.5 mg/kg/dose twice daily with a maximum dose of 250 mg/dose. At least
one mechanism by which acetazolamide is thought to work in the treatment of altitude illness is
by its effect of speeding acclimatization. Further ascent is safe as soon as the symptoms of AMS
resolve after treatment with acetazolamide.
DEXAMETHASONE
Dexamethasone is a very effective medication for the treatment of AMS84,117,118 at a dose of 4 mg
every 6 hours. Because dexamethasone does not speed acclimatization, further ascent should be
delayed until the patient is no longer asymptomatic and has not taken dexamethasone for 2 or 3
days.
Dexamethasone is the pharmacologic adjunctive treatment of choice for HACE. The dose for
treating HACE is 8 mg (intramuscular, intravenous, or oral), followed by 4 mg every 6 hours
until symptoms resolve. The pediatric dose is 0.15 mg/kg every 6 hours.

Table 15.5 Recommended Medications for Treatment of Altitude Illness

Medication Dose Start/Stop
AMS/HACE
Acetazolamide 250 mg by mouth twice daily Start: at onset of AMS
Pediatric: 2.5 mg/kg by mouth twice daily Stop: when AMS resolves
Dexamethasone 8 mg by mouth, IV, IO, or IM initially then 4 mg Start: immediately once HACE is diagnosed
IV, IO, or IM every 6 hours Stop: after descent
Pediatric: 0.15 mg/kg/dose by mouth, IV, IO, or Do not use for >10 d.
IM every 6 h
Acetazolamide + Same as individual medications. Same as individual medications
Dexamethasone Acetazolamide can be used with dexamethasone
Use only for treatment in the treatment of HACE
of HACE
HAPE
Nifedipine 60 mg (extended release) by mouth daily in 2–3 Start: day before ascent
divided doses Stop: after 5 d at highest sleeping altitude or when
starting descent

AMS, acute mountain sickness; HACE, high altitude cerebral edema; HAPE, high altitude pulmonary edema; IV, intravenous;
IO, intraosseous; IM, intramuscular.

STRATEGY FOR THE TREATMENT OF AMS/HACE

Conditions that mimic AMS or HACE should be ruled out and treated.78 Once diagnosed with
AMS, a patient should not ascend further until symptoms have resolved (Box 15.3). A patient
with mild to moderate AMS may stay at the same altitude in order to acclimatize. Symptomatic
treatment of headache, nausea, and vomiting is reasonable. Acetazolamide can be used as an
adjunctive treatment to speed acclimatization. Dexamethasone, used alone, is very effective in
the treatment of AMS if there are no plans for further ascent. A patient with AMS, who has not
received dexamethasone, can ascend further once symptoms have resolved, whether or not non-
opioid analgesics or antiemetics have been used.78 After the use of dexamethasone, a patient
should wait 2 to 3 days before ascending. A patient with severe AMS should descend
immediately. Use of acetazolamide at the preventive dose of 125 mg twice daily during reascent
or further ascent is advisable.

Box 15.3 Treatment of High Altitude Illness

AMS
Mild Symptoms
No further ascent until symptoms resolve (with or without treatment).
OR
Descend until symptoms improve, usually at least 500 m (1,500 ft).
Acetazolamide 250 mg by mouth twice daily to speed acclimatization
Treat headache with analgesics such as acetaminophen (paracetamol in some other countries) or ibuprofen. Treat nausea or
vomiting with ondansetron or prochlorperazine.
 Moderate Symptoms or Symptoms Not Resolving
Consider adding oxygen 1–2 L/min OR hyperbaric therapy with or without dexamethasone 4 mg by mouth every 6 h
OR
Descend until symptoms improve, usually at least 500 m (1,500 ft).
If Patient is ataxic or has altered mental status, Treat for HACE.

HACE
Immediate descent or evacuation
Oxygen at 2–4 L/min OR hyperbaric therapy
Dexamethasone 8 mg by mouth, IM, IV, or IO initially, then 4 mg by mouth, IM, IV, or IO every 6 hours

HAPE
Minimize exertion and keep warm
If pulse oximetry >90% with oxygen 2–4 L/min or in a hyperbaric chamber and immediate descent or evacuation not
feasible, the patient may be able to recover at altitude. HAPE should resolve within 24 hours
OR
Urgent descent or evacuation
During descent or while awaiting evacuation:
Oxygen 4 to 6 L/min until improving then keep SpO2 ≥90% OR hyperbaric therapy
Nifedipine extended release 60 mg daily in 2–3 divided doses

A patient with HACE should descend immediately.20 Because many patients with HACE are
ataxic, a HACE patient may need significant help walking or may need to be carried. A HACE
patient should not descend by walking on a narrow trail where a long fall would be possible, nor
should a HACE patient descend in technical terrain. A HACE patient should receive the initial
dose of dexamethasone 8 mg orally if able to swallow safely. Otherwise the first dose can be
given IM, IV, or IO. If available, oxygen should also be given.
A comatose patient with HACE should be treated as a head-injured patient, with intubation
and bladder catheter placement if available, but only after oxygen and dexamethasone have been
administered. Comatose patients with HACE often wake up with supplemental oxygen.
Hyperventilation is not recommended.
The standard treatment of pilgrims with HACE at Gosainkund Lake (4,380 m or 14,370 ft) in
Nepal has been a single dose of dexamethasone 8 mg, orally or IM, and oxygen to keep SpO2 at
or above 90% until a porter can be found to carry the patient down. It typically takes less than 30
minutes to find a porter. Once the porter is ready to descend carrying the patient, oxygen is
discontinued and there is no further treatment other than descent. There have been no known
fatalities in over 20 years of HRA Health Camps at Gosainkund Lake using this regimen.
Although there are no relevant data, a patient who has been treated for HACE should not
reascend for a minimum of several weeks after complete recovery.

Treatment of HAPE
NON-PHARMACOLOGIC TREATMENT OF HAPE
As is the case with AMS and HACE, descent is the ideal treatment for HAPE, but descent is not
necessary for patients with mild HAPE who do not also have HACE.32,119 Patients with mild
HAPE alone or with AMS can be treated with supplemental oxygen or with simulated descent in
a portable hyperbaric chamber.114,120 The goal of treatment is to keep SpO2 greater than 90%. For
children with mild reascent pulmonary edema, bed rest alone is usually adequate treatment.121
For adults with HAPE, in the absence of oxygen or a hyperbaric chamber, descent is mandatory.
The patient should descend at least 1,000 m (about 3,300 ft) or until symptoms resolve. Passive
descent is better than active descent. If active descent is necessary, there should be as little
exertion on the part of the patient as possible. A rescuer should carry the patient’s pack. Exertion
should be avoided because it causes increased pulmonary artery pressure.
NON-PHARMACOLOGIC TREATMENT OF HAPE: CONTINUOUS POSITIVE AIRWAY PRESSURE
A mask that provided expiratory positive airway pressure was shown to improve gas exchange in
patients with HAPE in one small study.122 No clinical benefit has been demonstrated. The use of
continuous positive airway pressure (CPAP) has become common in many conditions, including
cardiogenic pulmonary edema, but there are no studies suggesting a role for CPAP in the
treatment of HAPE. CPAP machines have become smaller and more portable. It is conceivable
that a role for the use of CPAP for the treatment of HAPE may be established in future.
PHARMACOLOGIC TREATMENT OF HAPE
See Table 15.5.

Nifedipine: The only drug that has been formally studied for the treatment of HAPE is
nifedipine. In a small study, nifedipine alone, without oxygen or descent, was effective in
treating HAPE in HAPE-S subjects.123 There is also substantial clinical experience supporting the
use of nifedipine in combination with oxygen and actual or simulated descent. The standard dose
is nifedipine 30 mg extended release given twice daily by mouth. Although hypotension is a
potential risk of treatment with nifedipine, this is not usually seen in practice. Most patients with
HAPE have an adrenergic response with very high levels of circulating catecholamines and are
hypertensive.

Phosphodiesterase Inhibitors: Phosphodiesterase inhibitors cause pulmonary vasodilation and

decrease pulmonary artery pressure. Phosphodiesterase inhibitors have been used in the
treatment of HAPE,124 but have not been formally studied. The most commonly used drugs are
sildenafil and tadalafil.

Beta-agonists: Although limited data suggest that salmeterol is beneficial in the prevention of
HAPE, there are no data to support the use of salmeterol or albuterol in the treatment of HAPE.
Inhaled beta-agonists have been used in combination with nifedipine in the treatment of
HAPE,124 but it is unlikely that beta-agonists add any benefit.

Dexamethasone: Like beta-agonists, limited data suggest that dexamethasone may be useful to
prevent HAPE.109 There are anecdotal reports of the use of dexamethasone as an adjunctive
treatment for HAPE, but there are no firm data that suggest that it is beneficial.

Diuretics: Furosemide was widely used in the past for the treatment of HAPE and seemed to be
beneficial,125 but caused volume depletion and was likely responsible for fatal cases due to
hypotension. Because many patients with HAPE already have intravascular volume depletion,
the use of furosemide is contraindicated in the treatment of HAPE.
STRATEGY FOR THE TREATMENT OF HAPE
The differential diagnosis of HAPE includes other causes of respiratory symptoms such as
pneumonia, bronchitis (viral upper respiratory infection), bronchospasm, mucus plugging,
pulmonary embolus, and acute coronary syndrome (Box 15.3). If HAPE is the most likely
diagnosis, descent is the usual treatment of choice. If descent is not feasible, descent can be
simulated using supplemental oxygen or a portable hyperbaric chamber. A patient with mild
HAPE can be treated with simulated descent if SpO2 can be maintained above 90% with either
oxygen126 or a chamber.114 When descent is not possible, a severely ill patient with HAPE may
benefit from simultaneous use of oxygen and a chamber. The oxygen tubing can be introduced
into the chamber at the end of the zipper that seals the chamber. The zipper is closed as tightly as
possible without squeezing the tube so hard that the flow of oxygen is obstructed. The resulting
leak, if any, is usually minimal. Nifedipine can be used as an adjunct to actual or simulated
descent. Nifedipine alone should only be used if actual or simulated descent is impossible.123 A
phosphodiesterase inhibitor such as sildenafil or tadalafil can be used if nifedipine is not
available.78 Multiple vasodilators, such as nifedipine and a phosphodiesterase inhibitor, should
not be used concurrently. Acetazolamide, beta-agonists, such as salmeterol, and diuretics are not
indicated for the treatment of HAPE.
A patient who has been treated for HAPE may reascend and may ascend further once
symptoms have completely resolved and SpO2 is stable at rest and with mild exercise without
oxygen or ongoing pharmacologic treatment. Use of nifedipine for reascent or further ascent is
advisable.78

Treatment of Combined AMS or HACE and HAPE

Patients with AMS and HAPE may be treated in situ, as described above for AMS and HAPE, if
neither condition is severe enough to require descent. Immediate descent is mandatory for a
patient who has both HACE and HAPE. Supplemental oxygen or simulated descent in a portable
hyperbaric chamber can be used as a temporizing measure if actual descent is not possible.
Specific pharmacologic treatment, usually dexamethasone and nifedipine, should also be
administered to a patient who has HACE and HAPE.78

First Aid
First aid for high altitude illness is descent. Simulated descent in a portable hyperbaric chamber
is an alternative first step, but should only be used if immediate descent is not possible. No
formal medical training is required to use a portable hyperbaric chamber, but a prescription is
required to buy a portable hyperbaric chamber in the United States.

Basic Life Support

Basic life support (BLS) for high altitude illness includes descent, both actual and simulated, by
a portable hyperbaric chamber. In addition, BLS for high altitude illness may include use of
oxygen. In many EMS systems, supraglottic airways may be available to BLS providers to
control the airway and support ventilation for patients with altered mental status. Most patients
with HACE or HAPE do not require supported ventilation.

Advanced Life Support

In addition to descent, both actual and simulated, and oxygen, advanced life support
interventions for altitude illness include medications and airway control by intubation for
patients with altered mental status. There is no clear role for noninvasive ventilation for the
prevention or treatment of altitude illness.

Clinician
In some systems, rapid sequence intubation may be allowed for clinicians but not for paramedics.
Many of the medications discussed in this chapter require a prescription, or medical oversight,
from a clinician.

Equipment Summary
Pulse Oximeter
Pulse oximeters have long been ubiquitous in health care settings (Figure 15.2). The
development of the finger pulse oximeter has made accurate assessment of oxygen saturation a
reality in the wilderness. The weight and size of a finger pulse oximeter are negligible. A finger
pulse oximeter should be carried by any WEMS provider who expects to be operating at high
altitude. Finger pulse oximeters have also become mandatory equipment for WEMS, even at sea
level. When measured using a pulse oximeter, oxygen saturation is abbreviated as SpO2. “True”
oxygen saturation, measured by arterial blood gas, is not necessary or desirable to assess patients
with altitude illness who are not intubated.
Like all equipment for WEMS, pulse oximeters have limitations. They should be kept warm
to assure adequate battery power. Cold fingers or ear lobes have limited circulation due to
vasoconstriction. Under cold conditions, it is often difficult or impossible to obtain an accurate
reading of SpO2. Cold skin can produce a falsely low reading of SpO2. Even the least expensive
pulse oximeters are adequate for diagnosis and treatment of high altitude illness.

FIGURE 15.2. Low-cost portable pulse oximeter.

Portable Fabric Hyperbaric Chamber

Several models of portable hyperbaric chambers are available for the treatment of high altitude
illness by simulated descent, including the Gamow Bag, Portable Altitude Chamber, and the
Certec Bag. A portable fabric hyperbaric chamber is a bag that can accommodate a patient. Once
the patient is sealed in the bag, the bag is inflated using a pump to an internal pressure 0.14
atmosphere (102 mm Hg) above ambient pressure.77 A “pop-off” valve regulates the pressure and
releases carbon dioxide (CO2). With regular pumping, pressure is maintained at 0.14 atmosphere
and there is minimal buildup of CO2 in the bag. The amount of simulated descent increased with
altitude. At 4,000 m, inflating the bag simulates a 1,560 m descent to 2,440 m. At 6,000 m, the
simulated descent is 2,025 to 3,975 m (for conversion of these values to feet, see Table 15.6).
The technology is identical to that used in inflatable rafts. Portable hyperbaric chambers are
relatively lightweight. One current model weighs under 6 kg, including the pump and the
carrying pack. The bag can be used indefinitely, unlike bottled oxygen.
In order to treat a patient, the bag is inflated using the pump. Air flow is maintained to vent
expired air in order to avoid buildup of CO2. This is accomplished by pumping every 5 seconds
(12 times a minute). The patient should be warmly dressed or placed in a sleeping bag, because
the air inside the bag will become cool and moist. A sleeping pad or mattress should be placed in
or under the bag. A patient with HAPE may not tolerate lying flat in the bag. Once the bag is
inflated and is rigid, the head end can be propped up. The patient must be breathing
spontaneously and should be conscious. The possibility of vomiting is a relative contraindication.
Although the bag has windows, a severely claustrophobic patient may not tolerate being
enclosed.
There is no standard protocol for treating HAPE or HACE with a portable hyperbaric
chamber.114 Typically the patient is placed in the bag for 1 hour at a time. The patient may be
markedly improved after treatment or may need multiple treatments. Between sessions, the
patient gets a short break to eat, drink, and urinate. A patient whose symptoms are sufficiently
improved and who is maintaining SpO2 near normal for the altitude can be observed outside the
bag. It is common for symptoms or relative hypoxemia to recur, necessitating further treatments.
If descent is feasible, treatment in a portable hyperbaric chamber should not be used as a
substitute for descent.

Table 15.6 Simulated Descent in a Portable Fabric Hyperbaric Chamber

Altitude Effective Altitude in Chamber
3,000 m 9,843 ft 1,555 m 5,102 ft
4,500 m 14,765 ft 2,787 m 9,144 ft
6,000 m 19,686 ft 3,975 m 13,1042 ft
7,500 m 24,608 ft 5,113 m 16,776 ft

Modified from Zafren K, Honigman B. High-altitude medicine. Emerg Med Clin North Am. 1997;15(1):191-222

Portable Ultrasound for High Altitude Illness

Portable ultrasound, sometimes called point-of-care ultrasound, has many uses in WEMS. It is
not an indispensable tool for high altitude illness, but may be a useful adjunct in some cases.
Ultrasound is likely to be more useful in the diagnosis of traumatic conditions at high altitude
than it is for high altitude illness.
Portable ultrasound has been used to determine optic nerve sheath diameter (ONSD) as a
surrogate marker for intracranial pressure in AMS.127–130 Results have been equivocal. It is
unlikely that measurement of ONSD will prove to be useful in the diagnosis or treatment of
AMS or HACE.
Portable ultrasound may be a useful adjunct in the diagnosis of HAPE. HAPE patients have a
higher comet tail score than patients without HAPE.124

SPECIAL CONSIDERATIONS FOR HIGH ALTITUDE

RESCUE

Limitations of Human and Equipment Performance

High altitude environments are often austere. Human performance and safety can be limited by
environmental conditions, including extremes of temperature and humidity, snow, rain, and
wind. Natural hazards in high altitude environments can include lightning, rock and icefall,
avalanches and terrain features such as cliffs, swift streams, and glaciers. The performance of
aircraft and other equipment can also be limited by environmental conditions, especially by
extreme cold or heat and by wind, rain, and snow.
Fluid losses may be increased by low humidity. Insensible fluid losses increase due to
increased ventilation at altitude. In cold conditions at high altitude, the need for warm bulky
clothing can affect dexterity. Sunglasses with ultraviolet protection are necessary for humans to
work safely on snow at high altitude, but their use can degrade the visual performance that may
be necessary to accomplish many tasks. Sunscreen is also necessary to protect exposed skin from
UV radiation.
In addition to environmental conditions and natural hazards, which are not unique to high
altitude environments, low atmospheric pressure associated with hypobaric hypoxia imposes
limits to human performance. Human work performance can be severely limited at high
altitudes.131 Maximum exercise capacity (VO2max) is decreased due to hypoxia. Human mental
performance can also be degraded. Cognitive132 and sensory impairment133,134 are inevitable at
very high altitudes and may be more severe in individuals who are not fully acclimatized. These
limitations may also affect patients who may have limited ability to assist in their own rescues.
Environmental conditions and weather hazards can cause critical hazards for aircraft. Even in
good weather, aircraft performance can be severely limited at altitude. Reduced performance of
aircraft may severely limit payloads compared to payloads at lower altitudes. Service ceilings
and payload capacity of helicopters and fixed wing aircraft can be improved up to a point by
removing unnecessary equipment and personnel and by limiting fuel. Unfortunately, unnecessary
equipment and personnel are often medical equipment and personnel. This can limit the
effectiveness of aircraft in providing medical care. Some helicopters that are useful for rescue at
low altitudes cannot be operated safely or effectively at higher altitudes, especially with the usual
complement of equipment and crew. The crash of a Pave Hawk helicopter during a rescue on Mt.
Hood in Oregon in 2002 illustrated the risks of using a helicopter above its effective service
ceiling.135 Even for helicopters operating within relatively safe limits, maneuvers such as short
haul or winching decrease the margin of safety. Use of helicopters at altitudes above 5,000 m
(16,404 ft) is extremely risky, even by the most experienced pilots. A few successful rescues
have taken place above 6,000 m (19,686 ft) in the Himalayas, although one of the most
experienced pilots in Nepal was killed in a crash above 6,000 m (19,686 ft) in 2010.
 Computers, including those associated with ultrasound, are prone to overheating at high
altitude due to decreased heat transfer of air at atmospheric pressures that are substantially lower
than the pressure at sea level. Hard drives are at risk of crashing, especially above 5,000 m
(16,404 ft), because the read-write heads are suspended above a disk on a cushion of air. At
altitude, the amount of air may not be enough to prevent physical contact of the read-write heads
with the disk. Computers with solid-state “hard drives” are not susceptible to this failure mode.
Other hazards to computers in WEMS that are not unique to high altitude include rough
handling, moisture, especially in a “condensing atmosphere,” and static electricity.

SUMMARY
High altitude illnesses are preventable and treatable. WEMS providers should understand
prevention and treatment for their own safety when operating at high altitude as well as for the
benefit of their patients with high altitude illness.

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79. Consolazio CF, Matoush LO, Johnson HL, et al. Effects of high-carbohydrate diets on performance and clinical
symptomatology after rapid ascent to high altitude. Fed Proc. 1969;28(3):937-943.
80. Basnyat B, Gertsch JH, Johnson EW, et al. Efficacy of low-dose acetazolamide (125 mg BID) for the prophylaxis of acute
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81. Basnyat B, Gertsch JH, Holck PS, et al. Acetazolamide 125 mg BD is not significantly different from 375 mg BD in the
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82. van Patot MC, Leadbetter G, Keyes LE, et al. Prophylactic low-dose acetazolamide reduces the incidence and severity of
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83. Rock PB, Johnson TS, Larsen RF, et al. Dexamethasone as prophylaxis for acute mountain sickness. Effect of dose level.
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84. Hackett PH, Roach RC, Wood RA, et al. Dexamethasone for prevention and treatment of acute mountain sickness. Aviat
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86. Lipman GS, Kanaan NC, Holck PS, et al. Ibuprofen prevents altitude illness: A randomized controlled trial for prevention
of altitude illness with nonsteroidal anti-inflammatories. Ann Emerg Med. 2012;59(6):484-490.
87. Gertsch JH, Lipman GS, Holck PS, et al. Prospective, double-blind, randomized, placebo-controlled comparison of
acetazolamide versus ibuprofen for prophylaxis against high altitude headache: the Headache Evaluation at Altitude Trial
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88. Zafren K. Does ibuprofen prevent acute mountain sickness? Wilderness Environ Med. 2012;23(4):297-299.
89. Gertsch JH, Seto TB, Mor J, Onopa J. Ginkgo biloba for the prevention of severe acute mountain sickness (AMS) starting
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91. Moraga FA, Flores A, Serra J, et al. Ginkgo biloba decreases acute mountain sickness in people ascending to high altitude
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92. Chow T, Browne V, Heileson HL, et al. Ginkgo biloba and acetazolamide prophylaxis for acute mountain sickness: a
randomized, placebo-controlled trial. Arch Intern Med. 2005;165(3):296-301.
93. Gertsch JH, Basnyat B, Johnson EW, et al. Randomised, double blind, placebo controlled comparison of Ginkgo biloba and
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94. Leadbetter G, Keyes LE, Maakestad KM, et al. Ginkgo biloba does--and does not--prevent acute mountain sickness.
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95. Leadbetter G, Keyes LE, Maakestad KM, et al. Ginkgo biloba does–and does not–prevent acute mountain sickness.
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96. Jafarian S, Gorouhi F, Salimi S, Lotfi J. Sumatriptan for prevention of acute mountain sickness: randomized clinical trial.
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97. Jafarian S, Abolfazli R, Gorouhi F, et al. Gabapentin for prevention of hypobaric hypoxia-induced headache: randomized
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98. Meehan RT, Cymerman A, Rock P, et al. The effect of naproxen on acute mountain sickness and vascular responses to
hypoxia. Am J Med Sci. 1986;292(1):15-20.
99. Jain SC, Singh MV, Sharma VM, et al. Amelioration of acute mountain sickness: comparative study of acetazolamide and
spironolactone. Int J Biometeorol. 1986;30(4):293-300.
100. Larsen RF, Rock PB, Fulco CS, et al. Effect of spironolactone on acute mountain sickness. Aviat Space Environ Med.
1986;57(6):543-547.
101. Basnyat B, Holck PS, Pun M, et al. Spironolactone does not prevent acute mountain sickness: a prospective, double-blind,
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102. Roach RC, Larson EB, Hornbein TF, et al. Acute mountain sickness, antacids, and ventilation during rapid, active ascent of
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103. Dumont L, Lysakowski C, Tramer MR, et al. Magnesium for the prevention and treatment of acute mountain sickness. Clin
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104. Hohenhaus E, Niroomand F, Goerre S, et al. Nifedipine does not prevent acute mountain sickness. Am J Respir Crit Care
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105. Wright AD, Beazley MF, Bradwell AR, et al. Medroxyprogesterone at high altitude. The effects on blood gases, cerebral
regional oxygenation, and acute mountain sickness. Wilderness Environ Med. 2004;15(1):25-31.
106. Baillie JK, Thompson AA, Irving JB, et al. Oral antioxidant supplementation does not prevent acute mountain sickness:
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107. Zafren K. Prevention of high altitude illness. Travel Med Infect Dis. 2014;12(1):29-39.
108. Sartori C, Allemann Y, Duplain H, et al. Salmeterol for the prevention of high-altitude pulmonary edema. N Engl J Med.
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109. Maggiorini M, Brunner-La Rocca HP, Peth S, et al. Both tadalafil and dexamethasone may reduce the incidence of high-
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114. Taber RL. Protocols for the use of a portable hyperbaric chamber for the treatment of high altitude disorders. J Wilderness
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*When measured by pulse oximeter, oxygen saturation is reported as SpO2 as opposed to SaO2, which is oxygen saturation
measured by blood gas analysis. Blood gas analysis has no role in WEMS.
INTRODUCTION
Water covers more than 70% of the earth and can be beautiful, fun, and life sustaining. But, for
as long as there have been people, the hazards of water have caused morbidity and mortality.
From backyard swimming pools to placid lakes, from the ocean to fast-moving rivers, water
presents an opportunity for fun, beauty, or tragedy.

Definition
The term drowning has often been used to describe death from being underwater. There were
numerous published definitions of drowning and ancillary terms such as “near,” “wet,” “dry,”
“secondary,” or “delayed” drowning. These terms are poorly defined throughout the scientific
literature and in common usage. As a medical, research, scientific, and lay community, we have
long used these terms to try and explain those persons who drown and survive the initial
incident. To provide clarity, a consensus definition was created in 2002 and subsequently
accepted by the World Health Organization, the International Liaison Committee on
Resuscitation, the Wilderness Medical Society, the Utstein Style system, the International
Lifesaving Federation, the International Conference on Drowning, Starfish Aquatics Institute, the
American Red Cross, the U.S. Centers for Disease Control and Prevention, the American Red
Cross, and numerous other medical, first aid, and cardiopulmonary resuscitation (CPR) societies.
All these groups specifically caution against the use of older terminology, such as “dry,”
“secondary,” or “near” drowning, or their analogues.”1–9 There are only three outcomes to the
drowning process—death, survival with morbidity, and survival without morbidity. The
emphasis of the new definition is to understand drowning as a process and not as an outcome.5
Every year, thousands of people in the United States survive heart attacks or stroke. Some of
these survivors return to their normal activities of daily living and some require around the clock
care from family or skilled nursing facilities. You would not refer to these survivors as having
had a “near-stroke” or “near-heart attack”; in the same way, you should not refer to the survivor
of a drowning incident as a “near-drowning.”10 It is possible to drown and survive with the
outcome of death; with no morbidity; and with mild, moderate, or severe morbidity. The
preferred terminology would be to refer to a drowning incident as fatal or non-fatal.

Scope of Discussion
Similar to cardiac arrest, there is a drowning chain of survival11 (Figure 16.1).
Most simply, it is prevention, rescue, and treatment. As with most things in the outdoors,
knowledge of the risks and hazards is the most important tool of prevention. Once prevention has
failed, timely rescue and appropriate treatment are vital to reduce morbidity and prevent death.
This chapter will cover the physiology, prevention, rescue, and treatment of drowning and its
associated injuries. Rescue techniques and technical rescue are beyond the scope of this chapter.
However, technical rescue in general is covered in Section Three of this book, with swiftwater
rescue covered in Chapter 26 and open water rescue covered in Chapter 27.

EPIDEMIOLOGY
Drowning is common and often underreported. The discussion of its epidemiology is confusing
and can be misleading. According to the 2014 World Health Organization Global report
Drowning: Preventing a Leading Killer, it is the third leading cause of unintentional injury death
with 372,000 drowning deaths per year.12 More than 90% of the world’s drowning deaths occur
in low and middle income countries. Frequently, these deaths occur in settings where there are
no formal emergency medical services (EMS) or hospitals, so data are lacking.13 The most
conservative estimate is that for every drowning death that is reported, an additional five receive
care in the emergency department (ED).14–16 Additionally, for every fatal drowning incident,
there are four or more non-fatal drowning incidents.14–16 The 372,000 drowning deaths likely
represent 1,860,000 deaths and an additional 7,444,000 non-fatal drowning incidents, though
exact numbers are difficult to confirm. The outcome of the non-fatal drowning is not well studied
and ranges from mild developmental delay to neurologic devastation and anoxic brain injury
requiring around the clock care.17

FIGURE 16.1. Drowning chain of survival. From Szpilman D, Webber J, Quan L, et al. Creating a drowning chain of survival.
Resuscitation. 2014;85(9):1149-1152.

To further complicate data collection, drowning deaths that occur as a result of boating,
floods, or natural disasters are classified separately. The exact number of drowning deaths and
non-fatal drowning incidents that occur during floods and natural disasters is difficult to obtain.
In the United States, there are an average of 3,563 drowning deaths per year plus an additional
332 boating-related deaths.*,†
At the time of this writing, there is a massive humanitarian crisis of refugees fleeing the
Middle East and Africa into Europe via North Africa and the Mediterranean Sea. By mid-
November 1, 2016, there were 332,674 persons arriving in Europe by the sea route with 3,930
dead or missing. Though there were 1,015,078 arrivals by sea in 2015, there were only 3,771
dead or missing at sea, making 2016 far deadlier for those making the treacherous crossing.
These deaths are not reported as “drowning” incidents and are often tabulated as aquatic
transport accidents.
Worldwide, the highest risk group for drowning is 1- to 4-year-old children who wander into
residential swimming pools or natural bodies of water during brief lapses in supervision, often
from a nonparent caregiver. Drowning kills more children aged 1 to 4 than any cause other than
birth defects.18 Another high risk group is teenaged or college aged recreational boaters without
lifejackets. In 2015 alone, the United States Coast Guard recorded 626 fatal boating incidents, of
which 85% were not wearing a life jacket.19 Across the spectrum of low, middle, and high
income countries, males represent approximately 80% of drowning deaths. Drowning accounts
for the highest number of fatalities at U.S. National Parks, even more than heat, cold, wildlife,
vehicle, boat, bus, bike, and airplane collisions combined.20

CLINICAL MANAGEMENT
Drowning patients can present with mild, moderate, or severe symptoms.21 The primary source
of morbidity and mortality is anoxic brain injury, and the immediate treatment priority after
rescue is providing oxygen to the brain.22,23 If the person survives the initial incident, then further
morbidity and deterioration are determined by the amount of anoxic brain injury. Drowning is a
brain problem with lung complications.

Identification
The drowning process begins when the mouth and nose fall below the water, or are immersed
from the action of waves, sea spray, swiftwater, or other such means. During the initial struggle,
there is breath holding. Very little, if any, water enters the lungs during the struggle, and the
amount that does enter is typically less than 30 mL.21
The published medical literature and anecdotal experience show that time to unconsciousness
and pulselessness in drowning patients is varied based on the person’s age, comorbidities,
underlying physical conditioning, and physiologic state.24,25 In operating room studies of normal,
healthy, adults, the time to unsafe apnea, with resultant loss of consciousness, is 1 minute, as
compared to 8 minutes if they receive high flow oxygenation prior to induction of paralysis.
From the same studies, an obese (127 kg) adult would only have 162 seconds of safe apnea after
prolonged preoxygenation and a 10-kg child only 200 seconds.24,25 This time is expected to be
significantly shortened in a drowning person who obviously did not receive preoxygenation.
Thus, many drowning persons will lose consciousness within seconds or 1 to 2 minutes.
Before losing consciousness, there may or may not be additional aspiration of water. This
was previously attributed to laryngospasm, which is much more rare than previously described
and in reality occurs in only 3% to 5% of drowning patients.21 In the first few minutes after
losing consciousness, the person will still have protective airway reflexes. As water enters the
mouth, oropharynx, and upper airways, it may be spat out or reflexively swallowed, which
prevents water from entering the lungs. Autopsy studies of known drowning patients show that
only 1 to 2 mL/kg body weight actually enters the lungs.26 It is thought that some of the water
may also be absorbed across the alveolar membrane. Conversely, these same patients may have
no water or several liters of water in the stomach.26 Drowning is not necessarily a problem of the
lungs filling with water.27 While the person is underwater, the blood becomes progressively more
hypoxemic and acidemic. The brain is the most sensitive organ to hypoxemia and may begin to
suffer irreversible damage within minutes.21,26 Drowning is a brain problem with lung
complications. Reversing the cerebral hypoxia is the primary goal of emergent treatment.
The small volumes of water that enter the lungs can still complicate efforts at initial
oxygenation and ventilation. Regardless of salinity, the water damages pneumocytes resulting in
atelectasis and impaired gas exchange at the alveolar level.21,26
The aspirated water also mixes with the pulmonary surfactant, causing atelectasis and
creating potentially large volumes of non-cardiogenic pulmonary edema (foam). Pediatric
patients, the elderly, and persons with medical comorbidities are the most sensitive to
decompensation from an initially minor drowning incident. In the absence of an anoxic brain
injury, the amount of water aspirated determines the severity of initial injury. For patients who
survive the initial incident without cerebral hypoxia, long-term pulmonary morbidity has not
been described in the literature, and the lungs tend to heal themselves over the next 24 to 48
hours.21,26,28
The largest case series to date on drowning patients describes the rescue and treatment of
nearly 42,000 patients rescued by ocean lifeguards in Brazil.29 In the model proposed by this case
series, drowning patients may present with mild, moderate, or severe symptoms (Table 16.1).

The Minimally Symptomatic Grade: Grade 0 to 1

These patients may have been underwater for only a brief time, or have had their face
intermittently immersed from waves, whitewater, sea spray, etc. Their symptoms are limited to a
mild cough and no foam present at the mouth or nose. There is typically no aspirated water in the
lower airways and they are able to clear the upper airways by coughing alone. Based on the
largest case series to date, mortality is 0%.

The Moderately Symptomatic Grade: Grade 2 to 3

These patients will present with small or large amounts of foam from the mouth or nose. They
may be conscious and coughing or, due to decreased oxygen delivery to the brain, their mental
status may range from confused to combative to unconscious. Whether the patient is an adult
struggling in whitewater or a child sinking silently to the bottom of a pond, they are releasing
large amounts of epinephrine and endogenous catecholamines to keep the hypoxic heart beating.
Upon rescue, they will likely be completely exhausted and seemingly unresponsive despite being
conscious. Grade 2 and 3 drowning patients will often have reversible degrees of cerebral
hypoxia and respond well to oxygenation and interruption of the drowning process. Mortality in
this group is 0.5% to 5%.
These patients have previously been mislabeled as “dry,” “secondary,” “delayed,” “near,” or
“parking lot” drownings. There is no accepted medical definition of these terms and all major
accrediting bodies actively discourage their use. Because the term “drowning” is often used to
mean death, we often are at a loss for a way to describe the patients who are initially
symptomatic and later survive. These cases are frequently described in the media as children or
adolescents who “drown on dry land” or “drown in their sleep,” which can be frightening to
medical professionals and the lay public. In reality, these patients show symptoms as soon as
they come out of the water. There are no published case reports of a completely asymptomatic
patient later developing symptoms. With a mortality of 0.5% to 5%, all symptomatic patients
require evaluation in an ED and are monitored for the development of symptoms over the next 4
to 8 hours. Disposition is discussed in detail below.

Table 16.1 Classification of Drowning Patients

Signs/Symptoms Mortality (%) Treatment
Grade 1 Cough, no foam at mouth/nose 0 Thorough history—Release home with
education
Grade 2 Small amount foam in mouth or nose, 0.6 N/C O2—Hospital
+Rales
Grade 3 Large amount foam, normal BP (radial 5.2 ETT/NRB O2—Hospital
pulse present)
Grade 4 Large amount foam, low BP (radial pulse 19.4 ETT/NRB O2, IV Fluids—Hospital
absent)
Grade 5 Respiratory arrest 44 ETT/NRB O2, IV Fluids—Hospital
Grade 6 Cardiopulmonary arrest 93 ETT/NRB O2, IV Fluids, AED—Hospital
Do not resuscitate if down >1 h

From Szpilman D. Near-drowning and drowning classification: a proposal to stratify mortality based on the analysis of 1,831
cases. Chest. 1997;112(3):660-665.

The Severely Symptomatic Patient: Grade 4 to 6

Progressive hypoxemia eventually leads to hypotension followed by respiratory and then cardiac
arrest. There is often a large amount of foam in the mouth and nose, cold, clammy, cyanotic skin,
and rapid heart rate. Grade 4 to 6 patients are unconscious and in need of immediate resuscitation
to interrupt the drowning process. Mortality in this group ranges from 20% to 93%.

Prevention
As with most injuries, prevention has a far greater ability to save lives and prevent tragedy than
rescue and treatment. Prevention can be categorized according to the risk factors for specific age
groups.

Drowning Prevention in Ages Younger than Six

Worldwide, and across income levels, this is the highest risk age group for drowning, and for
many of the same reasons. Children at this age are mobile enough to fall into small and large
bodies of water, from buckets to toilets to pools or ponds, without necessarily being able to right
themselves or self-extricate. They are often unaware of the hazards and can be drawn to the
shimmer of the water, pool toys, or other such objects without being aware of the danger.
Throughout the developed world, water is typically restricted to recreational or utility areas. In
developing nations and wilderness settings, water may be ubiquitous and is the source of
sustenance for drinking, bathing, commerce, and transportation. Where there is water, there is
always risk. It is impossible to make water safe, so we must strive to make it safer. There is no
single “silver bullet” strategy and prevention requires layers of protection (Figure 16.2).
Maneuvers for injury prevention in this age group can be remembered by the familiar EMS
mnemonic ABCD, repurposed here for drowning prevention.

A. Adults. Adult supervision must be constant and uninterrupted. The risk of drowning
increases significantly when the child is being supervised by a non-primary adult (eg,
babysitter, aunt, sibling, etc.) or by another child. Numerous cases involve brief lapses in
supervision, with the caregiver often reporting “I only turned away for a moment.” A child
will only struggle at the surface of the water for approximately 20 seconds before sinking,
and the struggle is often silent. While around the water, “touch supervision” is
recommended, with the child within arm’s length of the caregiver at all times. During
outdoor or backyard events where there is a pool or natural water nearby, a lifeguard or
“Water Watcher” (Figure 16.3) should be appointed. There are numerous variations of the
water watcher program, but this should be a sober, responsible adult who watches the body
of water, without interruption from eating, drinking, telephone, text messaging, or other
distractions.

FIGURE 16.2. The ABCD’s of drowning prevention.

A whistle or water watcher tag often worn to denote responsibility is handed off to the
next adult who assumes responsibility. Numerous fatal and non-fatal child drowning
incidents have occurred with a large number of adults around the body of water, incorrectly
assuming that someone else was watching the children.
B. Barriers. Pool fences with self-latching gates that cover the pool on all four sides are
preferred to those that surround only three sides, with the fourth side being the home. With
 only three sides covered, the child can access the pool from an unsecured back door, doggie
door, or sliding glass door. Load bearing pool covers, door and gate alarms, pool alarms,
and child wearable devices all contribute to the layers of protection.
C. Classes. The American Academy of Pediatrics recommends swim lessons for ALL children
age 4 years and older and suggests swim lessons for kids age 1 to 4 years based upon their
individual developmental abilities.29 There are favorable studies showing a lifelong benefit
and reduced risk of death by drowning for kids enrolled in formal swim lessons under age
four.30,31 Swim lessons should not replace touch supervision, but are part of the layers of
protection. Parents and caregivers should also take age-appropriate CPR classes that include
specific instructions for chest compressions and ventilation in pediatric cardiac arrest.

FIGURE 16.3. Example of Water Watcher tag. Copyright 2016 by Colin’s Hope. All rights reserved. This document may be
copied and distributed for personal and educational purposes provided the content is unchanged. All reproductions must include
this copy permission statement, the copyright notice, the Colin’s Hope Logo and website link, http://www.colinshope.org.

D. Devices. Safety equipment such as life rings, shepherd hooks, throw bags, and rescue buoys
should be readily available and in good working order while around the water. Age-
appropriate, properly fitted, United States Coast Guard–approved life jackets should be
worn at all times when on the water, and strongly considered when around the water.
Many of these interventions are unique to high income countries and settings. With so
many of the world’s drowning deaths occurring in low and middle income countries,
additional strategies are employed, many with corollary to the wilderness EMS
environment. The largest survey to date showed that most of the drowning deaths in this age
group in Bangladesh occurred between the hours of 0900 and 1300, while dad as at work
and mom was busy doing household chores.32 The creation of community day care
 “crèches,” providing locally sourced playpens, and water safety community “theater” have
been effective in reducing the number of drowning deaths in resource-deficit
environments.33–36

Drowning Prevention in Ages 5 to 10

In addition to the ABCDs, increased emphasis is placed on swim lessons and teaching the
importance of water safety and the use of lifejackets when around the water. Swim lessons are
not a substitute for swimming with a buddy, life jacket use, or adult supervision where
appropriate. Swim lessons have also been effective in reducing the burden of drowning in
resource-deficit countries.37 Additionally, one study showed that many of the children in this age
group who drowned had an age-matched peer with them at the time.37 There is a learn-to-swim
program in Bangladesh that has also been effective in teaching 5-to-10-year-olds how to perform
a “reaching” rescue with the ever present bamboo pole.37

Drowning Prevention in Ages 10 to 55

In addition to lack of swimming ability, risk-taking behavior contributes to drowning deaths in
this age group. Avoidance of drugs and alcohol while on the water, usage of lifejackets, helmets
where appropriate, and knowledge of water and weather conditions help to reduce risk.38

Drowning Prevention in Ages 55+

Primary cardiac, neurologic, or endocrine medical events and polypharmacy contribute to
drowning incidents in this age group.39,40 These can be prevented by attention to these primary
medical conditions, and monitoring patient’s alertness and possible side effects of drugs (or
drugs in combination) when around water. In addition, many of these drownings occur in bathing
circumstances. This is less likely to be relevant for a wilderness EMS team but may be operative
if responding to wilderness huts or expedition bases.

Treatment and Disposition

Minimally symptomatic patients (those with grade one based on Table 16.1) can be released after
rescue with appropriate education. They do not require any additional treatment beyond initial
rescue and reassurance. The patient should be evaluated for any concomitant traumatic injuries
where appropriate. They should be advised to seek care if they develop a cough, difficulty
breathing, confusion, or any other symptoms within the next 8 hours.
Moderately symptomatic patients (grades 2 and 3) who are conscious, but with altered
mental status or difficulty breathing, should be provided supplemental oxygen by any delivery
method and concentration that is available. A reasonable approach is to start with a partial
rebreather mask or bag valve mask (BVM) and de-escalate to a simple mask or nasal cannula as
guided by the patient’s response. In the urban setting, all patients who require supplemental
oxygen should be transported to an ED for observation. In the wilderness setting, this may not be
practical and there is some guidance in the section above as to which patients may not need
emergent evacuation. Conversely, if the patient’s symptoms continue to progress after the initial
evaluation, then it can be expected that their condition will worsen and evacuation should be
arranged and expedited.
Previous guidelines for the disposition of minimally symptomatic patients have expressed
concern over the development of symptoms 12, 24, or 48 hours after the initial non-fatal
drowning incident. The available literature on the topic is limited and of low quality. One study
showed that 10% of pediatric patients were asymptomatic by the time they reached the ED and
70% were asymptomatic at 8 hours.41 A retrospective review of 61 pediatric patients showed that
all patients who were asymptomatic with a normal oxygen saturation at 4 to 6 hours remained
asymptomatic.42 No patients in a series of 22 asymptomatic drowning patients presenting to the
ED later developed symptoms, calling into question the idea that there is a truly asymptomatic
period that can later progress to deterioration.43
All symptomatic patients require evaluation in an ED. A prudent approach that is advocated
by some ED physicians is to observe patients for a period of 4 to 8 hours. The patients who
qualify for safe ED discharge are those with the following characteristics:

a normal mental status

normal respiratory effort
normal oxygen saturation on room air
submersion was brief
no advanced cardiac life support interventions were needed during the observation period.

In an austere environment or wilderness setting, evacuation to definitive care may take more
than 4 to 8 hours. Though local protocols and policies should be followed at all times, a
reasonable approach may be to observe the minimally symptomatic patient in the field for 4 to 8
hours. Those who become asymptomatic during that time may not require evacuation and
transport to definitive care. Conversely, a minimally symptomatic drowning patient whose
symptoms become worse can be expected to continue to deteriorate and requires priority
evacuation and aggressive oxygenation. A moderately symptomatic drowning patient (grades 2
to 3) who shows clinical deterioration may be considered for emergent evacuation via fixed or
rotor wing transport if available.
Moderately or severely symptomatic patients (grades 2 to 5) who are unconscious or
unresponsive require immediate oxygenation and ventilation by any means available. Among
other agencies, the State of North Carolina Office of EMS, California State Parks, and the
European Resuscitation Council advocate for initial resuscitation with five rescue breaths before
checking for a pulse.44,45 The American Heart Association and other agencies recommend
starting with two breaths.22 If a pulse and signs of circulation are absent, then commence chest
compressions and ventilations according to standard CPR guidelines. If a pulse or signs of
circulation are present, then continue with rescue breathing according to standard guidelines.
Supplemental oxygen should be provided at the highest concentration by whatever means are
available. If no supplemental oxygen is available, then ventilations can be performed with a
BVM using room air, or with ventilations utilizing mouth to mouth or mouth to mask techniques.
It has been specifically studied in the post-HIV era that the risk of serious disease transmission
from performing mouth to mouth on a drowning patient is negligible, approaching one in one
billion.46,47 EMS professionals on duty should not be placed in a situation where they must
perform ventilations without appropriate barrier devices. However, in the off duty setting, when
it is your child or your niece, nephew, or friend’s child that is pulled from the water, you must be
the professional rescuer that ensures both breaths and compressions are provided, even if no
barrier device is available. Patients who are grade 2 to 5 require evacuation and additional
treatment by the most rapid and practical means necessary.
Moderately and severely symptomatic drowning patients (grades 2 to 5) may have large
amounts of non-cardiogenic pulmonary edema (foam) in the airway and oropharynx. During the
initial resuscitation, it is easy for the rescuer to become distracted with “clearing the airway” and
focus on suctioning and clearing this foam at the expense of oxygenation and ventilation. Several
articles have addressed this and recommend to not spend significant time or resources clearing
the airway of foam, as it only delays oxygenation and ventilation.21,48,49 Even if it is cleared from
the upper airways, it is not removed from the alveoli and therefore not effective. If the airway is
obstructed by vomitus or water, then it must be cleared since these will occlude air from entering
the trachea. An Australian study of over 400 rescues over a 10-year-period found that 86% of
drowning patients vomited during resuscitation. Providers should train appropriately for this
contingency.48
Many drowning patients will have some degree of hypothermia after they are rescued and
may need passive or active rewarming. The treatment of hypothermia is beyond the scope of this
chapter and is discussed in detail in Chapter 13.
Search and rescue (SAR), field treatment, and evacuation of drowned persons in cold water
can be complex, risky, and resource intensive. With unlimited safety, financial, and human
resources, SAR operations could go on indefinitely. But the realities of the operational
environment require that agencies have guidance in determining the allocation of resources.
Bluntly, when should a rescue operation be scaled back into a recovery? When a person is
recovered, under what circumstances should resuscitation be initiated, and under what
circumstances is it futile?
Though there are many legends and tales among EMS, SAR, and wilderness rescue
communities of survival after prolonged submersion in cold water, the reality is that duration of
submersion is the only factor that predicts outcome. There are only 43 published cases of
survival after prolonged submersion in cold water, 29 of whom were children under 12 years of
age. In a meta-analysis of 1,254 patients in 6°C to 8°C water and 1,335 patients in 15°C to 17°C
water, there was no difference in survival for drowned patients. In the final cohort of 2,628
patients in 15°C to 17°C water, outcomes were worse for those drowned in cold water.50,51
Age of the patient, salinity, and whether or not the drowning incident was witnessed did not
predict outcome. Patients with a known submersion time of less than 5 minutes had an 86% rate
of survival versus only 11% for those submerged longer. Additionally, survival was 77% when
submersion was less than 10 minutes versus 4% for longer than 10 minutes. Outcomes of
patients with submersion times of 15 to 25 minutes are widely varied and patients who
submerged longer than 25 minutes have universally bad outcomes.
Agency-specific patient SAR operation versus body recovery operation guidelines must
consider numerous factors beyond just the published data on prognosis. A strict guideline for an
agency with limited resources or a hazardous operational environment may be to transition from
SAR to recovery after 30 minutes of known submersion, regardless of age or water temperature.
A more conservative guideline may be more in line with the one used by the United Kingdom
Fire Rescue Service and incorporates duration of submersion, age, and water temperature
(Figure 16.4). A dynamic risk assessment is undertaken upon arrival of fire/EMS and the clock
is started. If the water temperature is greater than 6°C and the patient is an adult, then operation
transitions to a recovery after 30 minutes. If the patient is a child or the water is 6°C or less, then
the rescue continues for a total of 60 minutes. If the water is less than 6°C and the patient a child,
then the search continues for a total of 90 minutes.
FIGURE 16.4. Algorithm of the United Kingdom Fire and Rescue Services National Operational Guidance Program for
managing water-related emergencies. DRA, dynamic risk assessment. Modified from Water Rescue and Flooding. National
Operational Guidance Programme website. Available at: https://fireandrescue-public.sharepoint.com/. Updated January 13,
2017. Accessed May 10, 2017.
 Though individual protocols will vary among agencies, it is important that a policy be in
place to guide rescuers.

Drownings in Submerged Vehicles

The proper approach to take to prevent drowning in a submerging vehicle has been controversial,
and new evidence is helping us understand better the best ways to help these types of patients.
This is another area where evidence-based medicine has influenced practices, as the
recommendations existing before scientific scrutiny were often the opposite of what we now feel
is most appropriate care. Drowning as the result of motor vehicles going into water is common,
but often underreported.52,53 While it is more frequently encountered during disasters, drowning
in motor vehicles may account for as much as 10% of all drowning deaths in the United
States.54–57 In addition to the trauma of the motor vehicle collision itself, increased mortality may
be due to the driver or passenger’s inability to escape. A lack of public awareness, a lack of
definitive guidelines, and popular misconception on how to escape a sinking vehicle all
contribute to the difficulty in escaping a sinking vehicle.
Many popular culture sources recommend the ill-fated practices of letting the vehicle fill
with water or sink to the bottom before trying to escape, kicking out the windshield, opening the
doors, or breathing trapped air.55,58 The most recent and thorough experiments on sinking
vehicles shows that vehicles float for only 30 to 120 seconds before sinking. During this time,
the windows should be rolled down and the vehicle exited as quickly as possible.59 This phase
can be further complicated if the conditions outside the vehicle are unsafe (eg, swiftwater) or if
the driver cannot swim, but the risk of staying in the vehicle is certain death. The same study
showed that three adults were able to exit the vehicle and release a child manikin from the rear
seat in 51 seconds. Once the vehicle has sunk at approximately 2 minutes, there is an ever
decreasing amount of air in the vehicle as it fills with water and it becomes increasingly difficult
to open doors or windows.
EMS and EMD agencies often interface with the public to deliver safety messages on
drowning, fire prevention, helmet use, and other preventable injuries. In addition to taking the
first step and including discussions on how to survive a sinking vehicle, the message must be
simple and accurate. Uniform messaging for escaping a sinking vehicle should include directions
to immediately remove seatbelt, open windows, and escape. If children are present, adults should
remove their own seatbelt, open their own window, then release the children’s seatbelt and bring
them closer to themselves. If necessary, children can also be pushed out of a window and
immediately followed by the adult (Box 16.1).

Recommended Algorithm for Escaping from a Submerging

Box 16.1
Vehicle55,59,60
• Seatbelts: unfastened
• Windows: open
• Children: if present, released from restraints and brought close to an adult who can assist in their escape
• Out: children should be pushed out of the window first, and followed immediately

First Aid
The spectrum of drowning ranges from mild to moderate to severe. First aid for the drowning
patient should be to remove them from the water and deliver oxygen to the brain by the highest
concentration available. For conscious patients who still have some respiratory effort, passive
oxygenation may be sufficient, but unconscious patients will often require active airway
management and positive pressure ventilation. It should be noted, however, that drowning
patients of all grades will often have some degree of hypothermia and, if so, rewarming should
begin immediately.
For agencies that are tasked with performing technical rescues in the water, consideration
should be given to starting rescue breathing while in the water.61,62 A series of ocean lifeguard
rescues in Brazil shows a three times increase in survival when rescue breathing was initiated in
the water. The context for this study was that lifeguards frequently performed rescues in heavy
surf and, rather than swim the patient in, would stay beyond the surf impact zone and perform
rescue breathing while awaiting extraction from a helicopter.
The drowning patient is dying from lack of oxygen to the brain and the sooner the drowning
process is interrupted, the greater the chance for neurologically intact survival. Rescue breathing
in the water is a technically difficult task that requires recurrent training to perform correctly.
Chest compressions should never be attempted while in the water as they are ineffective and
would further delay removal from the water and effective resuscitation.
There is no “one size fits all” approach to performing rescue breathing in the water. A
swimmer or diver who has likely suffered a primary cardiac arrest in the water needs to be
defibrillated as quickly as possible and extrication should not be delayed to perform rescue
breaths. In swiftwater or heavy surf, the risk to the rescuer may be too great to perform this
technical task and efforts should be focused on rapid, safe rescue, and extrication from the
dangerous conditions. However, if a rescuer reaches a drowned person and can safely provide
five rescue breaths before beginning the swim toward the boat or shoreline, then this may
interrupt the drowning process sooner and provide much needed oxygen to the brain.
Decades of EMS training has focused on the importance of “protecting the c-spine” in all
patients who are unconscious from an unknown etiology. The rationale was often that movement
of the neck by rescuers would exacerbate the initial injury and cause paralysis. In a drowning
patient with respiratory distress or apnea, initial resuscitation should focus on getting oxygen to
the brain. Cervical collars are known to further complicate airway management in the
unconscious drowning patient and may lead to worse outcomes from cerebral hypoxia. An in-
depth discussion of cervical spine management and packaging in the context of trauma can be
found in Chapters 21 and 24. In the context of the drowning patient, the largest series to date
shows that less than 1% of drowning patients have a concomitant cervical spine injury.63 All of
the patients in that study with a cervical spine injury would have been identified by a high
velocity mechanism. In addition, as discussed in Chapters 21 and 24, modern wilderness EMS
principles exclude the use of long spine boards or other attempts at immobilization of the
remainder of the spine as well. Long spine boards in the drowning environment may have utility
for extrication (removal of patient from the aquatic or technical environment) but should not be
used for immobilization. Routine immobilization of the conscious or unconscious drowning
patient is not indicated.

Basic Life Support

For all drowning patients with altered mental status or unconsciousness, initial attention must be
given to interrupting the drowning process by giving breaths via mouth to mouth, mouth to
mask, or BVM. After providing the initial breaths, quality chest compressions and ventilations
are vital. Due to the hypoxemic nature of cardiac arrest in drowning patients, automated external
defibrillators (AEDs) are effective in less than 10% of drowning patients, but should be applied
and in some circumstances may be useful.
The role of the emergency medical dispatcher (EMD) has expanded in recent years.
Dispatcher-assisted CPR has improved outcomes from out-of-hospital cardiac arrest (OHCA) by
directing bystanders to provide compression-only CPR while awaiting the arrival of EMS.64–69
Earlier recognition by dispatchers of the need for chest compressions and the simplification of
bystander CPR to exclude ventilations are likely the biggest factors contributing to increased
survival. This presents a dilemma for the EMD provider presented with a drowning patient.
Compression-only CPR is beneficial in circulating oxygenated blood as a bridge until the arrival
of an AED. The drowning patient is likely unconscious or in cardiac arrest due to hypoxemia and
compression-only CPR would only circulate deoxygenated blood. The unconscious drowned
person is in desperate need of rescue breaths, which can be difficult or impossible to deliver
effectively by untrained bystanders. A reasonable approach under the difficult circumstance of an
EMD providing pre-arrival instructions to an untrained who may be in a state of panic is to
provide compression-only CPR, even in a drowned person.
Another significant treatment intervention specifically for patients drowning in a submerged
vehicle can be implemented by EMDs. As noted above, many times individuals in an actively
submerging vehicle are able to reach 911 and may be on the phone with a public safety
answering point while their vehicle is submerging. The Medical Priority Dispatch System, under
Dr. Jeffrey Clawson’s medical direction, is one of the most commonly used dispatch protocols in
the country by formally certified EMDs.70,* They have developed an extremely rare pull-out card
(Card 29-D2, one of only a few pull-out cards that exist in the entire card-based protocol
system).70 It instructs EMDs not to get a location for a submerging vehicle, and instead to have a
caller get out of the vehicle if it is submerging,55 a significant deviation from standard EMD
practice, which instead usually perseverates on location before moving further in managing an
emergency call.

Advanced Life Support

Though the patient may require advanced airway intervention, it is more prudent to optimize
oxygenation before proceeding to endotracheal intubation, especially in cases of rapid sequence
induction. Continuous positive airway pressure (CPAP) has been described as successful in
drowning patients, though it has not been rigorously studied.71 Attention must be given to the
patient’s mental status and ability to maintain a clear airway while on CPAP. There is conflicting
evidence on the utility of supraglottic airway devices in the resuscitation of the drowned person.
One study shows they can be successfully applied, while a smaller series showed that it was
difficult to overcome the increased airway pressures caused by fluid in the lungs and
atelectasis.72–75

Clinician
For minimal to moderately symptomatic drowning patients (grades 0 to 3) who are awake, but
show signs of respiratory difficulty, early, aggressive oxygenation is indicated. Prognosis is good
in patients who arrive awake, but difficult to predict in patients who arrive unconscious.
Numerous grading symptoms have failed to produce an adequate prognostic system for
unconscious drowning patients.
In unconscious or unresponsive patients, definitive airway management is indicated. A lung
protective ventilation strategy similar to the ARDSNet guidelines with tidal volumes of 4 to 8
mL/kg predicted body weight is recommended.76,77 This can be accomplished with a pediatric
BVM.
No single laboratory study has been shown to predict outcome, though other precipitating
etiologies of unconsciousness should be investigated. A normal initial chest radiograph is
predictive of a good outcome, but an abnormal initial chest radiograph does not predict severity
or outcome. Computed tomography (CT) of the brain also fails to adequately predict outcome.21
An abnormal initial head CT is a bad prognostic indicator, but a normal head CT cannot predict a
better outcome.
Except in the search for an underlying etiology that could have caused the drowning incident,
routine laboratory studies are not indicated. Drowning patients may have a leukocytosis from
stress demargination, an infiltrate on their chest radiograph, and a fever from the inflammatory
response caused by the aspirated water. Clinically, this may be indistinguishable from
pneumonia, but routine, empiric antibiotic administration (even if available to WEMS providers)
is not indicated. The one exception might be if antibiotic selection and use is guided by lung
aspirate cultures or knowledge of local aquatic pathogens, which is unlikely to be part of any
standard WEMS operation unless prearrangements are made via medical oversight given known,
dangerous pathogens in a specific water source.
Parenteral steroids have previously been studied with the intended effect of surfactant
production. However, no study has ever shown benefit and routine steroid administration is not
indicated,78 even if available in the WEMS environment.
The administration of exogenous surfactant seems intuitive, but the literature is inconclusive.
Administration of surfactant should be guided by the patient’s clinical picture and the provider’s
discretion.21,79–81
In the severely hypoxemic drowning patient, with or without severe hypothermia,
extracorporeal membrane oxygenation (ECMO) has been used with some success and should be
considered in centers with the appropriate resources. If choosing between destination centers,
WEMS providers might select centers capable of ECMO in such patients, but this decision
should usually be driven by destination facility protocols or online medical oversight.
Mild therapeutic hypothermia (TH) has been used with success in cardiac arrest patients
presenting with witnessed ventricular fibrillation and pulseless ventricular tachycardia. TH has
now also been successfully utilized in patients with return of spontaneous circulation after all
types of cardiac arrest, including pulseless electrical activity and asystole. There is recent
discussion on the exact target temperature and some postulate that it is actually the prevention of
a fever rather than the hypothermia itself that provides the benefit of improved outcomes. The
literature is mixed and limited in TH for drowning patients, but should be considered where
clinically appropriate.52
Ultimately, severely symptomatic drowning patients should ideally be considered for
transport to a tertiary medical center that has experience in the management of peri- and post-
cardiac arrest patients, with age-specific resources, and as noted above, potential access to
ECMO. Clearly this will be conditioned by contextual circumstances including transport
resources, distance of travel, and patient and environmental circumstances.

Equipment Summary
In addition to safety and technical equipment needed to perform the rescue, equipment to deliver
oxygen should be available. If resources permit, CPAP apparatus should be considered.
 Rescuers tasked with performing rescue breathing in the water should utilize CPR masks that
contain a mechanical filter rather than a standard paper filter.82 For the bystander turned rescuer,
mouth to mouth can be an effective tool for providing oxygen until additional equipment arrives.

SUMMARY
Drowning is common worldwide and in numerous settings, from the backyard pool to raging
whitewater. The best tool for the treatment of drowning is layers of prevention. Learning to
swim, knowing the risks of the water, using appropriate safety equipment such as lifejackets, and
using safety barriers will help to prevent drowning. The morbidity and mortality of drowning is
the direct result of anoxic brain injury. Once drowning occurs, interruption of the drowning
process by getting oxygen to the brain is the primary goal. The only validated factor in the
prognosis of drowning patients is the duration of submersion and the resultant degree of anoxic
brain injury.

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corticosteroids in the management of near-drowning. Emerg Med J. 2001;18:465-466.
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Accessed July 1, 2017.
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INTRODUCTION
Diving medical emergencies are among the most rewarding calls to which emergency medical
services (EMS) personnel are summoned. The responder must employ physics, human
physiology, anatomy, the activity involved, past medical history, underwater breathing
equipment, and the environment both above and below the surface to care for their patient. Each
of these key elements will provide the necessary information when considered together to create
a working diagnosis and effective intervention.

DEFINITIONS
The topic of this chapter is compressed air underwater diving. This is not to be confused with
diving into a pool or cliff diving. This chapter will discuss in detail the problems that arise from
individuals breathing compressed gas (usually air) underwater. An individual utilizing this
technology to breathe while underwater will be termed a “diver” in this chapter.
A brief mention of breath hold diving will also be included, and they will be referred to
specifically as “breath hold divers.” Divers breathing compressed air underwater are distinctly
different than those divers holding their breath to get below the water surface. In the not so
distant past, excellent health and fitness was a requirement to be a diver. So, when such a diver
presented with a dramatic life or limb threatening problem, it was usually a dive related problem.
But, today the popularity of the sport has also attracted those with increasing age and significant
medical conditions to become divers. Well conducted diving history and physical examinations
are now especially important to identify and outline the risks of diving tailored to each patient.
Conditions such as asthma, diabetes, patent foramen ovale (PFO), and heart disease are examples
that require detailed discussion.1
SCOPE OF DISCUSSION
Some of the most important steps in the care of diving-related injuries are field-based
interventions. EMS personnel can be the primary medical professionals responsible for
stabilizing or even reversing the pathologic process. These early measures can improve the
overall outcome even if emergent recompression therapy is needed. A background into the
environment and pathophysiology will make these conditions more easily understood, and will
help make the measures recommended understandable in terms of reasonable medical sense to
the responder.2 This section will also identify specific environments that may share similar
pathophysiology to compressed air diving, such as iatrogenic air embolism or passenger egress
from an air pocket in a submerged vehicle. The WEMS provider may be the only one to
recognize early and include these life-threatening causes in the differential during on-scene care.
Lastly, there can be significant interactions between diving injuries and a patient’s underlying
medical condition. The number of such considerations is beyond the scope of this chapter but is
important to consider, including seeking additional guidance from medical oversight, especially
with patients who have known underlying chronic medical conditions.
Manned underwater activity is almost as old as humankind itself. From simple breath hold
diving to deep commercial saturation diving, the desire to work productively has driven humans
to innovate and develop means to continue to breathe underwater. Breathing compressed gas has
become the most efficient way for humans to conduct useful work while he is underwater.
As with most advanced technologies, militaries have adapted and even developed better
technologies to improve human performance underwater. Commercial interests, especially to
support offshore oil production, have also adapted and further improved diving techniques.
However, the most explosive growth in diving populations has been in recreational diving. It is
also the most challenging group, mainly because these divers are the most diverse. They come in
all sizes, ages, fitness levels, experience, motivation, gender, training level, and health status.
This is in stark contrast to military and commercial divers, who are a relatively homogeneous
group in comparison. In addition, professional divers generally will have medical support that is
often quite impressive. In fact, it would not be unusual and often the requirement for professional
divers to have recompression chamber capability and medical support at the dive site with a
diving medical physician involved in all phases of the dive. So, this chapter will be primarily
devoted to the emergency response to the injured recreational diver who arguably poses the
greatest challenge to manage.
The chapter will explain the physics associated with diving. It will explain the environment
and the interaction with the diver’s physiology. Specific injuries will be explained, the approach
to differentiate one from the other, and the definitive treatment measures to implement. Special
considerations during transport and description of the treatment to be rendered when delivered to
a facility for definitive care will be discussed. The basic principles for the evaluation and
management for the recreational diver should be applicable to management of any diving injury,
and exceptions to this principle will be illustrated.

EPIDEMIOLOGY
In 2015, there was an estimated 3,000,000 scuba divers in the United States with ~1,400
Americans presenting at the emergency department (ED) for dive injuries annually. Many more
injuries do not result in ED presentations. At various locations and times, among various diving
groups, using methods from self-reporting to hospital diagnosis, overall diving injury rates have
been reported as high as 13 per 20,000 dives. The frequency of ED presentations for dive injuries
is thought to be around 1 per 20,000 dives, with 50 to 60 recreational dive fatalities per year in
the United States. In the United States, it is estimated there are two dive-related deaths per
hundred thousand recreational divers per year, or an incidence of two deaths per million
recreational scuba dives.3
The following will discuss the clinical management of diving-related injuries and illnesses.
There were 146 recreational diving and 35 breath hold diving deaths in 2015 worldwide.
However, it is important to remember that routine medical conditions (discussed in Chapter 22)
can also occur in the diving environment, and can be a significant source of morbidity and
mortality. For example, the leading known cause of diving deaths in divers over 40 is cardiac
related, not any specific diving illness. This may have some part in the fact that male and female
divers over 40 years of age accounted for 84% and 69% of all 2010 to 2013 U.S. and Canadian
diving fatalities, respectively. Overweight and obese divers account for 80% of fatalities.3

CLINICAL MANAGEMENT
The clinical management of diving injuries will include a brief description of the physics
involved, merely to serve as a refresher for previous physics and chemistry instruction. A more
in-depth discussion of the pathophysiology will then be followed by treatment. Each section
dealing with a specific diving injury will be followed by methods of prevention. It is convenient
to think of most diving injuries as those resulting from barotrauma and those occurring because
of dissolved gases/decompression injury.

Barotrauma
Barotrauma is essentially tissue trauma that results from unequal pressures acting on sensitive
structures in the body. These injuries can range from a slight ear discomfort to gas escaping into
the cerebral arteries and causing dramatic life-threatening problems (Figure 17.1).
Physics: The relationship between gas volume and pressure is described by Boyle’s law. It
states that the pressure of a gas is inversely proportional to its volume. It is often written as:

Pi × Vi = Pf × Vf

where the product of the initial volume (Vi) and initial pressure (Pi) equals the product of the
final pressure (Pf) and volume (Vf). One can see that if the pressure decreases, then volume must
increase (Figure 17.2).
This can best be seen when a balloon is inflated underwater. As it ascends and the ambient
pressure lessens, the volume increases, and the balloon may even burst before it reaches the
surface.
This may occur while diving if a deep breath of compressed gas is taken at depth and then an
ascent occurs while the breath is held. The lungs rupture and release gas into the tissue.
The effects of Boyle’s law are responsible for the barotrauma that can affect various parts of
the body, such as skin, sinuses, eye, middle ear, dental caries (cavities), lungs, and intestines.
This trauma can either be due to a positive or negative relative pressure gradient exposure to a
given body tissue. If that air space is at a pressure lower than the surrounding environment, then
a relative vacuum is created. This is known as a squeeze. This effect normally occurs when
descending, where the trapped gas at ambient or surface atmospheric pressure is surrounded by
ever-increasing pressure that occurs with descent. It has been said that nature abhors a vacuum
and delivers that message clearly to divers if allowed to occur. The body will attempt to fill that
space with swollen tissue, serous fluid, and even blood. On ascent from depth, if gas is trapped in
an air space at that increased pressure and cannot be vented, then that space will expand or even
burst as the trapped gas pressure continues to expand. This is known as a reverse squeeze.
Barotrauma injures various organs in characteristic ways, which will now be detailed
individually.

FIGURE 17.1. Barotrauma to the lungs can result in pulmonary overinflation syndrome (POIS) with cerebral air embolism,
subcutaneous emphysema, pneumomediastinum, and pneumothorax possible. Courtesy of Rick Melvin and DAN, Divers Alert
Network, Inc.
FIGURE 17.2. Pressure–Volume Relationship of Gas. The same gas exposed to half the absolute ambient pressure will occupy
twice the volume. Courtesy of Rick Melvin and DAN, Divers Alert Network, Inc.

Skin Barotrauma
Barotrauma can happen to the skin. This is commonly called “suit squeeze” and can occur in dry
suits where air fills the space between the suit and the skin. If a pocket of dry suit material is in
tight contact with the skin and unable to equalize with ambient pressure, a relative negative
pressure may form. The underlying skin is variably affected. The diver may be able to relate a
squeezing or pinching sensation on descent with unusually shaped bruising where this occurred.
This requires no intervention. It needs to be differentiated from cutaneous decompression
sickness (DCS), which usually occurs later after the end of the dive rather than initially on
descent.
Air trapped below the skin during pulmonary overinflation syndrome (POIS), known as
subcutaneous emphysema, may expand with ascent and become easily palpable as crepitus.

Sinus Barotrauma
The sinuses are air-filled spaces that are situated throughout the skull. These air-filled spaces
communicate with ambient pressure via small openings, also known as ostia. These small
openings, like the sinuses, are lined by mucous cells which are susceptible to blockage from
mucosal swelling or copious mucous production, especially following persistent attempts at
descent or if there is difficulty equalizing pressures between compartments. Severe pain may
ensue as well as noticeable amount of blood via the nose. Blood may also be seen with coughing
since blood from the sinuses can drain into the back of the throat.

Ear Barotrauma
The ear is the most common site of injury caused by barotrauma and is the most common diving
injury overall. The ear is divided into the outer (or ear canal), middle, and inner ear (Figure
17.3).
These regions can be injured by barotrauma. The outer ear canal can become a closed air
space if the external meatus is occluded by ear plugs, tight-fitting hood, or even cerumen. On
otoscopic examination, the canal itself may be inflamed and the tympanic membrane
erythematous. This must be differentiated from acute otitis externa (AOE)—AOE will often have
an exudate present due to infection.
The middle ear is a closed air space except that it relies on the Eustachian tube to ensure the
space is equalized to ambient pressures. If this tube is obstructed by mucous, congestion, or other
materials, the middle ear will not equalize properly.4 The tympanic membrane will be drawn into
the space and may drive the footplate of the stapes, into the inner ear, causing injury to the organ
that affects hearing and balance. Blood and fluid may also fill the space in attempts to alleviate
the relative vacuum created. Otoscopic examination will reveal erythema, hemorrhage, and even
perforation of the tympanic membrane.
Treatment of tympanic membrane injury is usually supportive. Certainly, no further diving
should be undertaken until the condition is resolved. Avoid changes in ambient pressure that can
further traumatize the ear. A decongestant may help open the Eustachian tube and vent the
middle ear space.
Injury to the inner ear will manifest as vertigo and hearing loss. Injuries to the inner ear must
be differentiated from inner ear DCS (which will be discussed later) because the treatment is
very different. Barotrauma will normally occur on descent or upon reaching the bottom. There is
usually a history of difficulty equalizing the middle ear and evidence of trauma to the middle ear
may be evident on otoscopy, while inner ear DCS will normally occur just after surfacing and
may be associated with other neurologic abnormalities. Treatment for inner ear barotrauma
includes placing in position of comfort and transporting to a medical center.5 An ENT surgeon
may later be required for the repair of the rupture to either the round or oval window resulting in
a perilymph fistula in order to correct debilitating vertigo or hearing loss.
FIGURE 17.3. Outer, middle, and inner ear. Inadequate equalization of the outer or middle ear can result in barotrauma. The
extremely important inner ear functions of balance and hearing can also be injured because of barotrauma. Courtesy of Rick
Melvin and DAN, Divers Alert Network, Inc.

Dental Barotrauma
Poor dentition can result in spaces in the tooth that trap air. On descent, this may cause some
discomfort, and will eventually resolve as air slowly equilibrates with that space. On ascent, this
air may not be able to escape quickly enough resulting in discomfort again, but the pressure may
increase to the point that the decayed tooth may fracture. Supportive measures for dental injury
may be required. The differential includes reverse barotrauma to the maxillary sinus that may
cause pain on ascent when pressure builds in the sinus, in which case pain may be referred to the
upper teeth.

Lung Barotrauma
The lung may also be affected by unequal pressure differential between the air-containing sacs
known as alveoli and the ambient pressure. In fact, the mechanics of the lung utilizes pressure
differentials for inhalation and exhalation required for ventilation. POIS may occur when air is
trapped in the lungs and ascent to the surface is performed without allowing that air to escape
freely. This commonly occurs when a diver holds his breath on ascent to the surface. The trapped
air expands in accordance with Boyle’s law, overinflating the alveoli and lung injury may occur.
This results in a variety of conditions grouped together as POIS. When the lung ruptures, the
escaping air moves to various locations. It is by these locations that the subgroups of POIS are
named. Multiple subgroups may occur when a case of POIS is encountered.
Subcutaneous emphysema occurs when the air escapes into the soft tissue and skin. Crepitus
(snap, crackle, and pop sensation felt with palpation of the skin) is characteristic. It is often
found around the upper chest, neck, and even around the head. Moderate neck pain may be
experienced. This condition usually requires only surface level oxygen administration; serial
ongoing evaluation of the respiratory and nervous system is recommended to rule out more
serious associated injuries discussed later in this section.
Mediastinal emphysema manifests as air in the mediastinum, including around the heart.
Chest pain, which can be seen in other serious medical conditions as well, is often noted in POIS,
perhaps as result of lung stretch receptor stimulation or trauma to the tissues affected by the
escaping, expanding air mass. Voice change might be noticed because of the air tracking into the
neck. This usually requires oxygen administration and again ongoing evaluation of the lung and
nervous system.
Pneumothorax can be a manifestation of POIS. The ruptured lung may allow air to escape
and collect between the lung and chest cavity. If it occurred while ascending, the air may further
expand or a situation where air continues to escape from the lung but cannot return from this
expanding space. This results in a tension pneumothorax, a life-threatening emergency. Critical
cardiopulmonary impairment can result if this situation is not reversed quickly. Shock, dyspnea,
tracheal deviation to the contralateral side as well as absent breath sounds and tympanic
percussion are found on the affected side in the case of tension pneumothorax. Needle placement
or a definitive treatment with a chest tube may be indicated emergently. These interventions are
discussed in a WEMS context within Chapter 21 (Trauma Management).
Arterial gas embolism (AGE) may develop from air escaping from the alveoli and entering
the pulmonary blood vessels.6 The air, in the form of a bubble, can then travel and lodge in distal
vascular structures supplying vital organs and block blood flow to these areas. The central
nervous system (CNS) is vulnerable to this insult and demonstrates rapid, dramatic neurologic
deficits minutes after the POIS episode.7 Symptoms can include numbness, weakness, dizziness,
extreme fatigue, hearing changes, tremors, chest pain, mental status changes, lack of
coordination, nausea/vomiting, bloody sputum, and paralysis. Convulsion, loss of consciousness,
arrest, and even death can occur. Often the disabled diver reaches the surface and is unable to
swim to safety, sinks, and subsequently drowns.
Lung overinflation or POIS should be suspected in anyone who makes a rapid ascent and
may have inadequately exhaled while ascending to the surface.8 Evidence of any of the above
symptoms for any of the subgroups should warrant9:

1. removal of the patient from the water and placement in supine or seating position
2. airway and breathing assessment; supplemental oxygen administration
3. if indicated, needle placement to treat a tension pneumothorax
4. evaluation of lungs and trachea and then chest, neck
5. careful neurologic examination
6. evacuation to ED for additional testing that may include lung imaging

POIS is often seen in novice divers who may have panicked for a number of reasons while
underwater or during initial training. Even experienced divers can incur this injury, especially
when their air supply is suddenly interrupted and they bolt to the surface. In addition, certain
medical conditions such as asthma have been implicated in POIS. It is thought that the narrowed,
mucous-filled, reactive airway may impede airflow and allow the lung to overinflate during
ascent.
The first responder should always be alert to POIS for anyone, not just scuba divers, who
may have breathed compressed air. Such individuals include non-divers who might have been
swimming underwater and breathing from an air pocket underwater or from a friend’s regulator
and then held their breath while swimming to the surface. As perplexing to a first responder
would be the patient egressing from a submerged vehicle accident who takes one last deep breath
from the compressed air pocket inside the vehicle (by Boyle’s law that air has been compressed
to the depth of the vehicle) before holding his breath and making it to the surface. The patient
may have been seen at the surface before sinking back to depth or collapsing upon reaching the
shore. Cardiopulmonary or neurologic difficulties may be something seen when called to care for
such a patient at the scene.
A reverse squeeze can occur when the pressure in the lung is less than the ambient pressure.
This occurs predominantly in breath hold free divers. These divers do not use scuba or
compressed gas while diving. Instead, they hold their breath. The depth limitation is determined
not just by the limit of their ability to hold their breath, but also at the point where the relative
negative pressure causes lung trauma that results in fluid and even blood leak into the air spaces.
Loss of consciousness can ensue if not addressed promptly. If the diver is successfully rescued,
aggressive measures to maintain breathing and airway may be required before evacuation to the
nearest ED.

Gastrointestinal Barotrauma
The gastrointestinal (GI) tract can be affected by Boyle’s law. Barotrauma on descent is not
likely, since any gas trapped in the GI tract will be compressed by the nonrigid structure of the
bowel. However, on ascent, any compressible gas will expand and normally will be safely
expelled at either the entry or exit orifices to the GI tract. If there is obstruction that blocks this
expulsion, GI tract rupture could occur. Fortunately, this is an extremely rare event.

Decompression Illness
This section deals with both DCS and AGE. Decompression illness (DCI) is the term that
includes either DCS or AGE.10 Both conditions involve the pathologic effects of bubbles that can
occur when scuba diving.
Both DCS and AGE can occur at the same time. This is usually the consequence of a rapid,
often uncontrolled ascent from a deep long dive. They are difficult to manage and have been
termed type III DCS. Fortunately, it is not often seen since the management can be quite
challenging.11 The symptoms and the requirement for prompt recompression in a hyperbaric
oxygen chamber bear close similarities, so it is convenient for emergency personnel to use the
term DCI to manage these patients.
However, there are some significant differences between AGE and DCS. DCS is also called
the bends. It may have received this name because severe cases can result in abdominal pain
causing the victim to bend forward in an attempt to achieve some relief. So, someone suffering
from DCS might be referred to you by his dive team as “being bent.”
AGE was discussed in some detail in the POIS section earlier. It can be a dramatic
presentation ranging from paresthesia to loss of consciousness shortly upon reaching the surface.
It can occur in depths as shallow as 4 to 5 ft of water and with little or no time at depth. DCS
incidence and severity has a positive correlation with increasing depth and time of a given dive.
AGE presents within minutes following a dive while DCS may require more time to evolve.
Most DCS cases present within a few hours of surfacing, with nearly all appearing within 24
hours. The U.S. Navy reports that 42%, 60%, 83%, and 98% of symptoms occurred within 1, 3,
8 and 24 hours following a dive, respectively (Figure 17.4).12
DCS is attributable to the imbalance between the limit of inert gas (nitrogen) that can safely
remain dissolved in tissue (including blood) and the actual amount of gas in those same tissues.13
Keeping gas in solution and from shifting to the harmful gas phase is what dive tables and dive
computers determine. They limit a diver’s time and depth to limit the risk of DCS. Henry’s law
describes the fact that the amount of dissolved gas is proportional to the pressure that gas exerts
over that substance. Think of a warm bottle of cola. If opened abruptly, the gas in solution will
come out of the solution violently and bubble out of the top. But if opened very slowly to allow
the gas to slowly escape and allow gas to gently transition to the surface and out of the bottle,
this violent display is averted.
The nitrogen in the diver’s tissues works in a somewhat comparable manner. Adherence to
depth and time limits the amount of nitrogen dissolved in the tissue, slow ascents, and stops
along the way allowing nitrogen to be transported to the lungs and safely expelled before finally
leaving the water. But even with the most carefully planned dive, DCS can still occur as the
degree of risk can be minimized but never completely eliminated. That is why a good dive
operation will always have an emergency action plan (EAP) that will include EMS in a key role
for initial management and prompt evacuation to an ED, with probable recompression therapy.14
Detailed information about the dive is important. DCS is thought to be a probabilistic event.
This means that there is always a risk that a diver can suffer an episode of DCS. That risk is
increased with multiple days of multiple dives per day and closely related to the time and depth
of each dive. The use of nitrox (adding oxygen to increase its fraction above 21%) can mitigate
this risk. The bottom line is that DCS should be considered for dives deeper than the 30 to 40 ft
of sea water (fsw) range. Consider AGE for symptoms arising after shallower dives.15

FIGURE 17.4. DCS symptom onset time vs % of cases presenting after surfacing from their last dives. Adapted from Rivera JC.
Decompression sickness among divers: an analysis of 935 cases. Mil Med. 1964;129:316.

DCS has been divided into type 1 (mild) and type 2 (serious). It is prudent for any early case
of DCS to evaluate the ABCs that include oxygen delivery, perform detailed serial neurologic
examinations (every 30–60 minutes for at least 6 hrs or until stable), and evacuate to the ED if
available. It is the serial neurologic exam that will help determine the DCS severity.13 DCS can
be divided by the location of the findings. Symptoms that occur in the peripheral tissues are
commonly termed DCS type 1 while those affecting the CNS (brain and spinal cord) or
cardiopulmonary systems are termed type 2. These symptoms can occur together and one can
progress to include the other.
Diving injured patients are often dehydrated from poor intake, exposure to sun/elements, sea
sickness, immersion diuresis, and severe DCS. Rehydrate with a balanced salt solution. Glucose-
containing solutions should be avoided.16 Monitor urine output and color (use second urine
collection since the first post-dive urine will appear dilute since it still reflects the results of
immersion diuresis.)
Remember, for WEMS responders, once evidence of AGE or DCS is discovered, transport to
the ED is required when feasible, with attention to ABCDE. Considerations on scene and en
route include delivery of 100% oxygen,17 a balanced salt solution (lactated ringers or normal
saline), and conducting serial neurologic examinations.
Once the diagnosis is confirmed by the ED, arrangement for transportation to a
recompression chamber for hyperbaric oxygen therapy (HBOT) is made.18 It is important to
understand that throughout most of the world, recompression chambers are an extremely limited
resource, especially true here in the United States. For example, in the entire state of Florida,
there are only four dive chambers that will care for recreational divers, despite the popularity of
the sport in that state.19
The most common HBOT table is the U.S. Navy Treatment Table 6 (Figure 17.5).20

DCS Type 1
DCS type 1 has been termed mild, and is sometimes characterized by pain alone without other
consequences. A dull boring joint pain is a common way to describe such pain. Pain in peripheral
joints only (knee, hand, ankle, shoulder) and skin following a dive can be DCS type 1. A
mnemonic to help remember the distinction is to think of unilateral joint pain that occurs outside
the tank top and shorts of a basketball uniform. Movement and palpation often has little effect on
the nature or intensity of the pain. This contrasts with the musculoskeletal etiology. A detailed
history of previous problems with the joint in question as well as history of trauma or overuse
during the dive should be obtained. Symptoms in bilateral joints are considered more serious or
type 2 since there is a good possibility the symptoms may be a result of a DCS involvement of
the spinal cord causing bilateral referred radicular pain. Other type 1 symptoms to consider are
skin changes and lymph node swelling. The following should be performed:

1. ABCDE evaluation, placement on 100% oxygen, administration of PO or IV fluids

2. Performance of serial detailed neurologic examination since the condition may evolve
3. Transportation to an ED for consideration of HBOT recompression therapy, although the
absolute requirement for recompression is being reconsidered in very remote settings.

DCS Type 2
DCS type 2 is a more serious condition and comprises those symptoms thought to be arising
from bubble formation in the CNS (brain and spinal cord) or cardiopulmonary systems, or in the
inner ear.
 Cerebral DCS can manifest in slight mood changes to loss of consciousness. The mental
status exam is essential for detecting early subtle changes associated with lesions affecting the
brain.21
Deficits in hearing and balance can be directly related to inner ear DCS. Differentiating inner
ear DCS from inner ear barotrauma requires a good history.22 As discussed previously,
barotrauma is associated with equalization problems and is often seen on descent. Inner ear DCS
is usually seen following a dive. It has been associated with a patent foramen ovale.23,24

FIGURE 17.5. The U.S. Navy Treatment Table 6. This table is used extensively to treat decompression illness. It incorporates
hyperbaric oxygen breathing periods (green) with air breaks (blue) to avoid oxygen toxicity during treatment. Courtesy of Rick
Melvin and DAN, Divers Alert Network, Inc. Modified from the Navy Department. US Navy Diving Manual. Revision 7 Naval
Sea Systems Command. Washington, DC: US Navy; 2016.

Spinal cord DCS can result in motor and sensory deficits along associated dermatomes.
Numbness, weakness, and complete paralysis can be seen.14 Abdominal and girdle pain with
tingling in the legs is an ominous presenting complaint that can advance to complete paraplegia,
bladder, and bowel dysfunction.
The treatment for DCS type 2 is:

1. Attention to the ABCDEs with administration of 100% oxygen

2. Serial neurologic examination
3. Hydration with IV or PO fluids
4. Prompt evacuation to an ED for HBOT recompression therapy

As can be seen, DCS type 1 and 2, as well as AGE, share some of the same common
emergency responses as well as the need for HBOT recompression therapy.10 Administer 100%
oxygen to all DCI patients even if normoxic on room air.

Other Diving Injuries

Immersion Pulmonary Edema
A diver who surfaces from a dive and presents with pink frothy sputum, dyspnea, cyanosis, and
altered mental status presents a challenge. The differential diagnoses can include drowning and a
cardiac-related syndrome known as immersion pulmonary edema.
What makes immersion pulmonary edema unusual is that it can happen in the most fit
individuals. It has occurred in well-conditioned triathletes (swimming-induced pulmonary
edema) and even Navy divers. It appears that a combination of factors may be responsible.25 The
balance between elevations in intravascular pressure and negative airway pressures lead to
extravasation of fluid into the alveoli. There are several factors that tip this fine balance, some
specific to scuba diving. Immersion itself introduces a surge of intravascular fluid centrally.
Experts in diving safety have advocated hydration, and some take that to extremes with
overhydration. Both immersion and aggressive hydration combine to increase the cardiac
preload. The breathing apparatus may introduce a negative inspiratory pressure and elevated
pulmonary artery pressures. Moderate to severe exertion with the associated increase in
respiratory effort will generate additional negative airway pressures. Most scuba dives will
generate venous bubbles that make their way to the lungs where they may cause some elevation
in intravascular pressure.26 Decrease in cardiac function will also add to this elevated
intravascular pressure. Then shortness of breath, panic, and even loss of consciousness can
result. The diver (or swimmer) can aspirate and drown. Panic can cause an uncontrolled rapid
ascent that puts the diver at risk of POIS (pneumothorax or AGE) and/or DCS.
Treatment includes prompt removal from the water which will lessen preload in addition to
the following:

1. Evaluate ABCDEs and administer 100% oxygen.

2. Monitor vital signs.
3. Transport to ED.

Hypoxic Blackout
This potentially lethal phenomenon is seen with breath hold divers who are not breathing self-
contained air while underwater.27 It has been called shallow water blackout, hypoxia of ascent,
surface blackout, and static apnea blackout. All these names describe various mechanisms for
blackout seen in divers and swimmers practicing specific breath-holding techniques. It occurs in
swimmers who attempt to hold their breath to the limit of their endurance and is often
experienced by those who have intentionally hyperventilated just prior to their breath hold dive.
The hyperventilation allows the CO2 to slowly rise to normal levels while the oxygen in the lungs
is consumed. In normal individuals without chronic obstructive pulmonary disease, the primary
stimulus for breathing is CO2. Depth helps to maintain enough oxygen to remain conscious with
the elevated partial pressure of oxygen that results from the elevated ambient pressure that occurs
at depth and is subsequently decreased to hypoxic levels when the diver ascends. This can cause
loss of consciousness. If not rescued quickly by others, then drowning will occur. Even in
swimmers not at significant depth or at a maintained depth, the decrease in PO2 is more rapid
than the increase in PCO2 when predive hyperventilation has occurred. Since the drive to breathe
occurs from increased PCO2, swimmers may not even perceive a need to breathe before they lose
consciousness. Both pathophysiological variants of this tragedy have occurred in skilled
swimmers even in swimming pools.28 More details regarding its incidence in shallow
environments and recreational swimming in lakes and pools are covered in Chapter 16
(Submersion Injuries), but it is important to recognize that it can also be an issue in diving
environments.

Nitrogen Narcosis
Some inert gases, including nitrogen, can cause narcosis when breathed at higher pressures. In
other words, the greater the depth (where the pressures are greater), the greater the impairment
becomes. The effect becomes increasing evident at depths greater than 100 fsw. It has been
called the “martini effect” where every additional 50 fsw of depth is described as equal to
drinking another martini (although this relationship is less than linear and the effects vary
between individuals). This impairment can be a factor in mistakes and poor judgments leading to
diving injuries. As the diver returns to the surface, the effect resolves. This is important since it
may be a factor in why an injury occurred but since it resolves upon reaching the surface, it
should NOT be in the differential diagnoses of altered mental status seen after a dive.

Oxygen Toxicity
Everyone knows that oxygen is essential to life and its deprivation even briefly leads to
disastrous consequences. However, too much oxygen also can lead to significant problems that
involve vital organs such as the brain, lungs, and eyes. Much has been written on oxygen
toxicity, so a summary will be provided here as it applies to your role in resuscitation if this
condition is encountered.
Most are aware that surface level oxygen given at high partial pressures over time can lead to
pulmonary oxygen toxicity. This is an important factor when supplementing oxygen over several
days in the intensive care unit. But remember, in the acute phase of managing a diving injury,
delivery of oxygen at the highest concentration available should be done for reasons described
earlier. Problems with pulmonary oxygen toxicity can be dealt with later.
Central nervous system oxygen toxicity is unique to breathing oxygen at pressures greater
than those seen at sea level. CNS oxygen toxicity can result in seizure while underwater that can
result in drowning if not promptly recovered by others. Both the depth and time of depth affect
its onset. First responders will not witness the event since it occurred while underwater, but you
will be attending divers who have been recovered and in need of resuscitation. You will most
likely be addressing a drowning patient who may have also suffered pulmonary overinflation
(AGE, pneumothorax) since his exhalation to the surface may have been inadequate to empty his
lungs during his emergent rescue from depth.
Divers may see levels of oxygen exceeding 100% (surface) or 1 atmosphere while at depth.
This occurs while breathing air to deeper depths. These higher oxygen partial pressures can be
reached even sooner since some divers may employ nitrox (higher percentage of oxygen in the
breathing mix) or even pure oxygen during the dive in part to decrease the decompression risk
with their dives. Various events including mistakes can enhance this risk. Again, resuscitation
with the highest partial pressure of oxygen should still be administered to the stricken diver.

Hazardous Marine Life

Hazardous marine life will be covered in more detail in a later chapter. It is a good practice to
understand the marine life that is relevant to your geographic region as the level of concern is
much different in this regard.29 Such injuries can be divided into:

1. Toxic ingestions that commonly occurs when eating affected seafood.

2. Trauma that can range from coral scrapes, sea urchin puncture, to massive tissue loss from
shark or crocodile attack
3. Envenomation that range from toxic fish punctures, sea snakes, and the range of jellyfish.
These encounters can range from pain to life-threatening envenomation.

Cave Diving Emergencies

Cave diving is a particularly technical branch of diving, combining elements of caving and
diving. Caving emergencies are discussed in more detail in Chapter 29. Certification courses
exist for cave diving, such as the National Speleological Society’s Cave Diving Section (NSS-
CDS) cave diver certification program. The NSS-CDS program offers an extensive roster of
courses, including Basic Cave Diver, Apprentice Cave Diver, Cave Diver, Advanced Cave
Diver, and specialty courses such as Stage Diving, Diver Propulsion Vehicle Pilot, Advanced
Sidemount, Basic Underwater Cave Surveying, Cartography, Trimix Cave Diver, Overhead
Nitrox Diver, Rebreather Cave Diver, and Cave Diver Supervisor. Many of the courses could be
of utility to WEMS providers tasked with cave diving response and medical care, such as
Recovery Diver. Injury patterns and medical care considerations are, as one would expect, a
merger of those seen in caving and diving. Often access becomes the most significant challenge
to rescue and medical care, including accessing rescuers suitably trained in the dual skill sets of
diving and caving.
A subspecialty of cave diving is known as “sump diving” whereby divers will exit the water
sometimes far underground, engage in caving for some distance, then dive through a second
flooded passage, then a third, fourth, and so on (Figure 17.6). Often the “dry” sections of a cave
are, in fact, wet and slippery and trauma that would, in other circumstances, be considered
relatively innocuous (for example a badly twisted ankle) might be considered life-threatening
when the patient is far inside a cave system.
The second air bell of Cocklebiddy Cave in Australia, for example, is entered via a 500 ft
climb over strewn boulders 300 ft below the surface of the desert, 600 miles from the nearest
city, followed by a 2,800-ft swim through flooded passage, a climb over a second pile of
boulders 60 ft high, followed by a second dive for a further 7,500 ft through flooded cave.
Current estimates are that anyone breaking a leg in this air chamber would need to be kept alive
for 6 days until a rescue party could attempt extraction. Accordingly, there is now a cave radio
system and an emergency cache permanently located inside this chamber.
FIGURE 17.6. A cave diver (coauthor) surfaces in an air bell after diving through a flooded passage. Courtesy of Peter
Buzzacott.

Cave diving rescue groups have formed in France, Italy, Australia, Mexico, and other
countries where a history of exploration is well established. Currently the world appears divided
equally between evacuating a diver out by stretcher through the flooded sections on his back,
supine facing the ceiling, or facing the floor, prone. Proponents of the supine technique argue
that WEMS providers have greater control of the patient, and can sooner respond to problems in
an environment where the difference between life and death can be measured in seconds.
Proponents of the prone technique argue that the positive buoyancy of the lungs facilitates gas
exchange and the pressure differential between the regulator in the mouth and within the lungs
improves ease of breathing. Simulated caving and cave-diving rescues are held around the world
each year to maintain an experienced pool of capable rescuers (Figure 17.7).
Whereas planning a dive to a shipwreck involves reaching a planned depth and
decompression can be affected relatively predictably, cave diving decompression is often
determined by the nature of the cave. In France, for example, it is common for divers to descend
to 250 ft depth, then surface inside an air chamber back at sea-level ambient pressure, explore for
a while and then return via the 250-ft depth. Back-to-back dives to a shipwreck at 250 ft would
be thought of by many divers as reckless but in cave diving such profiles are more common,
driven by the urge to witness places seen by so few people. It is common for cave divers to carry
tanks of pure oxygen to accelerate their decompression obligations but often the only regulators
they will have to deliver the oxygen is the humble demand valve, which may become difficult to
tolerate in the event a diver suffers DCS with pulmonary involvement or oxygen toxicity. In such
cases the WEMS provider should supply a constant flow regulator with nonreturn valve mask.
FIGURE 17.7. Cave divers simulate rescuing a caver with a broken leg, from an isolated air chamber, through a flooded passage.
(Courtesy of Peter Buzzacott and German Yañez.)

In warmer climes, caves offer cool shelter for snakes and there can be some straw-drawing to
determine which member of the team will enter a cave first. Certainly, first aid preparations
should include those for snakebite in regions where the possibility exists. Where there is a
necessity to lower and raise scuba equipment by rope, first aid resources should be cached at the
bottom, and the top, of the pitch. Personal hygiene becomes a team issue in such confines. The
usual practice in caving is to carry one’s waste out during the exit and in cave diving this is
achieved by towing “poop-tubes” made of 4’ diameter irrigation pipe capped at one end and with
a screw-down cap at the other. When in an air chamber, divers use a bag to catch their waste and
then seal the bag inside the tube for towing out through the flooded section. During extended
underground camps of a few days or even a week, a bad case of diarrhea can debilitate a cave
diver to the point where assistance is required to successfully exit. Accordingly, sanitation is a
priority when camping underground on the far side of a flooded cave passage.
Other types of injuries specific to cave diving include trauma to the head either from contact
with the roof in one of the dry sections or from high-speed contact while propelled by a diver
propulsion vehicle. Both are reasons for cave divers to wear helmets. Lifting multiple heavy dive
tanks over sections of dry cave offers opportunities for sprains and strains, slips and trips. The
quality of the air in some chambers can range from the uncomfortable, such as containing 4%
carbon dioxide, to mixtures that will not support human life. CNS oxygen toxicity seizures are
also a very real concern for cave divers, who often carry multiple blends of gases, each of which
is safe, or toxic, at different depths. During travel through the flooded cave, divers will swap
from tank to tank as they reach critical depths. Of 67 trained cave divers who died while in U.S.
caves, seven (10%) died following CNS seizures.30
By far the most common cause of death in cave diving is drowning, following depletion of
available breathing gas. Reasons for this include getting lost in a complex system, becoming
disoriented due to stirring up silt from the floor, or failing to turn around and start exiting while
gas held in reserve is still enough to handle unexpected delays. These causes of death have been
studied extensively, are largely addressed by cave diver training, and the number of cave diving
fatalities in the United States each year has steadily fallen since cresting in the 1970s. The most
effective strategy for injury prevention in cave diving is to require all divers are suitably trained
and to dissuade untrained divers from entering the cave, even if it is “just for a quick look.” In
the United States and in many other countries, warning signs are commonly found just inside the
cave entrance warning recreational divers who lack specific cave diver training to turn around
and exit (Figure 17.8).

FIGURE 17.8. A common warning sign urging recreational divers to stay out of flooded caves.

Equipment Summary
There is little additional equipment that you will need to respond to a diving injury that you
probably do not already carry to any wilderness emergency response. One exception would be
the requirement for adequate supply of oxygen which is almost always indicated in diving
emergencies. Some general considerations for equipment that might be helpful at the scene of a
diving injury include (Box 17.1):

1. Means to resuscitate cardiac arrest patient: In severe incidents, the diver may be in
complete cardiopulmonary arrest. Both basic and advanced resuscitative gear should be
available, so they may be accessed by those qualified to use the equipment.
2. Means to deliver oxygen: Oxygen often needs to be delivered at the highest concentration,
such as via a demand valve or non-rebreather mask. A bag mask may be needed to provide
adequate ventilation for those in full or partial respiratory arrest. Figure 17.9 shows a
Divers Alert Network (DAN) oxygen kit, one example of an oxygen delivery system
 configured for a diving emergency.
3. Means to deliver fluids: Preferably, there would be the capability to deliver fluids
intravenously with a balanced salt solution. Avoid glucose-containing solutions.
4. Foley catheter: A Foley catheter would be used both to measure urine production and color
to help assess hydration, perfusion, etc., as well as to avoid bladder damage from distention
of a neurogenic bladder in spinal cord DCS.

Box 17.1 Suggested Equipment for a DMT Medical Kit

Stethoscope
Otoscope (ophthalmoscope optional) and batteries
Sphygmomanometer (aneroid type only, case vented for hyperbaric use)
Reflex hammer
Tuning fork
Pinwheel
Tongue depressors
Thermometer/temperature measurement tool (non-mercury type)
Pulse oximeter
Disposable exam gloves
Skin marker
Pocket eye chart (Snellen)
Oropharyngeal airways (#4 and #5 Guedel-type or equivalent)
Nasal airways (#32F and #34F latex rubber)
Lidocaine jelly (2%)
Self-inflating bag valve mask (disposable BVM)
Suction apparatus with appropriate suction tips
Tension pneumothorax relief with 3.25-inch, large-bore catheter on a needle
Cricothyrotomy kit
Adhesive tape (2-inch waterproof)
Elastic-wrap bandage for a pressure bandage (2- and 4-inch)
Pressure dressing
Appropriate tourniquet
Trauma scissors
Sterile 4 × 4s
Cravats

Additional equipment:
Alternative emergency airway device such as intubating laryngeal mask airway, disposable gel-filled LMA
Fastrach kit, size 4–5
Syringe and sterile water for cuff inflation (10 mL)
Sterile lubricant
Qualitative colorimetric end-tidal CO2 detector (ETCO2)
Consider small continuous, quantitative ETCO2 device
Chest tube
BD Bard Parker Heimlich chest drain valve (or other device to provide one-way flow of gas out of the chest)
#11 knife blade and handle
Sterile gloves (size 6–8)
Surgical masks (4)
Swabs or wipes 10% povidone-iodine, o-chlorhexidine solution (preferred)
1% Lidocaine solution
21 gauge. 1½-inch needles on 5 mL syringes (2)
Curved Kelly forceps
Intravenous infusion therapy
Pressure bag
Catheter on a needle unit, intravenous (16 and 20 gauge—4 ea)
 Adult interosseous infusion device (IO) for rapid vascular access
Intravenous infusion sets (2 standard drip and 2 micro-drip)
Syringes (5, 10, and 30 mL)
Sterile needles (18, 22, and 25 gauge)
Normal saline (1 L bag [4])
IV Start Kit (skin prep, 2 × 2 gauze sponges, Bioclusive dressing, ¾-inch adhesive tape, phlebotomy tourniquet)
Band aids
Sam Splint
Miscellaneous
Nasogastric tube
60 mL Toomey syringe (optional)
Urinary catheterization set with collection bag (appropriate size [12 Fr–14 Fr] Foley-type sterile catheters)
Suture kit (or skin stapler)
Assorted suture material (0-silk with and without curved needles)
Needle driver
Sharps disposable box
Disposable minor surgical tray can substitute for items listed below:
Straight and curved hemostats (2 of each)
Blunt straight surgical scissors
Needle driver
Sterile towels
Sterile gauze pads
A portable oxygen supply with an E cylinder (approximately 669 L of oxygen) with a regulator capable of delivering 12 L of
oxygen per minute by mask/reservoir.

5. Stethoscope: This is used to assess vital signs and confirm bilateral breath sounds to rule out
significant pneumothorax.
6. Means for needle thoracentesis: This could be a needle decompression kit or, less likely,
capability for a full chest tube placement, for use in tension pneumothorax.
7. Otoscope: This tool is needed to exam ear canal and tympanic membrane.
8. Memory aid: This can be a small laminated card, or could be an app on a personal digital
assistant or smartphone. Completion of a full mental status and neurologic exam is critical
in diving care, and this helps support thinking during crisis, when key elements can be
forgotten.
9. Means to warm diver: This will be critically important in cases of hypothermia.
10. Optional gear requiring specialized advanced training:
a. Hyperbaric stretcher (Figure 17.10) can perform a full hyperbaric oxygen treatment
table while transporting the patient from the scene of the injury to a medical facility,
hyperbaric stretcher. The patient and chamber can both be taken inside a multi-place
treatment chamber and the patient can be transferred under pressure to complete the
remainder of his hyperbaric treatment. The benefits of a multi-place facility can then be
utilized such as bedside tender/physician support, environmental control, and extended
treatment table. Completion of the full course of treatment is sometimes completed
before reaching the multi-place chamber. Specialized training for use of this chamber is
necessary to utilize this chamber’s novel fabric design and auxiliary equipment is
required for its safe operation.
FIGURE 17.9. Divers Alert Network (DAN) dual oxygen RescuePak. Courtesy of Rick Melvin and DAN, Divers Alert
Network, Inc.

b. In-water recompression (IWR) can be performed by returning a diver with DCS back
into the water quickly upon presentation of symptoms. Note that in-water
recompression (IWR) is a different technique than in-water resuscitation (IWR)
discussed in Chapter 16 (Management of Drowning). This procedure requires additional
equipment and specialized training to overcome the risk/benefit for its use. It is
sometimes employed when considerable delay is anticipated before a stricken diver can
be transported to a recompression chamber facility for treatment. Hypothermia, CNS
oxygen toxicity, worsening condition are some of the risks that must be considered and
addressed before utilization of this technique.31 A full-face mask with communications
and thermal protection is recommended. There are different treatment protocols using
different depths and time while breathing treatment gas (preferably oxygen) while
underwater. There are various protocols. One such set of procedures is found in the U.S.
Navy Dive Manual that uses the following procedure for IWR using oxygen:
FIGURE 17.10. Hyperlite: portable one-man hyperbaric chamber/stretcher. Courtesy of Doug Kessling.

Descend to a depth of 30 ft with a standby diver.

Remain at 30 ft, at rest, for 60 minutes for type I symptoms and 90 minutes for Type
II symptoms. Ascend to 20 ft even if symptoms are still present.
Decompress to the surface by taking 60-minute stops at 20 ft and 10 ft.
After surfacing, continue breathing 100% oxygen for an additional 3 hours.
If symptoms persist or recur on the surface, arrange for transport to a recompression
facility regardless of the delay (Figure 17.11).
FIGURE 17.11. In-water recompression has been utilized to treat decompression sickness by returning the injured diver back
into the water while breathing oxygen. A full-face mask is recommended for additional safety in the event of oxygen-induced
seizure or loss of consciousness. It also affords the ability to communicate with the topside personnel. From Navy Department.
US Navy Diving Manual. Revision 7. Naval Sea Systems Command. Washington, DC: US Navy; 2016.

11. Communication gear: This could be radio, phone, or another telecommunications tool,
depending on the environment. Evacuations will need communications that minimize
exposure to elevation in altitude to avoid worsening bubble-related injury.32 Not only will
this be needed for intra-agency communication during a WEMS operation, but specifically
in diving emergencies, this will be needed to contact DAN (Figure 17.12).
12. DMT Medical Kit: Specific equipment should be included in this kit. There are various
organizations including the U.S. Navy that make such recommendations. Box 17.1 lists
some equipment that might be considered those charged with outfitting a specific response
team, and likely to be important for WEMS responders to have on scene when responding
to a diving emergency.
13. Emergency Action Plan: A formal EAP should be developed for each dive. As in most
accidents, having critical emergency information readily available can be lifesaving and
allows one to focus on caring for the patient. DAN has a slate that can be used to fill this
 need (Figure 17.13).

FIGURE 17.12. Divers Alert Network (DAN) is a nonprofit organization dedicated to the health and safety of divers worldwide.
DAN maintains expert diving medics and physicians on call 24 hours a day to deliver the very best diving medical information
for diving medical emergencies anywhere in the world. DAN also answers non-emergent information calls, provides training,
resources, and conducts practical research/workshops to make diving safer overall. DAN also focuses on prevention. Currently,
there are 10 improvements that DAN is actively promoting to the diving population to make diving even safer. They are: correct
weighting, greater buoyancy control, more attention to gas planning, better ascent rate control, increased use of checklists, fewer
equalizing injuries, improved cardiovascular health in divers,33 diving more often (or more pre-trip refresher training), greater
attention to diving within limits, and fewer equipment issues/improved maintenance. Some specific diving injury prevention
interventions include targeting lobster divers in Florida, recreational divers at freshwater dive sites, divers who utilize enriched
air, improper use of scuba valves, and other known at-risk groups or identified hazards. These and other injury prevention efforts
are described each year in the DAN Annual Diving Report. This is the longest running diving injury surveillance report in the
world and it is now available through PubMed.34 Courtesy of DAN, Divers Alert Network, Inc.

Training
The role served by EMTs and paramedics who have completed advanced training to become
diving medical technicians is invaluable to any emergency medical system or dive team. This
training is recommended for WEMS providers who have a reasonable expectation to respond to
the occasional dive emergencies. This certification would be important for any WEMS provider
specifically serving as the medical staff on a diving team. DAN has formal courses dedicated for
those seeking diving medical training that are of increasing level of detail to match one’s
professional medical development. Military and commercial diving operations are typically
required to have medical professionals with the highest level of this training. Expert emergency
medical technicians work to prevent injuries, quickly recognize abnormal conditions when they
occur, promptly administer initial care, and who often will attend the stricken diver while in the
recompression chamber for definitive care.

SUMMARY
In conclusion, the evaluation and management of diving injuries may be one of the most
rewarding experiences of emergency medicine responders. There are few medical conditions
where first responders have the best insight in the precipitating event, where their five senses are
the primary diagnostic tools needed, and the correct intervention may be the definitive treatment.
Prompt recognition, response, and evacuation by WEMS providers may be key to receiving care
that can prevent or minimize serious neurologic impairment and even death.
This chapter was written for the effective first responder response to a diving injury.
Hopefully it also stoked your interest in this fascinating area of medicine. Remember you have
many sources to assist you that can include your medical personnel, local diving medical
physicians, local recompression chambers, military resources, and DAN, which is available 24
hours a day specifically to help you do the best job possible. Your efforts complement the careful
preparation by the dive team to make each dive successful and safe as possible (Figure 17-14).
FIGURE 17.13. Emergency action plan. Courtesy of DAN, Divers Alert Network, Inc.

FIGURE 17.14. Coauthor during a 4,000 ft spectacular underwater cave penetration without incident. Courtesy of Peter
Buzzacott.)

References
1. Harrison D, Lloyd-Smith R, Khazei A, Hunte G, Lepawsky M. Controversies in the medical clearance of recreational scuba
divers: updates on asthma, diabetes mellitus, coronary artery disease, and patent foramen ovale. Curr Sports Med Rep.
2005;4:275.
2. Edmonds C, Bennett M, Lippmann J, Mitchell S. Diving and Subaquatic Medicine. 5th ed. London: Hodder Arnold; 2016.
3. Buzzacot P. DAN Annual Diving Report 2016 Edition. Durham, NC: DAN, 2016.
4. Farmer JC Jr. Eustachian tube function and otologic barotrauma. Ann Otol Rhinol Laryngol. 1985;120:45.
5. Klingmann C, Benton P, Schellinger P, Knauth M. A safe treatment concept for divers with acute inner ear disorders.
Laryngoscope. 2004;114:2048
6. Moon RE, Vann RD, Bennett PB. The physiology of decompression illness. Sci Am. 1995;273:70.
7. Dick AP, Massey EW. Neurologic presentation of decompression sickness and air embolism in sport divers. Neurology.
1985;35:667.
8. Hardy KR. Diving-related emergencies. Emerg Med Clin North Am. 1997;15:223.
9. Leitch DR, Green RD. Pulmonary barotrauma in divers and the treatment of cerebral arterial gas embolism. Aviat Space
Environ Med. 1986; 57:931.
10. Neuman TS, Bove AA. Combined arterial gas embolism and decompression sickness following no-stop dives. Undersea
Biomed Res. 1990;17:429-436.
11. Taylor DM, O’Toole KS, Ryan CM. Experienced scuba divers in Australia and the United States suffer considerable injury
and morbidity. Wilderness Environ Med. 2003;14:83
12. Rivera, JC. Decompression sickness among divers: an analysis of 935 cases. Milit Med. 1964;129:316
13. Erde A, Edmonds C. Decompression sickness: a clinical series. J Occup Med. 1975;17:324.
14. Moon RE. Treatment of diving emergencies. Crit Care Clin. 1999;15:429.
15. Vann RD, Butler FK, Mitchell SJ, Moon RE. Decompression illness. Lancet. 2011;377:153-164.
16. Bennett MH, Lehm JP, Mitchell SJ, Wasiak J. Recompression and adjunctive therapy for decompression illness. Cochrane
Database Syst Rev. 2012;(5):CD005277
17. Longphre JM, Denoble PJ, Moon RE, Vann RD, Freiberger JJ. First aid normobaric oxygen for the treatment of
recreational diving injuries. Undersea Hyperbaric Med. 2007;34:43-49.
18. Green RD, Leitch DR. Twenty years of treating decompression sickness. Aviat Space Environ Med. 1987; 58:362
19. Chimiak, JM. Crisis in 24/7 chamber availability. In: Plenary Session, 2016 Annual Undersea and Hyperbaric Medical
Society Annual Scientific Meeting.
20. Navy Department. US Navy Diving Manual. Revision 7 Naval Sea Systems Command. Washington, DC: US Navy; 2016.
21. Newton HB. Neurologic complications of scuba diving. Am Fam Physician. 2001;63:2211.
22. Parell GJ, Becker GD. Conservative management of inner ear barotrauma resulting from scuba diving. Otolaryngol Head
 Neck Surg. 1985;93:393.
23. Wilmshurst PT, Byrne JC, Webb-Peploe MM. Relation between interatrial shunts and decompression sickness in divers.
Lancet. 1989;2:1302.
24. Moon RE, Camporesi EM, Kisslo JA. Patent foramen ovale and decompression sickness in divers. Lancet. 1989;1:513.
25. Slade JB Jr, Hattori T, Ray CS, Bove AA, Cianci P. Pulmonary edema associated with scuba diving: case reports and
review. Chest. 2001;120:1686.
26. Dunford RG, Vann RD, Gerth WA, et al. The incidence of venous gas emboli in recreational diving. Undersea Hyperb
Med. 2002;29:247-259.
27. Pearn JH, Franklin RC, Peden AE. Hypoxic blackout: diagnosis, risks, and prevention. Int J Aquat Res Ed. 2015;9:342-347.
28. Lindholm P, Pollock NW, Lundgren CEG. Breathold diving 2006 workshop. In: UHMS/DAN, June 2006.
29. Nocetto M. Hazardous Marine Life. Durham, NC: Divers Alert Network; 2015.
30. Potts L, Buzzacott P, Denoble PJ. Thirty years of American cave diving fatalities. Diving Hyperb Med. 2016;46(3):150-
154.
31. Blatteau JE, Pontier JM, Buzzacott P, et al. Prevention and treatment of decompression sickness using training and in-water
recompression among fishermen divers in Vietnam. Inj Prev. 2016;22(1):25-32.
32. Freiberger JJ, Denoble PJ, Pieper CF, Uguccioni DM, Pollock NW, Vann RD. The relative risk of decompression sickness
during and after air travel following diving. Aviat Space Environ Med. 2002;73:980.
33. Kanter AS, Stewart BF, Costello JA, Hampson NB. Myocardial infarction during scuba diving: a case report and review.
Am Heart J. 1995;130:1292.
34. FreibergerJJ, Denoble PJ, Pieper CF, Uguccioni DM, Pollock NW, Vann RD. The relative risk of decompression sickness
during and after air travel following diving. Aviat Space Environ Med. 2002;73:980-984.
INTRODUCTION
Lightning and severe storms are natural weather phenomena occurring daily across our entire
planet. Because no single agency requires reporting of these phenomena, the true incidence of
related injury and death is unknown. In addition to lack of mandatory reporting, self-reporting by
the individual may not occur and some subjects of injury may not seek medical treatment. In
some instances, individuals found dead outdoors may have suffered a lightning strike and this
may not be recognized as the cause of death.
Lightning is consistently among the top four killers from weather-related conditions. Those
most at risk of lightning strike are found outdoors participating in sporting events, recreational
activities including mountain climbing, golf, ball field games, and water-related activities.
Individuals who work primarily outdoors such as farming, construction, and military personnel
are also at risk of injury. Lightning may also involve more than one subject as many outdoor
activities are done in groups, where lightning can injure multiple people simultaneously with
variable severity.
We tend to think of lightning and severe storms as warm weather events, but lightning can
occur during snowstorms or even out of a clear blue sky. Under certain conditions during winter
storms, sleet and graupel are formed. Graupel is frozen precipitation seen as snow pellets or soft
hail. This indicates large differences in electrical potential in the air, large areas of positive and
negative charges, which can lead to the formation of lightning strikes.1,2
EMS providers encounter injuries from lightning events and severe storms; in fact, EMS will
likely be the first medical provider to make contact with a patient of lightning injury. Therefore,
they must understand the basic principles of lightning injury, both the subtle and often dramatic
presentations of a lightning strike patient, myths associated with lightning injury, the concept of
reverse triage, initial care and stabilization, appropriate transport destinations, and prudent advice
to the patient who may not wish to seek further medical care. EMS should also serve as an expert
resource when providing medical coverage for mass-gathering events where lightning and severe
storms are possible as the prevention of injury from lightning strike is paramount. Provider
safety is the first priority. EMS providers should have an understanding of how to maintain their
own safety and prevent injury from lightning and severe storms.

Definition
Lightning is a form of electrical energy, which is the flow of electrons from a high concentration
to a low concentration. The difference between the high and low concentration of electrons is the
potential or volts, represented by the abbreviation V. When electrons move or flow, this is called
the current that is represented by the abbreviation I. Electrons flow over time and through an
object or the air. When electrons or electricity moves through the human body, it encounters
resistance, or impedance to flow, and is represented by the abbreviation R. The resistance to
electrical flow generates heat with subsequent injury and burns to the tissue. Flow is one of the
most important determinants of injury, with high-voltage injuries usually causing increased
morbidity since voltage is directly related to current. The longer tissue is exposed to current,
typically the more injury sustained. The following equation is helpful to highlight the
relationships of current, voltage, and injury. Q (heat generated) = I × V × t(time duration).3
Electrons move by way of two different paths or circuits. Alternating current, or AC, is the
flow of electrons in a cyclical fashion while direct current, or DC, is the flow of electrons in a
one-way fashion. AC is represented by household electricity, typically on the order of either 110
or 240 V in the United States and 220 to 240 V in Europe. Batteries, railways, automobiles, and
defibrillators represent DC current. Lightning is neither AC nor DC current and can be described
as a unidirectional massive current measured in millions of volts lasting over just 1 or 2 ms.4
Electrical injuries result from the direct damage of organs and tissue by the electrical current,
the conversion of electricity into heat causing burns, and blunt trauma. The extent and type of
injury depends on multiple factors, including whether it is AC or DC current, the path of the
current, its voltage, the resistance of the skin, and the duration of the contact.3 The flow of
electrical energy follows the path of least resistance. In the human body, the resistance to
electrical flow from least to greatest is nerves < blood < muscle < skin < fat < bone (Table
18.1).3
Lightning is the discharge of electrical energy in the air. Thunder is the result of a shock
wave created by heating and cooling of the air surrounding the channel of lightning. During a
thunderstorm, winds inside the thunderclouds cause water and ice particles to collide. This
removes electrons from ice crystals, and larger particles of soft hail gain these electrons. Wind
movement redistributes the charges within the thundercloud moving the heavier, more negatively
charged soft hail particles to layer in the middle and lower part of the thundercloud. The cloud
becomes more negatively charged at the bottom, which causes the earth below the thundercloud
to become more positively charged.
As the charge difference increases between the thundercloud and the ground, the negative
charges in the lower segment of the cloud start moving toward the more positively charged
ground. When this movement occurs, it creates a conductive path to the ground following a
zigzag pattern as the negative charge jumps through different segments in the cloud and air. This
moving zigzag negative charge is called the leader stroke.2,5 When the negative charge reaches
the positively charged ground, a current jumps through the zigzag path creating a brilliant,
visible lightning bolt.1
Scope of Discussion
This discussion will focus mainly on the prevention of lightning strike and the initial recognition
and stabilization of the lightning subject, appropriate facility destinations, and provider safety.
We will discuss how EMS responds to both single and multiple patient of lightning injury
highlighting the concept of reverse triage. While electrical injuries encompass lightning, the
discussion of injuries from all electrical sources is beyond the scope of this chapter.
We will also discuss preparation of EMS facing severe storms as well as provider safety.
However, full discussion of the response to severe storms from an emergency management
perspective and disaster response is beyond the scope of this discussion.

EPIDEMIOLOGY
Lightning strikes the earth greater than 100 times each second—eight million times each day—
with over 50,000 thunderstorms occurring daily around the world (Figure 18.1).6 Deaths from
lightning injury, both direct and indirect, from 1968 to 2010 have decreased significantly in both
males (by 78.6%) and females (by 70.6%). During this period, 3,389 deaths from lightning
occurred with an average of 79 deaths annually. This total includes lightning as the underlying
cause of death and includes both direct and indirect strikes.6

Table 18.1 Comparisons of Injury/Clinical Findings in Low Voltage, High Voltage, and
Lightning
Age/Clinical Finding/Injury Low Voltage High Voltage Lightning
Young children Frequent Rare Rare
Adolescent/adult Uncommon Frequent Rare
Cardiac arrest:
Ventricular Fibrillation Frequent Common Rare
Asystole Rare Common Frequent
Skin burns Rare Frequent Uncommon
Deep tissue burns Rare Frequent Rare
Cataracts Rare Uncommon Uncommon
Myoglobinuria Rare Common Rare
Multisystem trauma Rare Common Uncommon
Surgical amputation Rare Common Rare
Death Rare Frequent Common

Modified from Ota FS, Purdue GF. Emergent injuries to children and adolescents due to electricity and lightning strikes. Pediatr
Emerg Med Pract. 2005;2(8):4.
FIGURE 18.1. Lightning over desert.

The chance of being struck by lightning is about one in 960,000 to one in 1,190,000. The
chance of being struck by lightning in your lifetime is about one in 12,000.7 From 2006 to 2013,
261 people were struck and killed by lightning in the United States. About 66% of these were
engaged in outdoor activity. Eighty-one percent of all fatalities were male and 90% of all deaths
involved fishing and outdoor sports. June, July, and August are the peak months for lightning
injuries across the United States: more than 70% of all lightning deaths occur within these
months. During the day cloud-to-ground lightning is most common in the afternoon with nearly
50% of all strikes occurring between noon and 6:00 PM. Internationally, an estimated 24,000
fatalities and 240,000 injuries occur from lightning strikes.4,8
 Injuries sustained from lightning strikes during activity occurring from greatest to least are
fishing > camping > boating > beach activity > soccer > golf.9 Texas, Florida, and the Gulf of
Mexico now comprise the largest number of deaths, whereas between 1968 and 1985, Wyoming
and New Mexico had the highest number of deaths due to lightning (Table 18.2).9
Lightning strikes occur in six fashions.

First is direct strike, where the subject becomes part of the main lightning channel or within
the path of the negatively charged thundercloud and the ground. While this is not the most
common mode, it is usually the most deadly.
Second is called the side flash or side splash where lightning strikes a taller object near the
subject and a portion of the current jumps over to the subject. This may occur when a person
seeks shelter at the base of a tree or other tall objects.
Third is ground current exposure. When lightning strikes a tall object the current moves
down the object and spreads over the surface of the ground. This ground current can affect a
large area and results in most lightning deaths and injuries. The ground current enters the
body by contact points such as both legs. The greater the distance between the contact points,
the greater the potential for serious injury or death.
A fourth way, documented in case reports, is the subject becoming part of the upward
streamer or leader stroke.
Fifth is conduction, or contact. This causes most indoor injury and death as the current from
lightning is conducted through metal wires, plumbing, metal surfaces, electrical outlets,
water faucets, showers, corded phone lines, windows, and doors.
Finally, the subject can experience a blast injury. Thunder, or the blast effect, can cause
either primary or tertiary blast injury. Primary blast injury may rupture tympanic membranes
and tertiary injury may present as blunt trauma when the subject falls or is thrown.10,11

CLINICAL MANAGEMENT
Lightning strikes cause death in about 10% of cases in developed countries. About 74% of
subjects suffer permanent injury and sequelae, though this is controversial, with some studies
reporting much less permanent injury. Cardiac arrest, central nervous system (CNS) injury,
chronic pain, superficial burns, ocular (eye) burns and cataracts, ruptured tympanic membranes,
memory deficits, anxiety, irritability, aphasia, sleep disturbance, and posttraumatic stress
disorder (PTSD) are all associated with lightning injury.12

Table 18.2 Lightning Fatalities Compared to Other Weather-Related Fatalities 2010-

2015
Year Lightning Male Female Tornado Flood Hurricanes
2010 29 22 7 45 103 0
2011 26 19 7 553 113 9
2012 28 25 3 70 29 4
2013 23 17 6 55 82 1
2014 26 21 5 47 38 0
2015 27 16 11 36 176 14
Data from NWS Weather Fatality, Injury and Damage Statistics. National Weather Service website.
http://www.nws.noaa.gov/om/hazstats.shtml. May 11, 2017. Accessed May 23, 2017.

Lightning injury primarily affects the cardiovascular system and the CNS. The
integumentary system, the musculoskeletal system, the eyes, and the ears may also be affected.
In general, the subject of a lightning strike should be treated as a blunt trauma patient with
attention to spinal cord protection as warranted. Lightning may strike multiple individuals
simultaneously causing a multi-causality incident. When faced with multiple patients of lightning
strike, the EMS provider must utilize the important concept of reverse triage.
When EMS is faced with multiple patients, the provider must quickly determine how to
deploy the limited resources immediately available to affect the greatest good for the greatest
number of patients. As you approach the injured, call out and ask those who can walk to begin
walking toward you, directing them to a safe area you have designated, and instruct them to
remain in that area. Next call out to those who cannot walk, but can hear and respond to your
commands, by asking them to wave their hands in the air. Those patients who do not walk or
wave are considered to be the most severely injured or possibly dead. You move quickly to those
patients and assess the need for lifesaving interventions. During this initial assessment, if the
patient is not breathing, they are categorized as expectant or dead and you move to other victims
for continued assessments. This is an example of the traditional SALT triage: Sort, Assess,
provision of Lifesaving interventions, and Treat or Transport. However, this is not the ideal form
of triage to use in a lightning scenario.13
Centers for Disease Control and Prevention proposes a counterintuitive approach to mass
casualties involving patients of lightning strike called reverse triage.10 The majority of deaths
from lightning strike are from cardiac arrest caused by lightning’s massive current essentially
defibrillating the heart, resulting in asystole or ventricular fibrillation. The defibrillation also
causes the brain’s respiratory centers in the medulla to stop working. As with conventional
cardiac defibrillation, the heart may return to an organized rhythm; however, the respiratory
center is slower to reactivate and the chest wall musculature may also experience transient
paralysis. So the patient may have return of spontaneous circulation only to die of hypoxia
leading to a second cardiac arrest.6
Unresponsive patients secondary to lightning strike should be resuscitated vigorously as they
may require rescue breathing and/or cardiopulmonary resuscitation (CPR), which have a high
likelihood of survival even with prolonged downtime periods.14 Patients who initially survive a
lightning strike typically have full recovery, emphasizing the important role for reverse triage in
these situations: “resuscitate the dead first.”
CNS injury is common in subjects of lightning strike. CNS injuries are divided into four
categories and include immediate and transient injury; immediate and prolonged or permanent
injury; possible delayed neurologic syndromes; and trauma from falls, burns, or blasts. The first
category of immediate and transient injuries is common. Eighty percent of patients have
paresthesias (burning, prickly pain, tingling) and general weakness. Loss of consciousness occurs
in 75% of patients. Other symptoms include confusion, amnesia, headaches, and
keraunoparalysis (Charcot’s paralysis). Keraunoparalysis is unique to lightning injury and is
thought to be due to a catecholamine surge manifested by transient paralysis, pallor,
vasoconstriction, hypertension, and loss of sensation. It typically impacts the lower extremities
primarily and lasts one to several hours. Keraunoparalysis is unique to lightning injury, and
lower extremity weakness should be considered a more general injury such as spinal injury,
stroke, or intracerebral injury until proven otherwise.10
 The second category of immediate and prolonged or permanent neurologic injury include
hypoxic injury to the peripheral nervous system or neuropathy, intracranial hemorrhage, post
cardiac arrest cerebral injury or infarction, and damage to the cerebellum. Spinal and peripheral
nerve damage is uncommon, unlike other high-voltage electrical injuries.10
The third category of possible delayed neurologic syndromes includes symptoms possibly
related to the lightning injury, but manifesting in a delayed fashion. These include a wide variety
of motor neuron diseases and movement disorders such as amyotrophic lateralizing sclerosis or
Parkinson’s disease.10
The fourth category involves trauma from falls, burns, or blast injuries. Lightning injury may
also be associated with long-term neuropsychological complaints. Symptoms may include
fatigue, lack of energy, poor concentration, irritability with emotional lability, and PTSD in
about 30% of patients. These are divided into functional or behavioral categories. Patients and
families can be referred to one of several support networks such as Lightning Strike and Electric
Shock Survivors International, Inc (http://www.lightning-strike.org).4,8
Eye and ear injuries can also occur. Tympanic membrane rupture is present in about 50% of
lightning strike survivors, and patients can also experience vestibular injury and deafness.
Lightning strikes create a shock wave capable of inducing tympanic membrane rupture. Note that
lightning can travel through telephone wires, creating an ideal circumstance for this type of
injury if on a wired phone during a lightning storm. Lightning and other high-voltage electrical
injuries can also cause cataracts appearing immediately after injury or as late as 4 years after the
initial injury.10 There is some experimental evidence that some of the lightning current enters the
eyes, ears, nose, and mouth. Entry into these orifices may also allow a pathway to the brainstem,
which may explain the number of eye and ear symptoms that occur, as well as interruption in
respirations.4
Four types of injuries, including linear injury, punctate injury, feathering injury, and thermal
injury, affect the integumentary system.
Linear burns usually follow areas of high sweat or moisture under the breasts, axilla, groin,
and down the center of the chest. Linear burns are usually 1 to 4 cm in diameter presenting
immediately or can be delayed over several hours. They are thought to develop following
vaporization of water on the skin.10
Punctate burns are small, circular burns which appear in closely spaced multiples. Some may
be full-thickness burns, but due to their small size rarely require treatment. Tips of fingers, toes,
and the soles of the feet should be carefully inspected for full-thickness punctate burns as a sign
of lightning injury and called the “tip-toe” sign.5,10
Feathering lesions are also known as Lichtenberg figures or keraunographic markings
(Figures 18.2 to 18.5). Lichtenberg figures are pathognomonic for lightning injury, but are not
always present and are transient, lasting only a few hours. No damage to the epidermis or dermis
occurs and they are not considered a thermal injury. They appear as fern-like, branching lesions
on the skin. These lesions are hypothesized to be caused by blood escaping into the subcutaneous
tissue and require no treatment.10

Identification
Often the subject of a lightning strike will present overtly either by way of personal account of
the experience or the presence of a bystander as a witness to the event. Patients found
unresponsive outdoors should have lightning strike included in their differential. Also patients
found unresponsive indoors should have lightning strike included in their differential, knowing
that lightning current can propagate through plumbing, electrical wiring, plumbing fixtures,
showers, and even telephones.

FIGURE 18.2. Lichtenberg figure on back of adolescent. Courtesy of Dr. Mary Ann Cooper, with permission.
FIGURE 18.3. Lichtenberg figure on chest of adolescent. Courtesy of Dr. Mary Ann Cooper, with permission.

FIGURE 18.4. Close-up of Lichtenberg figure on back of adolescent. Courtesy of Dr. Mary Ann Cooper, with permission.
FIGURE 18.5. Burn from metal necklace in contact with chest and neck of adult. Courtesy of Dr. Mary Ann Cooper, with
permission.

The EMS provider must maintain a high index of suspicion, as not all lightning injuries will
present in an obvious fashion. While high-voltage injuries are arbitrarily defined as greater than
600 or 1,000 V, lightning typically involves voltages greater than 200,000 V and even up to 30
million volts. Ironically, this extremely high voltage often will not manifest as obvious injuries
on exam. During a lightning strike, the electrical current flashes over the subject with the current
only lasting milliseconds, often leaving no discernable physical findings as total current contact
time dictates injury severity. If the subject has wet skin this may further decrease the risk of
internal injury as this may provide a path for the current to travel over the body. This flashover
explains why some patients of lightning strike have no obvious injuries, as well as why some
patients literally have their clothes “blown off” as the moisture on the skin combusts. This
phenomenon is especially common for socks and shoes, due to high sweat content of feet
(Figure 18.6). This large current however produces a pulsed magnetic field that can induce
injury in nearby persons and also disrupt the cardiovascular system and neurologic systems.15
In some areas of the United States, especially in more rural areas, paramedics or other EMS
providers are serving as medical examiners or coroners and are responsible for investigating
unnatural deaths. In the case of potential lightning injury, a forensic style investigation will serve
the provider when dealing with a salvageable patient as well as in the case of a decedent. Some
important questions to consider in the case history and scene investigation are listed in Tables
18.3 and 18.4.
FIGURE 18.6. Socks exploded from feet of a farmer killed by lightning strike. Courtesy of Dr. Mary Ann Cooper, with
permission.

Table 18.3 Forensic Investigation Case History

Was there a storm? Description of the lightning event
Was there lightning? How many people involved?
Did witness see lightning strike the subject? Survivors? Where are they located?
Where was the subject? What is the medical history of the decedent?
(Under a tree, open field, golf course) Any cardiac history?
Any resuscitation attempt? Was death immediate or delayed?
What activity was occurring before death? Storm activity asked from weather service?

From Davis C, Engeln A, Johnson EL, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of
lightning injuries: 2014 update. Wilderness Environ Med. 2014;25(4 suppl):S86-S95, with permission from Elsevier.

Prevention
Responder safety is our first priority, so EMS should be aware of simple techniques to decrease
the chance of lightning injury to crews as well as the public, especially if providing mass-
gathering event medical coverage. One should be aware of the weather forecast in your response
area or event area, as anticipation of lightning and avoidance is the best prevention. Media
outlets serve as a great source; however, today’s technology allows for the use of multiple
applications installed on a smartphone, tablet, or computer to give up-to-date severe storm
weather watches and warnings. It is also reasonable for an agency’s central communications
center to monitor weather activity and report to the EMS system.
In a WEMS operation, however, wireless services or Internet services may not be available,
rendering many smartphone, tablet, or computer lightning applications useless. There are a
multitude of handheld and portable lightning detection devices available ranging in price from
tens of dollars to thousands of dollars. The National Fire Protection Agency Standard 780
recommends a three-stage warning criterion, consisting of yellow, orange, and red. The yellow
stage alerts of a possible threat with lightning typically 30 miles away, while an orange
represents a probable threat and lightning 20 miles away, with red representing immediate
danger and lightning 10 miles away. Handheld and portable lightning detectors use variable
systems of detection such as radio frequency detectors, electric field mills, optical monitors, and
hybrid designs using multiple detection modes and may be better than single mode detectors.
One source for review and detailed descriptions of portable and handheld lightning detection
devices is www.ambientweather.com.16
Remain indoors during thunderstorms when able. In the case of mass-gathering events, you
may be making the decision or advising the incident commander or venue manager of potential
dangerous weather conditions and moving outdoor activities safely indoors or even postponing
the event. More information about mass gathering or special event wilderness EMS is included
in Chapter 9. The 30-30 rule (Table 18.5) is commonly quoted as a safety measure, which states
that if the flash of lightning seen is then followed by the sound of thunder in less than 30 seconds
you are at high risk of lightning injury. Thunder usually cannot be heard greater than 10 miles
away. Given the difference in speed of light and sound, a 30-second delay between flash and
thunder indicates a storm that is 6 miles away (Table 18.5).17

Table 18.4 Forensic Scene Investigation

Environmental Signs of Direct Structural Signs of Direct Lightning Trace Evidence Signs of Direct
Lightning Strike Strike Lightning Strike
Damage to nearby trees? Damage to walls or roof? Cindering of clothes?
Arc marks present nearby? Fire damage to structure? Arc marks on metal?
Ground displays fern pattern? Electrical damage? Burns from metal on skin?
Tubular forms in the soil? Plumbing damage? Fusing of metals?
Craters in the ground?

From Davis C, Engeln A, Johnson EL, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of
lightning injuries: 2014 update. Wilderness Environ Med. 2014;25(4 suppl):S86-S95, with permission from Elsevier.

A better rule is probably “when thunder roars, go indoors.” Once indoors you should remain
there 30 minutes after the last lightning flash or sound of thunder.10,12 However, recent evidence
supports a return to activity after waiting 15 minutes from the last lightning flash or sound of
thunder for individuals, as the risk of lightning threat is minimal after 15 minutes. Thirty minutes
is more useful in mass-gathering events to prevent moving a large number of spectators or
participants outside too quickly, only to return them back to shelter in the event of lightning or
thunder. The Wilderness Medical Society Practice Guidelines recommend 30 minutes.4,8
If trapped outdoors during a thunderstorm separate group members from one another and
make yourself as small as possible. Lightning can jump nearly 15 ft between objects, so separate
at least 20 ft from one another to limit mass casualties.8 An impending strike may be manifested
by a tingling sensation, hair standing on end, a crackling sound, or a visible glow called St.
Elmo’s Fire, seen at the top of a flag pole or ship’s mast for example.

Table 18.5 30-30 Flash-Bang Rule

Sound of Thunder Is Heard Lightning Is This Distance Away
5 s after flash 1 Mile away
10 s after flash 2 Miles away
15 s after flash 3 Miles away
20 s after flash 4 Miles away
25 s after flash 5 Miles away
30 s after flash 6 Miles away
35 s after flash 7 Miles away
40 s after flash 8 Miles away

Data from Lightning Safety: Health and Safety. NCAA website. http://www.ncaa.org/content-categories/health-and-safety. June
2014.

Many recommend crouching down with feet and knees together to limit your contact with
the ground and to stand or sit on a pack or nonconductive material. While controversial, it is
recommended by the Wilderness Medical Society as a last resort after other strategies have failed
or are not available.8 Do not lie on the ground, and do not stay in open vehicles such as
convertibles, bicycles, motorcycles, golf carts or other similar vehicles, such as all-terrain
vehicles (ATVs). ATVs are used in wilderness operations and are usually manufactured with
fiberglass, plastics, and metals, and are not equipped with doors and side or rear windows
making them an unsafe lightning shelter. During response or rescue operations, a safe and readily
available lightning shelter is a closed vehicle. The vehicle should be manufactured of metal and
have a closed roof. Windows should be in a fully closed position and you should not make
contact with anything inside the vehicle that communicates with the outside of the vehicle, such
as metal, window, or door handles. Construction type equipment with a rollover canopy system
is also safe during lightning strikes. Within any metal vehicle it is best to sit with hands in your
lap to avoid touching any object that could possibly connect with an outside structure. Vehicles
manufactured of fiberglass are unsafe as a lightning shelter. A closed metal vehicle acts as a
lightning shelter, essentially a Faraday cage, allowing the massive lightning current to flow over
the metal structure and onto the ground.18
Avoid open structures such as gazebos, dugouts, and porches as well as parks, playgrounds,
ponds, lakes, and other bodies of water as this puts you at risk of all types of lightning strike.
Finally move away from tall structures and do not handle metallic objects during a storm.12,19 In
remote areas seek shelter inside a deep cave, deep ravine, or far into a dense forest which is a
safer alternative than remaining in an open, exposed area.8
During wilderness operations, searches, rescues, climbing and mountaineering or trekking
planning to reduce the chance of lightning strike is paramount (Figure 18.7). Mountain peaks
and ridgelines should be avoided in the afternoon where possible, as this is the most frequent
time for storms. Ascent by noon and descent by two is a common principle to decrease exposure
on peaks and ridgelines.
FIGURE 18.7. Backcountry lightning risk. From Gookin J. Lightning risk management for backcountry campers and hikers.
National Weather Service Lightning Safety website. Available at: www.lightningsafety.noaa.gov. March 6, 2012. Accessed May
23, 2017.

Providers who are involved in climbing operations during a thunderstorm must tie-off
individually for safety. Climbing ropes, when saturated with water, become electrical conductors
and strikes can even occur between two or more climbers and a climber and a belayer. All metal
objects, such as ski poles and axes, should be isolated to prevent contact burns and injury from a
lightning strike. Direct contact with small metal objects such as carabiners, cable grabs, rigging,
or pulleys should also be avoided to the extent possible to prevent injury. Watches, belt buckles,
necklaces, and bracelets should also be removed to prevent contact burns.
If wilderness operations involve a body of water, including streams, rivers, or lakes, the
provider should leave the water immediately. Where operations involve a small watercraft move
to shore and away from the shoreline and in larger watercraft move below decks after locking the
helm.17,20,21
In mass-gathering events safety can be difficult to both find and reach in a timely manner.
Venue owners or managers should be educated on lightning risk. The National Collegiate
Athletic Association (NCAA) has developed a reasonable plan for outdoor athletic events, which
are applicable to other outdoor mass gatherings (see Table 18.6).
Table 18.6 NCAA Lightning Safety
Develop Lightning Safety Prearranged instructions and announcements for spectators and participants
Plan for Event Designated warning and all-clear signals
Identification of lightning-safe structures
Designate weather monitor Notify chain-of-command when individuals need to be moved to safety
Monitor weather reports daily Monitor skies for signs of thunderstorms
Monitor local weather outlets
Use online, weather apps, etc.
National Weather Service Monitor for watches and warnings
Warnings indicate imminent danger
Monitor NOAA Weather Radio broadcasts
Know closest lightning safe Know placement and time to evacuate to structure
structure or location Buildings normally occupied with plumbing and wiring—avoid windows and doorways
Hard metal roof vehicle such as bus
Lightning awareness First sound of thunder or site of lightning
Skies suggesting impending storm
Sound of thunder should prepare for evacuation
(Thunder may be difficult to hear due to noise)
Lightning—suspend activity and evacuate
Do not use landline telephones
Return to play Resume after 30 min from last thunder or lightning and evidence storm is moving away from
event

Adapted from from Lightning Safety: Health and Safety. NCAA website. http://www.ncaa.org/content-categories/health-and-
safety. June 2014.

Safe indoor places include homes, offices, shopping centers, and hardtop vehicles with
windows rolled up in the closed position. Ungrounded outbuildings are not a safe refuge. When
indoors, stay about 3 ft away from walls and at a distance not greater than the height of the wall,
for example, in a room with an eight-foot wall, stay within 3 to 8 ft of the wall. Do not contact
concrete as it has metal rebar inside which will conduct electrical current. Do not use corded
telephones, computers, take showers or wash hands in a sink, touch metal during thunderstorms,
and stay away from windows and doors.12,19,22

Treatment and Disposition

The most important aspect of treatment is the concept of reverse triage. Remember to resuscitate
the dead first. Subjects of lightning strike should be treated as blunt trauma patients and attention
given to spinal cord protection if warranted. The primary survey is initiated with lifesaving
interventions applied as needed followed by the secondary survey. During the secondary survey
look for both subtle and obvious skin and clothing findings, which may indicate a lightning strike
has occurred.
Some patients of lightning strike may have very few complaints and an unremarkable exam.
Based on their feeling of well-being they may wish to refuse treatment and/or transport. The
EMS provider should advise patients that lightning strike can have delayed onset of symptoms
and a formal medical evaluation should be sought. In the event a patient continues to refuse
treatment and/or transport, the provider should assess for and document the patient’s capacity for
refusal. This is easily applied using the CRAM mnemonic: assessing the patient’s ability to
Communicate a clear and stable choice, understand Relevant information, Appreciation of the
situation, and Manipulation of information in a rational manor.23 The American Burn Association
(ABA) recommends that all patients of lightning injury or burn be evaluated in a burn center.24

First Aid
First priority is your safety. Do not approach a subject unless it is safe for you to do so as
lightning may strike in the same location, contrary to popular belief. As storms accompany
lightning, power lines and trees may be down and pose a hazard. Remember that while a
lightning strike patient is no longer “electrical” and cannot transmit a charge, downed power
lines can electrocute you while attempting to care for a lightning subject. You should stay at least
10 m (32 ft) away from a downed power line; this may not even be without risk, and also away
from any metal support structure of the power line.
Subjects in contact with a power line or support structure may be energized and can transmit
this current to a rescuer. It is important to remember that specialized equipment is required to
handle power lines including tools to move the line, gloves, and boots. This equipment must be
tested regularly to insure insulation integrity. Otherwise electrical current of high voltages can
propagate through poles, gloves, and boots not specifically designed for this purpose. A lightning
strike patient not in proximity to a power line is never energized and cannot electrocute you.15
Patients of lightning strike respond well to aggressive resuscitation, as cardiac arrest is the
primary cause of death. However, a lightning patient may have sustained tertiary trauma, so
significant that it is incompatible with life and in this situation resuscitation should not be
attempted.
When the scene is safe, approach the patient and check for responsiveness. Call out for help,
call 911, or ask someone to call 911 for help. Locate an automated external defibrillator (AED) if
immediately available or ask someone to bring the AED to the patient’s side. Keep the phone by
the victim’s side and follow the instructions by the 911 dispatcher. Look for breathing, no
breathing, or abnormal breathing.
If the patient is breathing normally and has a pulse, move the patient into the recovery
position, monitor breathing and pulse, and look for any external hemorrhage while maintaining
the cervical spine in alignment. If hemorrhage is present, apply direct pressure and if not
controlled, apply a tourniquet. Keep the patient warm and wait for help.
If the patient has abnormal breathing and a pulse, provide rescue breaths every 5 to 6 seconds
at a rate of 10 to 12 breaths per minute. Continue to monitor the pulse every two minutes and if
pulses are lost, begin CPR immediately.
If the patient has no breathing or abnormal breathing and no pulse, begin CPR immediately.
Begin with 30 compressions and two breaths. Remember to use the AED as soon as available. If
an AED arrives, place the AED and allow the unit to analyze the rhythm and deliver a shock if so
advised. If no shock advised or if a shock is advised and delivered, immediately return to CPR
and check the pulse and allow AED rhythm analysis every 2 minutes.14,25

Basic Life Support

Safety of you and your crew are the highest priority. Do not enter the scene unless safe,
following the principles outlined in the section on First Aid. Lightning strike is not only an
electrical injury, but also a blunt traumatic injury, so spinal cord protections (discussed further in
Chapter 24) should be utilized. Chapter 21 has further discussion of general management of
blunt traumatic injury. Cardiac arrest is the primary cause of death in lightning strike and patients
responsive following a lightning injury typically recover from their injuries. Therefore, reverse
triage is of paramount importance. Perform aggressive resuscitation on patients of lightning who
are apneic and pulseless unless they have other injuries incompatible with life.
Health care providers, when dealing with a pediatric arrest, may switch to 15 compressions
and 2 ventilations with two or more providers. In EMS systems practicing bundles of care related
to cardiac arrest, such as pit crew or team-focused CPR, the adult cardiac arrest patient’s airway
is of lesser importance. Providing face mask–delivered oxygen during the first 600 compressions
or placing a blind insertion airway device later in the resuscitation sequence is often practiced in
these systems as well as in compression-only CPR, until adequate resources are available on
scene. It is important to remember that the lightning victim will be suffering from hypoxemia,
unlike most adults who experienced sudden cardiac arrest, and therefore the airway is very
important.
High-quality, minimally uninterrupted chest compressions and early defibrillation are the
two most important provisions of medical care in cardiac arrest. Utilize the AED as soon as one
becomes available. Ensure compressions are delivered at 100 to 120 compressions each minute
and ventilations are delivered at 30 compressions to 2 ventilations unless an advanced airway is
in place, then ventilations may be delivered every 6 seconds. It is important to prevent
hyperventilation in cardiac arrest as this leads to worse outcomes by preventing blood flow back
into the heart, which decreases cardiac output, and increased oxygen environments can cause
cellular damage to the brain.

Advanced Life Support

Scene safety is of primary importance. ALS personnel will follow the initial sequence of both
first aid and basic life support care. If a manual defibrillator is on scene this should be applied to
the patient. It is important to remember that the time surrounding a defibrillation is very
important in survival. A long pause before and after the defibrillation without delivering chest
compressions worsens survival and is called the perishock pause.
One strategy to minimize perishock pause is to have the compressor count aloud every 20th
compression and upon reaching compression 180, the next compressor should come to a ready
position to assume compressions, and ALS personnel should charge the defibrillator. At 200
compressions, change compressors, check pulses or end-tidal carbon dioxide, and assess the
ECG rhythm. If a shock is warranted, deliver the shock immediately, and then resume
compressions. Once ALS personnel have ensured a patent airway, ventilations without
hyperventilation, and high-quality, minimally interrupted compressions, intravenous or
intraosseous access should be obtained and standard advanced cardiac life support principles
employed.
The lightning strike subject should be treated as a trauma patient with attention to spinal cord
protection. However, in general, the lightning strike victim is not hypotensive, usually because
the injury is associated with catecholamine surge causing tachycardia and hypertension. If the
patient is hypotensive, then assume there are other injuries present with hemorrhagic blood loss.
ECG analysis is important, as injury may be seen, manifested by ST-segment elevation and QT-
interval prolongation, T-wave inversions are often seen especially with concomitant neurologic
injury. Myocardial infarction is unusual after lightning injury.14

Clinician
Scene safety remains a priority. If on scene, the practices outlined in the preceding sections
should be employed. If a lightning strike patient arrives to the emergency department it is
important to remember that many patients have a good chance of survival, even with prolonged
resuscitation attempts. Careful attention to the primary and secondary survey is important.
If available via iStat or a fixed facility such as an EMS expedition station, laboratory studies
may include CBC, BMP, creatinine, BUN, glucose, creatinine kinase, urinalysis, and
radiography studies as directed by exam findings. An ECG is also important as outlined in the
preceding section. The heart can also be affected by global depression of contractility, coronary
artery spasm, and pericardial effusion. Patients experiencing a direct strike or those with an
abnormal ECG or echocardiogram should be monitored for a minimum of 24 hours.8 Delayed or
recurring cardiac injury such as pericarditis or cardiomyopathy is possible, so patients who are
released from EMS or field care should be instructed to seek care again for new chest pain,
dyspnea, or dyspnea on exertion.8
Many lightning strike patients have loss of consciousness, lower extremity weakness or
transient paralysis, and even seizures. As the current passes through the brain, heat-induced
coagulation of the cerebral cortex may occur as well as intracranial hemorrhages. Autonomic
dysfunction can occur and present with anisocoria and/or pupillary dilation, which is not related
to brain injury and should not be used to predict outcome in the comatose patient.
Most neurologic symptoms resolve within 24 hours; however, delayed conditions may
manifest as progressive disease, including seizures, muscle atrophy, amyotrophic lateral
sclerosis, Parkinson-like movement disorders, cerebellar ataxia, myelopathy with paraplegia or
quadriplegia, and chronic pain syndromes. Transport to a facility capable of computed
tomography is warranted in coma, altered mental status, or persistent headaches or confusion.15
High-risk indicators in lightning strike patients are listed in Table 18.7. See Table 18.8 for
potential injuries from lightning by body system.

Equipment Summary
There is no specific equipment strictly for lightning events. It is important to remember that
typical personal protective equipment, turnout gear, boots, helmets, and gloves will not protect
you from a lightning injury. It is also important to be aware that metal objects should be removed
as they can transmit current and cause burns, but they do not specifically attract lightning.

Table 18.7 High-Risk Indicators in Lightning Strike Subjects

Suspected direct strike
Loss of consciousness
Focal neurologic deficits
Chest pain or dyspnea
Major trauma
Cranial burns, leg burns, or other burns > 10% Total Body Surface Area
Pregnancy

From Davis C, Engeln A, Johnson EL, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of
lightning injuries: 2014 update. Wilderness Environ Med. 2014;25(4 suppl):S86-S95, with permission from Elsevier.

Table 18.8 Body Systems and Potential Injuries from Lightning

Cardiac Hypertension, tachycardia, myocardia depression, coronary artery spasm, pericardial effusion,
atrial and ventricular arrhythmias, ST-segment elevation, QT-interval prolongation, T-wave
inversions, myocardial infarction (rare)
 Neurologic Loss of consciousness, coma, transient lower extremity paralysis, seizures, intracranial injury
or hemorrhage, heat-induced nerve damage, autonomic dysfunction with irregular pupils,
confusion, amnesia, and more delayed disease
Vascular Vasomotor spasm in an extremity, local arterial spasm, ischemia of peripheral nerves, skin
color changes (pallor and cyanosis followed by erythema), mottling of skin, cool extremities,
loss of sensation, transient paralysis, compartment syndrome (rare)
Ocular Cataracts (bilateral), hyphema, vitreous hemorrhage, corneal abrasion, uveitis, retinal
detachment or hemorrhage, macular perforations, optic nerve damage
Auditory Tympanic membrane rupture, tinnitus, deafness, ataxia, vertigo, and nystagmus
Musculoskeletal Fractures, muscle contractions producing shoulder dislocation, rhabdomyolysis (rare), spinal
fractures, keraunoparalysis
Integumentary Lichtenberg figures, flash burns, punctate burns, contact burns, superficial and blistering burns,
linear burns

Adapted from Bailey C. Electrical and Lightning Injuries. In Tintinalli, JE, ed. Tintinalli’s Emergency Medicine: A
Comprehensive Study Guide. 8th ed. New York, NY: McGraw Hill Education; 2016:1411-1419.

SEVERE STORMS
An in-depth discussion of EMS response to severe storms is beyond the scope of this chapter. A
severe storm may tax a given EMS agency from a few hours to several weeks depending on
severity, duration, population density, and damage to infrastructure. While many EMS bases may
have an emergency generator, beyond electricity, the preparation for days with limited food and
water sources are typically limited. Many providers lack basic preparation in their personal
homes, which may impact their willingness and ability to respond to their community in times of
need. The following discussion will focus on preparation of the individual responder and his/her
family as opposed to organizational preparedness.
In the event of a weather event, which taxes local resources, EMS providers have a
responsibility to respond to the needs of their community. In order to provide this service, the
provider must take the same steps of preparation as other members of the community. Knowing
your home is prepared for your family will decrease stress and allow you to better concentrate on
the community.
Numerous studies have concluded that less than 18% to 50% of agencies have prepared
themselves or their families for a multiday response and that nearly 50% admitted this type of
response would create a hardship for their family. About 66% admitted they would not respond
to an event in order to care for their own families and nearly 75% believed their department is ill-
prepared for a large-scale event.
What can the individual provider do to prepare their home and family for a disaster such as
might occur with a severe storm? Get an emergency supply kit, make a family emergency plan,
and become familiar with large-scale emergencies that you might respond to in your area and
what to do when disaster occurs. Responders across disciplines in general agree that their agency
and their families are not always prepared. Resources exist to guide responders in planning such
as Ready Responder at https://www.ready.gov/responder, Homeland Security at
http://www.firstresponder.gov/Pages/Ready-Responders.aspx, and the Federal Emergency
Management Agency at https://www.firstrespondertraining.gov/content.do. Tables 18.9 and
18.10 describe a personal home emergency supply kit and a family emergency plan.
From an agency perspective, a preplanned severe weather or storm plan should be developed
using all stakeholders and widely disseminated. EMS should have representation in the
Emergency Operations Command (EOC) structure. Utilization of the Incident Command System
and the role of the EOC during WEMS operations is discussed further in Chapter 3. Using
emergency alerts issued by the National Weather Service is one way a severe weather plan can
be initiated. Tables 18.11 and 18.12 serve as examples of severe weather alerts and weather-
related events that may initiate the severe weather or storm plan and can be tailored to your area.
The area emergency management agency or the EMS agency may initiate the plan. The
Primary Service Answering Point (PSAP) and local hospitals should be made aware the agency
is operating under a severe weather or storm plan. Notification of the public through local media
is suggested to inform the public of possible response delays and to instruct the public to call for
only emergencies during this period. In addition, PSAPs are often responsible for monitoring
weather and notifying ongoing WEMS operations when severe weather is approaching or may
impinge on operations.

Table 18.9 Home Emergency Supply Kit

Water supply 1 Gallon/person/day for 3 d
Remember pet needs as well
Food supply Nonperishable food
No refrigeration, cooking, and little to no water
Ready to eat foods
Manual can opener and utensils
Radio Battery or hand-cranked operated
Phones or two-way radios NOAA radio with alerts
Extra batteries
Ability to communicate with agency to coordinate assignments
Flash lights Extra batteries
First aid kit(s)
Whistle Signal for help if needed
Dust mask Plastic sheeting and duct tape to shelter in place
Personal sanitation Moist towelettes, sanitary wipes, garbage bags, and plastic ties
Utility management Wrench or pliers to turn off utilities
Local maps
Family documents Deeds, titles, and other ownership documents
Birth certificates, Social Security Cards, etc.
Marriage license, divorce papers, child custody documents
Passports and military documents
Appraisals of expensive items
Household inventory
Copy of will and trusts
Living wills, health care, and other power of attorney
Insurance policies, identification, bank accounts, etc.
Extra keys to property and vehicles
Maintain in waterproof and portable container
Consider renting a safe deposit box
Family special needs Prescription medications and extra glasses or contact lenses
Infant formula and diapers
Pet food, water for pet, leash, and collar
Books, games, puzzles, other activities for children
Assemble smaller kit In case of evacuation, assemble smaller kit
Data from Emergency Supply List. Ready.gov website. https://www.ready.gov/sites/default/files/documents/files/checklist3.pdf.
2017.

In general, agencies operating under a severe storm or weather plan should respond to
incidents with the least number of responders to manage the incident and use other agencies to
respond to confirm whether EMS is needed due to illness or injury when possible such as in
agencies using a multitier response configuration. When transport of multiple patients is
warranted, transport multiple patients in each ambulance to conserve resources. When your
PSAP utilizes a medical dispatch interrogation system, prioritization of responses is
straightforward. When medical calls exceed the number of available resources, EMS personnel
may perform telephone triage to more fully evaluate a caller’s need for medical response. When
response will be delayed, EMS personnel may also contact callers directly to explain the delay
and provide assistance over the phone where needed (Table 18.13).

Table 18.10 Family Emergency Plan

Family Emergency Plan Plan in advance with family what to do in an emergency
Out-of-town contact to relay information for your family
Learn about school and work emergency plans
Meeting places: Designate one meeting place in your
neighborhood and one outside your neighborhood
Contact numbers for entire family with each family member
Record medical conditions and needs for each family member
Children:
Make sure children know how to contact the family
Have current photos of children
School contact numbers
School emergency plans
Dual responder family needs special plans
Older family members or special needs:
Develop plan that considers each family member needs
Personal support network to call on if needed
Pets:
Plan with neighbors, friends, or relatives to care for pets if
you are unable
Make a plan in advance how to contact family members
and reassemble if separated

Data from Family Emergency Plan: Make a Plan. Ready.gov website. https://www.ready.gov/make-a-plan. 2017.

Table 18.11 National Weather Service Severe Weather Emergency Alerts

Emergency Alerts
Warnings Event posing significant threat to public safety and/or property
Probability of occurrence and location is high
Onset time is short
Watches Meets classification of warning
Probability of occurrence, location, or onset time is unknown
Emergencies Event alone would not kill, injure, or cause property damage
Indirectly may cause other hazards
Statements Message containing follow-up information to a warning, watch, or emergency

Data from Emergency Alert System (EAS) Event Codes. NOAA website. http://www.nws.noaa.gov/nwr/info/eventcodes.html.
June 30, 2004.
Table 18.12 National Weather Service Severe Weather-Related Events
Blizzard Warning Flood Watch Tornado Watch
Coastal Flood Watch Flood Warning Tornado Warning
Coastal Flood Warning Hurricane Watch Tropical Storm Watch
Dust Storm Warning Hurricane Warning Tropical Storm Warning
Flash Flood Watch Severe Thunderstorm Watch Winter Storm Watch
Flash Flood Warning Severe Thunderstorm Warning Winter Storm Warning

Data from Emergency Alert System (EAS) Event Codes. NOAA website. http://www.nws.noaa.gov/nwr/info/eventcodes.html.
June 30, 2004.

Triage and destination facilities may require adjustment during severe storms or weather. In
general, patients should be transported to the nearest facility that can accommodate patient
condition to conserve agency resources. It may be necessary to transport to the nearest facility
for stabilization and holding until conditions allow more distant transport to a more definitive
care facility. Scheduled transports and inter-facility transports may be delayed as necessary to
ensure safety of patient and crews. Priority inter-facility transports are given to conditions for
which the transferring facility does not have treatment capabilities (Table 18.14 and Table
18.15).

Table 18.13 EMS Agency/Personnel Response to Severe Storms

Ensure ample fuel supply Before, during, and after event
Ensure personnel vehicles are fueled
Test all power equipment Generators, emergency lightning, etc.
Ensure stations are well supplied Supplied for before, during, and after storm
Secure loose items around EMS base Trashcans, benches, chairs, etc.
All personnel have appropriate level of personal protective Helmets, goggles, work gloves, hearing protection, rain gear,
equipment turnout clothing
Proper work schedules/sleep schedules Sleep and rehabilitation cycles for multiday events
Move personnel vehicles to points of safety
Relocate EMS base to point of safety Example is anticipated flooding
Supplies for EMS personnel Toiletries, clothing, meals, for up to 72 h
Clean water source for EMS personnel Clean water for up to 72 h

Data from Ready Responder Toolkit. Ready.gov website.

https://www.ready.gov/sites/default/files/documents/files/RRToolkit.pdf. 2017.

Table 18.14 Recommendations When Facing a Tornado

Location Recommendations
Structure (residence, building, EMS Go to safe room if able
base, hospital, nursing home, Basement
multistory building) Storm cellar
Lowest building level (closet, interior hallway)
Away from corners, windows, doors, and outside walls
Under a sturdy table
Do not open doors or windows
Manufactured home or office/base Leave and seek shelter at a nearby building or storm shelter—predetermined place
 Mobile homes offer no protection
Outside No research-based recommendations
Enter a vehicle and buckle safety belts—drive to a sturdy building or storm shelter
If hit by flying debris—pull over and park
Take cover in vehicle. Buckle safety belts, wear helmet and goggles, and cover with
blankets or coats (turnout gear)
Lie in a low area, below roadway, cover and protect yourself as listed above
Do not park or lie under overpass or bridge
Do not try to outrun a tornado in urban or traffic-congested areas, exit vehicle and find
lowest point and protect yourself as listed above
Observe for flying debris—causes most injuries

Data from Tornadoes: Be Prepared. Ready.gov website. https://www.ready.gov/tornado. 2017..

Equipment Summary
Equipment will be dictated by environment in which the EMS team operates, type of severe
weather, length of weather, population density, and infrastructure damage as well as need for
evacuation assistance.

Severe Storm Case Study: “Thunderstorm Asthma”

On November 28, 2016, a thunderstorm struck areas near Melbourne and Victoria, Australia.
Several days following the storm, thousands of people were hospitalized due to respiratory
problems. An additional 60 ambulances were deployed in order to respond to over 1,900 calls for
help. At the time of this writing, over 8,500 patients were treated in area hospitals and 8 people
died as a direct result of thunderstorm asthma.26,27

Table 18.15 Recommendations When Facing a Hurricane and/or Floods

Family Emergency Communication Plan Ensure your family has evacuated to a predetermined place
along local evacuation routes
Supplies for EMS personnel Toiletries, clothing, meals, for up to 72 h
Clean water source for EMS personnel Clean water for up to 72 h
Turn refrigerator/freezers to coldest settings If power loss, open doors minimally to conserve food
preservation
Secure loose items around EMS base Trashcans, benches, chairs, etc.
Trim plants/trees before hurricane
Do not drive or walk through flood waters 6 inches of moving water can induce fall
24 inches of moving water can move a vehicle
Move to higher ground Relocate EMS base if prone to flooding

Data from Hurricanes: Be Prepared. Ready.gov website. https://www.ready.gov/hurricanes. 2017. and Floods: Be Prepared.
Ready.gov website. https://www.ready.gov/floods. 2017.

Thunderstorm asthma is used to describe an increase in acute bronchospasm following a

local thunderstorm. Several large asthma outbreaks following thunderstorms have been reported
mainly in Europe and Australia from 1983 to 2010, with some occurrence in the United States
and Canada. Prior to 2016, the largest thunderstorm asthma outbreak occurred in London on June
24, 1994, where 640 patients presented to local hospitals for treatment and 104 patients were
admitted with 5 admitted to the intensive care unit.
 While much is not known about the mechanism of thunderstorm asthma, evidence suggests
that it occurs when there are high atmospheric concentrations of certain pollens. Thunderstorms
concentrate pollen particles at ground level and when they become saturated with water, they
burst, releasing allergenic material. Strong electrical fields also occur during thunderstorms and
cause positive ions, released from the ground, to attach to pollen and enhance rupture with
allergenic material release. Grass pollens and starch particles attached to certain grass pollens
such as ryegrass are the likely cause. Other grass pollens, such as Parietaria (Wall Pellitory,
Lichwort, and Hammerwort), that do not contain starch particles are also implicated. Mold
spores are known to increase in thunderstorms and may also cause bronchospasm. Fungal spores
such as Alternaria and Cladosporium have been linked to bronchospasm.
In general, there is often a slight increase in health care utilization for bronchospasm
following a thunderstorm, but most thunderstorms are clearly not implicated in thunderstorm
asthma epidemics. Thunderstorm asthma is seen when pollen and outdoor mold counts are
highest and there is a lack of other atmospheric particulates to explain the phenomenon. It is also
known that during high pollen counts, when patients with pollen allergies remain indoors with
their doors and windows closed during a thunderstorm, they do not suffer bronchospasm and
nonallergenic individuals are not involved in thunderstorm asthma.28,29
It should be recognized that thunderstorm asthma may overwhelm local EMS and health care
systems. Many patients do not have an asthma diagnosis and only have mild hay fever, but can
suffer severe bronchospasm. Currently no meteorological or aerobiological parameters are
known with enough sensitivity and specificity to develop an early warning system. Treatment is
the same as other asthma exacerbations and even during thunderstorm asthma the vast majority
of patients are discharged from the emergency department after treatment.

SUMMARY
EMS providers will encounter lightning events and severe storms or weather. These events place
the provider in harm’s way and providers must be cognizant of the inherent danger. Provider and
crew safety must be the priority. When facing a lightning subject remember the patient is not
energized from a lightning strike and cannot electrocute the provider. However, when responding
to severe storms with downed power lines, a subject in contact with a power line or support
structures may very well be energized and can electrocute the provider. While no special
equipment exits to combat lightning, remember that most agencies do not carry the specialized
equipment or expertise to manipulate power supply lines.
Lightning injuries are very different from high-voltage injuries and the provider must
maintain a high index of suspicion and look carefully for clues indicating a lightning strike has
occurred. Patients who suffer cardiac arrest secondary to a lightning strike often have a good
recovery when CPR is initiated quickly with high-quality, minimally interrupted compressions,
and early defibrillation, as well as attention to the airway as often this is a hypoxic event. When
encountering multiple patients of lightning strike, utilize reverse triage and resuscitate the dead
first.
While we often think about how disasters will affect our community and our agency’s
response, we typically fail to prepare our own homes and families. Following a few simple
strategies will prepare your home and family, as well as your EMS base, for periods without
electricity and water.
References
1. National Oceanic and Atmospheric Administration. NOAA Knows. . .Lightning. May 2014. Available at:
http://www.lightningsafety.noaa.gov/resources/lightning3_050714.pdf. Accessed May 1, 2016.
2. National Oceanic and Atmospheric Administration. National Weather Service. Understanding Lightning: Thunderstorm
Electrification. Available at: http://www.lightningsafety.noaa.gov/science/science_electrication.htm. Accessed December 4,
2016.
3. Ota FS, Purdue FG. Emergent injuries to children and adolescents due to electricity and lightning strikes. Pediatr Emerg
Med Pract. 2005;2(8):1-18.
4. Cooper MA, Holle RL, Andrews CJ, et al. Lightning Injuries. In: Auerbach PS, ed. Wilderness Medicine. 6th ed.
Philadelphia, PA: Elsevier Mosby; 2012:60-103.
5. Whitcomb D, Martinez JA, Daberkow D. Lightning injuries. South Med J. 2002;95(11):1331-1334.
6. Centers for Disease Control and Prevention. MMWR. QuickStats: Number of Deaths from Lightning Among Males and
Females – National Vital Statistics System, United States, 1968-2010. July 2013. Available at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6228a6.htm. Accessed May 1, 2016.
7. National Weather Service. NOAA. How Dangerous is Lightning? 2014. Available at:
http://www.lightningsafety.noaa.gov/odds.shtml. Accessed May 1, 2016.
8. Davis C, Engeln A, Johnson EL, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of
lightning injuries: 2014 update. Wilderness Environ Med. 2014;25(4 suppl):S86-S95.
9. Jensenius JS. National Weather Service. NOAA. A Detailed Analysis of Lightning Deaths in the United States from 2006
through 2015. January 2016. Available at: http://www.lightningsafety.noaa.gov/fatalities/analysis06-15.pdf. Accessed May
1, 2016.
10. Ritenour AE, Morton MJ, McManus JG, et al. Lightning injury: a review. Burns. 2008;5(34):585-594.
11. National Weather Service. NOAA. Lightening Science: Five Ways Lightning Strikes People. 1999. Available at:
http://www.lightningsafety.noaa.gov/struck.shtml. Accessed May 1, 2016.
12. Cooper MA, Edlich RF. Medscape. Lightning Injuries. September 26, 2014. Available at:
http://emedicine.medscape.com/article/770642-overview. Accessed May 1, 2016.
13. Lerner EB, Schwartz RB, McGovern JE. Prehospital triage for mass casualties. In: Cone DC, ed. Emergency Medical
Services Clinical Practice and Systems Oversight. 2nd ed. United Kingdom: John Wiley & Sons; 2015:289.
14. American Heart Association. CPR and First Aid. Resuscitation Science. 2015. Available at:
https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-10-special-circumstances-of-resuscitation/.
Accessed May 1, 2016.
15. Bailey C. Electrical and Lightning Injuries. In Tintinalli JE, ed. Tintinalli’s Emergency Medicine: A Comprehensive Study
Guide. 8th ed. New York, NY: McGraw Hill Education; 2016:1411-1419.
16. Kithil R. National Lightning Safety Institute. Overview of Lightning Detection Equipment. Available at:
http://lightningsafety.com/nlsi_lhm/detectors.html. Accessed December 4, 2016.
17. Hawkins SC, Simon RB, Beissinger JP, Simon D. Vertical Aid: Essential Wilderness Medicine for Climbers, Trekkers, and
Mountaineers. Woodstock, VT: The Countryman Press; 2017.
18. National Lightning Safety Institute. Vehicles and Lightning. Available at:
http://lightningsafety.com/nlsi_pls/vehicle_strike.html. Accessed December 4, 2016.
19. Centers for Disease Control. Emergency Preparedness and Response. Lightning: Lightning Safety Tips. May 8, 2014.
Available at: http://emergency.cdc.gov/disasters/lightning/safetytips.asp. Accessed May 2, 2016.
20. National Weather Service. NOAA. Lightning: Risk Management for Backcountry Campers and Hikers. Available at:
http://www.lightningsafety.noaa.gov/resources/backcountry_lightning.pdf. Accessed December 4, 2016.
21. Gookin J. National Weather Service. NOAA. NOLS Backcountry Lightning Safety Guidelines. Available at:
http://rendezvous.nols.edu/files/Curriculum/research_projects/Risk%20Management%20Reports/NOLS%20Backcountry%20Lightning%20Safe
Accessed December 4, 2016.
22. National Weather Service. NOAA. Lightning Safety Indoors. Available at:
http://www.lightningsafety.noaa.gov/indoors.shtml. Accessed May 2, 2016.
23. Huffman JC, Stern TA. Capacity decisions in the general hospital: when can you refuse to follow a person’s wishes? Prim
Care Companion J Clin Psychiatry. 2003;5(4):177-181.
24. Ortiz-Pujols SM, Thompson K, Sheldon GF, et al. Burn Care: Are There Sufficient Providers and Facilities? Chapel Hill,
NC: American College of Surgeons Health Policy Research Institute; 2011.
25. Vanden Hoek TL, Morrison LJ, Shuster M, et al. Part 12: cardiac arrest in special situations. 2010 AHA Guidelines for
CPR and ECC. Circulation. 2010;122(18 suppl 3):S829-S861.
26. Griffiths J, Alexander R. Cable News Network. CNN. Thunderstorm asthma: 8 dead in Australia from freak illness.
November 28, 2016. Available at: http://www.cnn.com/2016/11/28/health/thunderstorm-asthma-australia/. Accessed
December 2, 2016.
27. Innis M. The New York Times. “Thunderstorm Asthma” kills 8 in Australia. November 29, 2016. Available at:
http://www.nytimes.com/2016/11/29/world/australia/melbourne-australia-thunderstorm-asthma-attacks.html?_r=0.
Accessed December 4, 2016.
28. Dabrera G, Murray V, Emberlin J, et al. Thunderstorm asthma: an overview of the evidence base and implications for
public health advice. QJM. 2013;106(3):207-217.
29. D’Amato G, Vitale C, D’Amato M, et al. Thunderstorm-related asthma: what happens and why. Clin Exp Allergy.
2016;46(3):390-396.
INTRODUCTION TO NONVENOMOUS ANIMAL BITES
The world has been co-inhabited by a wide variety of animals since the dawn of time. As humans
venture into the wilderness for both settlements and adventure-seeking, more and more animals
and humans have negative encounters. Decades ago people would avoid certain areas because of
dangerous wild animals, but more recently travel around the world specifically to see these same
wild animals in person and often “up close.” There is no animal that prefers humans as its natural
prey. Usually animal attacks are secondary to fear, real or perceived, territoriality, or accident.
Despite living in the age of the Internet, incomplete information and frank myth has continued to
spread, creating public misunderstandings of animal behavior. (As an aside, the Internet may
very well be responsible for some myth propagation itself, with some arguing that it and other
forces have moved us into a “post-truth era.”1 See further discussion of this topic in our
introductory chapter and Chapter 1.) However, some commonsensical publications have
suggested ways to navigate between truth and falsehood on the Internet.2 While this chapter
could easily be a separate textbook of its own, it will discuss prevention and care of animal bites
and envenomation. This chapter will focus discussion on general care of bites of particular
species more medically prevalent or important than others, the venoms of a sampling of snakes
and other reptiles, and the basics of antivenin; however, it is important to remember that it would
be impossible to cover every single variant.

Definitions of Nonvenomous Bites

Bites of both wild and domestic animals are similar from other traumatic injuries that can
damage skin, muscle, nerves, tendons, joints, blood vessels, and bones. This can be from the
penetration into the human body, similar to being stabbed with a knife; however, it can also be a
tearing or cutting mechanism as well as blunt trauma. Animal bites can lead to local infection as
any wound can from various environmental sources or from inoculation of bacteria that live in
the animal’s mouth.
 Poisonous animals are not the same as venomous animals. Animals that have developed
specific venom glands and venom delivery systems can be found in every class. The toxins and
the apparatus to deliver them vary from class to class. For example, rattlesnakes have modified
salivary glands and maxillary teeth, fangs that are mostly used for prey but also for defense. Bees
on the other hand have a modified ovipositor that is used for defense only. It is important to
discern that in this section venomous rather than poisonous animals are discussed. An animal
with toxins distributed throughout its body like certain fish or toads that would cause death to
humans after ingesting the animal is considered poisonous. More simply put, poisons must be
ingested, inhaled, or absorbed. However, only animals with specific toxins and a means to
deliver said toxin is considered venomous.

Scope of Discussion of Nonvenomous Bites

This chapter will cover a broad range of injuries and conditions related to wildlife, from bites to
stings to envenomation and beyond. Prevention is the best tool. But when problems do occur, it
is crucial for a good wilderness emergency medical services (WEMS) provider to be able to
identify and understand the potential risks and outcomes of such emergencies and their treatment
options in the wilderness environment.

EPIDEMIOLOGY OF NONVENOMOUS BITES

The incidence of animal bites and envenomation has been difficult to determine because many
are simply not reported. Domestic animal bites are relatively common, whereas data for wild
animal attacks are significantly weaker. Furthermore, data pertaining to bites, infections, and
envenomation is lacking in both quantity and quality. Perhaps the best epidemiologic data
available come from the US Centers for Disease Control and Prevention (CDC), but the data
sources are diverse and have varied over time, even among the most common types of animal–
human encounters such as dogs and cats. Estimates of bites from other species are even more
difficult to estimate in their data sources as reptilian and insect bites are also grouped into the
same category as stings from plants, jellyfish, and coral.
Mammalian bites represent common presentations in WEMS and emergency departments.
Most bites are from domesticated dogs and cats. Half of all Americans will be bitten by an
animal or another human during their lifetime.3,4 While, again, the true incidence is unknown, it
is estimated that over 2 million bites result in medical treatment just within the United States.5
Another source quotes about 4.7 million dog bites annually in the United States, with almost
19% of them requiring medical attention. In this series, children are 3.2 times more commonly
bitten than are adults.6,7 Outside of the United States as well, dog bites constitute a majority of
animal-related injuries. Data from 320 cases reported between 1998 and 2005 looked at animal-
associated injuries among returning travelers. It found dogs involved in 51.3% of cases, followed
by monkeys in 21.2%, cats in 8.2%, and bats tied with humans at 0.7%.8,9 This study also
showed, like others, that patients under the age of 15 years are more likely to have animal-
associated injuries. Depending on where the person is living, visiting, or working, large reptiles
without venom may be an important consideration, such as the crocodile or alligator.
CLINICAL MANAGEMENT OF NONVENOMOUS ANIMAL
BITES
Setting aside venomous bites and stings being for later in this chapter, management of
nonvenomous animal bites is similar to any other traumatic injury. Bites are traumatic injuries
that can damage skin, muscle, nerves, blood vessels, tendons, joints, and bones. Wounds
themselves may be lacerations, contusions, scratches, tears, or deep punctures. Contamination
from oral flora from the biting animal may be the principal treatment concern, but bleeding and
other damage are also concerning as well as, to a far lesser degree, the prospect of rabies or
tetanus.
Rabies is a viral illness transmitted when it is present in a rabid animal’s saliva and is
introduced into bite wounds or onto mucous membranes. Once deposited into peripheral tissues,
it travels to the central nervous system (CNS). Rabies causes tens of thousands of deaths
annually on almost every continent, but mostly affects underserved communities with limited
access to health care or incomplete rabies control programs. A huge majority of deaths occur in
Africa and Asia, with dogs being the main source. Once in the CNS, rabies causes acute,
progressive, incurable encephalitis. Where vaccination programs exist such as in the Americas,
bats are the main cause of infection followed by foxes, raccoons, skunks, jackals, mongooses,
and other carnivore host species. It should be known that less than 1% of human deaths occur
after exposure to animals other than dogs or bats.10-12 Although rabies is almost always fatal once
it becomes clinically evident, it is 100% preventable with vaccination. The CDC and the World
Health Organization (WHO) has numerous resources for information for determining both
preexposure prophylaxis (for those that are high risk) as well as postexposure prophylaxis (PEP).
PEP is determined on the basis of the likelihood the implicated animal was rabid, the severity of
exposure (activity and type of wound), the clinical features of the animal, and its vaccination
status.11,12

Prevention of Nonvenomous Animal Bites

The old adage that “an ounce of prevention is worth a pound of cure” could not be more
important to remember when it comes to animal bites and envenomation. It is important to have
the basic knowledge of wildlife indigenous to whatever region one may be visiting or practicing
in. Injuries caused by animals are considered “unintentional injuries” as opposed to “accidents”
because research shows that they have the same type of predictability and identifiable risk
factors.13 Unless provoked, domestic animals of any kind rarely attack. This is why it is
important to have a basic understanding of animal behavior so as to not accidentally provoke an
animal to feel that it needs to go to its last resort, which is a physical attack. This means humans
must have an understanding of basic attacks of animals and understand what might be a warning
sign. For instance, for the most part, if a human slowly and carefully backs away while acting
confident and calm, an animal will usually not become aggressive. Wild animals that are
captured, restrained, or kept as pets can be stressed and thus may be unpredictable and suddenly
attack in self-defense. Most wild animals exhibit ample warning signs by use of visual, auditory,
or olfactory senses before escalating to physical attack. People can often avoid injuries from
attacks by successfully interpreting these signs.
Identification of Nonvenomous Animal Bites
Examination of the patient begins before even contacting him or her. When treating patients of
animal attacks, whether domestic or wild, it is important to remain safe yourself. Auditory and
visual senses need to be used to size up the scene for safety as well as to piece together the
mechanism of injury and therefore potential injuries. Having an idea of the type of animal
involved and how it may act needs to be considered before approaching. One should take note of
what type of animal was involved, how the animal was acting, what may have provoked the
incident, and where the animal then went. The latter is particularly important for the rescuers’
safety. Once you have approached the patient, management is similar to the general trauma
patient. If possible and not already done, identify the type of animal and general behavior of the
animal. Remember, an animal put under duress can attack with more than impressive force.
Attacks by larger animals can easily produce major blood loss, thoracic injury, spinal cord
injury, or airway damage. As would be suspected, basic trauma care is needed and evacuation of
the victim to a hospital as soon as possible may be paramount. The patient should be assessed for
life-threatening hemorrhage, which often can be fairly obvious even at a distance while
approaching the patient. This exsanguination should be managed immediately. If other providers
or bystanders have begun care, it is important to confirm that this has been accomplished
appropriately. The patient should then systematically be evaluated to avoid missing other life- or
limb-threatening injuries. Chapter 21 contains more detailed information related to the further
identification and treatment of traumatic injuries in the austere environment.

Treatment and Disposition of Nonvenomous Animal Bites

Beyond major life-threatening injuries from animal bites such as exsanguination, wound care is
extremely important. When and to what extent a wound can be cleaned plays an important role in
wound infection and healing. Therefore, local wound treatment should be initiated almost
immediately if possible.9

First Aid
Basic first aid and trauma principles apply. Identify the problem overall. Be sure to identify all
wounds and dress them with clean dressings. If major bleeding occurs, apply direct pressure with
or without pressure points; this controls a majority of bleeding within 3 to 5 minutes. In cases of
severe bleeding and shock, tourniquet application can be lifesaving.14 After this, the wound
should be inspected, washed, and dressed with sterile dressing if possible.

Basic Life Support

Basic trauma principles apply. Identify the problems beginning with life-threatening problems.
Remember that some injuries may be more distracting than others. Identify any major bleeding
and apply direct pressure and pressure dressings as needed. In the case of severe, arterial, or life-
threatening bleeding, do not delay applying a commercial tourniquet or appropriate improvised
tourniquet high and tight on the affected extremity. Remember that properly placed tourniquets
should completely stop the bleeding and stop pulses distal to the tourniquet. Although
tourniquets can save life and limb, a tourniquet that is not tight enough can actually increase
venous bleeding.15-19 Chapter 21 discusses tourniquet placement in more detail. After any major
bleeding has been stopped, identify any other wounds and dress them with clean dressings. If
time allows without delaying evacuation, begin irrigation and cleaning of the wound with clean
water avoiding if possible products like hydrogen peroxide. Do not forget to reassess any
wounds you have already treated. Hand and foot wounds may require immobilization. Other
extremity injuries may also require immobilization.

Advanced Life Support

Same principles apply for the basic life support (BLS) provider as they do for the advanced life
support (ALS) provider. General principles for ALS trauma care discussed in Chapter 21 apply
to animal-related bites and take precedence. Remember the potential for blunt trauma and injury
to deeper and vital structures from falling or from penetrating claws, teeth, or horns. Spinal cord
protection (SCP) may be needed as well as airway management. See Chapters 21 and 24 for a
more complete discussion of the indications and procedure for SCP. Furthermore, be careful to
assess and reassess thoracic injuries for the potential sucking chest wound or pneumothorax that
may require occlusive dressings or needle decompression. After assessing and treating life-
threatening injuries, one should treat the wounds, especially bite wounds, as soon as possible.
Should you have fluids such as normal saline, irrigate the wound with moderate to high pressure
with copious amounts to try to decrease the likelihood of infection. Although guidelines have
varied regarding to how much fluid is needed for the irrigation of traumatic wounds, the actual
volume should vary depending on the size of the wound.20,21 The old dictum of “the solution to
pollution is dilution” rings true. Given its virucidal effect, irrigation with a 1% diluted povidone-
iodine solution may be beneficial in bites in which rabies is a concern. There are some systems
where ALS starts antibiotic therapy. Refer to the recommendations for the clinician below and
your local protocols if antibiotics are an option. Chapter 11 discusses antibiotics in the WEMS
environment in more detail. Going beyond immediate patient care, it is important to try to
ascertain information about the animal and the situation to help determine whether rabies
prophylaxis is needed. This information beyond type of animal includes unusual behavior, for
instance, complete absence of fear of humans or an unprovoked attack in broad daylight.

Clinician
Basic and advanced trauma principles also apply to the wilderness clinician. One needs to
evaluate for any potential blunt trauma and injury to deeper vital structures from penetrating
injuries or associated falls. The clinician should also evaluate for potential nerve or tendon
involvement as well as the more obvious blood vessel involvement. Tetanus immunization needs
to be ensured as soon as possible. Irrigation of the wound with copious volume of clean normal
saline (NS) or diluted 1% povidone-iodine is vital. Again, whenever possible even in austere
settings, wounds should be cleansed and irrigated thoroughly as soon as possible without
delaying major resuscitation efforts. Early wound care reduces the chance of infection and has
also proven beneficial in decreasing the risk of rabies transmission. It does this so well and is
considered so likely to be beneficial that a randomized controlled trial (RCT) is considered
unethical.22-24
Wounds should be covered with sterile dressings or a dry, clean cloth. Unlike some other
traumatic wounds, animal bites are not ever considered clean lacerations and should be treated as
contaminated wounds. They may also be combined with crush injuries with devitalized tissue.
Furthermore, especially in children, animal bites can penetrate vital structures such as joints or
the cranium. If the wounds are at high risk for infection and definitive treatment is hours away, it
is appropriate to start antibiotic therapy if an appropriate antibiotic is available. Chapter 11 and
Chapter 20 discuss antibiotics in more detail. Bite injuries that are more likely to be considered
low or lower risk for infection are based on location and the type of wound. Skin with a more
substantial blood supply, such as the scalp or face, usually can be considered lower risk, as can
large clean lacerations that can thoroughly be cleansed, partial-thickness abrasions, or simple
contusions that do not actually break the skin.
After adequate irrigation has been assured and evacuation to definitive care is not possible
for many hours, primary closure of some wounds may be considered if they are simple bite
wounds of the trunk or extremities (excluding hands and feet) less than 6 hours old or simple bite
wounds of the head or neck less than 12 hours old. Primary closure is not recommended for
clenched fist injuries, puncture wounds, hand and foot bites, bites with extensive crush injury,
bite wounds clinically infected, or bite wounds where antibiotic prophylaxis will be significantly
delayed. Certain species, including wild cats, primates, and pigs, tend to have bites that are more
prone to infection. In contrast, select mammalian bites such as dogs may be able to be closed
after adequate wound irrigation and preparation.25–31 Ideally, antibiotics should be given within a
few hours of the bite or injury.
Beyond physically treating the bite victim, the consideration of rabies is an important aspect
for the clinician. Information such as the species of animal, the behavior of the animal, the
vaccination status of the animal (if domesticated), and what actions brought on the encounter
with the animal is important in considering whether or not postexposure prophylaxis (PEP) for
rabies is needed. In the United States, most rabies transmission is from bats, raccoons, skunks,
and foxes. Given the frequency of bats in their environments, mountain and cave rescue teams in
particular should be versed in bat exposures and indications for rabies PEP to adequately counsel
patients and determine evacuation needs, as well as protect team safety given possible team
member exposure.32 Accidents in North American Climbing (formerly known as Accidents in
North American Mountaineering) describes multiple recent climber exposures to bats requiring
rabies PEP and immunoglobulin treatment.33,34 Also note that currently, in the case of bats, the
CDC recommends PEP if a patient is simply in proximity to a bat and cannot prove absence of
exposure, for example, waking up with the bat.35 For most teams, rabies PEP and
immunoglobulin needs will direct evacuation and destination facility but not field treatment. The
Wilderness Medical Society and climbing authorities recommend that a wound with possible
rabies be cleaned immediately and copiously with soap, water, and, if available, a virucidal agent
such as povidone-iodine or chlorine dioxide–treated water.32,36 Contacting receiving facilities to
ensure they have PEP series available may be helpful—some smaller hospitals will not stock
this, and although its urgency is measured in days rather than hours, for an extended WEMS
extrication this may become a time-sensitive consideration. Note that bats also provide an
important lesson that geography matters in logistical consideration, as, for example, the bats of
Hawai‘i have been proven to be rabies-free.35 Understanding local epidemiologic parameters like
this help ensure appropriate care and disposition decisions.
Another concern that needs to be remembered beyond rabies is tetanus. If there is any doubt
regarding a victim’s immunization status including a full series plus a booster within the last 5
years, 0.5 mL of diphtheria–tetanus booster vaccine should be administered at some point in the
patient’s care, although this is unlikely to be available to WEMS teams. Remember this is a
vaccination, not a treatment, and so may be more effective in preventing the next exposure than
the current one. If there is a concern for imminent tetanus exposure from the current wound, such
as a high-risk dirty wound, the patient should receive 250 to 500 units of tetanus human immune
globulin intramuscularly (IM), which is a more immediate treatment rather than preventive
vaccination.

Select Animal Habits

Alligators and crocodiles are large reptiles in the order Crocodilia that are without venom and
that have a well-known appearance among the few animal species that will attack and kill
humans without being provoked.37,38 Like other reptiles, these animals are ectothermic (cold-
blooded) and thus their activities vary depending on weather and the time of day as they rely on
the environment for body temperature. In cool environments, they can be found bathing in
sunlight out of the water and commonly on roadways. In warmer environments, they will spend
more time in the water to keep cool. Their long snouts have a keen sense of smell even when
mostly submerged and have extremely strong jaws refined for grabbing and tearing. These
reptiles are more commonly active during evening times, and most attacks have been seen during
summer months and afternoon to twilight hours. Because of their methods of crushing, tearing,
and drowning, crocodilian bites can produce severe crush injuries, punctures, lacerations,
avulsions, and drownings. Data have been sparse on the microbiology of human wounds inflicted
by crocodilians, but a few case reports indicate significant polymicrobial infections.39,40 Some
recommendations to prevent crocodilian attacks include being cautious with small pets or
children (even in relatively developed areas such as hotels),41 being cautious around still or slow-
moving brackish water or freshwater, avoiding swimming at night, being diligent to dispose of
food scraps, not feeding them or trying to handle them, and observing or photographing
crocodiles and alligators only from a safe distance. If an attack should occur, it is advised to be
aggressive and fight back while attempting to escape when they open their jaws for a better
purchase on their prey or to further crush their prey. Crocodilians usually persist in their attacks
until death or complete escape.
Primates including monkeys can cause extremely infectious bites.42 While in developed
countries primate on human attacks is usually more of a work-related risk (eg, laboratory or zoo
workers), developing countries have increased numbers of large and often aggressive primates
such as baboons. The more the animal has interacted with humans the less fear they have of
them; this leads to increased danger especially when food is involved.
Feral swine, such as pigs, boar, and javelina can be aggressive nocturnal creatures, especially
when injured or protecting their young. They have been known to cause a significant number of
tusk injuries and bites in developing regions.43-45

Equipment Summary
Knowing what equipment to bring for WEMS animal bite–related responses can prove to be
quite difficult. Bites may be small, local problems, but they may also be only part of a
constellation of significant injuries. The provider needs to weight the use of his or her supplies,
the likelihood of using it, and its size and weight. Items to be included in a medical kit are further
outlined and discussed in another chapter. Important thought needs to go into the need for
irrigation as well as wound dressing.

INTRODUCTION TO VENOMOUS ANIMAL BITES

Venomous animals account for a considerable amount of morbidity and mortality worldwide.
Venomous snakes exist naturally throughout many region of the world, especially in rural
tropics. Of over 3,000 species of snakes globally, about 600 are venomous and over 200 are
considered medically important.46 Although in more developed countries of the Western
Hemisphere the incidence of bites and deaths are significantly less than that in the Eastern
Hemisphere, they are a very important risk to be aware of in any austere environment given
considerations like time to treatment. Insects account for more fatal envenomations in the United
States than in other parts of the globe where snakes and spiders are more common. Ultimate
treatment, being supportive treatment and antivenin, can prove to be difficult to locate while still
being extremely time-dependent. As with other injuries, prevention is key in decreasing
morbidity and mortality. Understanding the basics about snakes and avoiding them can prove to
be the most beneficial. When prevention fails, appropriate identification of the snake and prompt
medical treatment is critical. In the past, there have been a wide variety of modalities of care for
snakebites that were based on customary practice or folklore. These practices include incising the
site of the bite, administration of electrical shocks, tourniquets, and applying suction to the
wound.47-51 An Internet review of prehospital and out-of-hospital recommendations showed that
more than half of the Internet sites reviewed contained inappropriate information.52 Research has
shown that the majority of these treatments not only is ineffective, but also may be harmful. It is
important, especially for the wilderness provider, to know what appropriate treatment of
snakebites is and what is not. This section will break down by family particular species of
venomous snakes, lizards, and hymenoptera, describe venom and antivenin, and discuss
particular case examples.

Definition of Venomous Animal Bites

As mentioned earlier, animals can be venomous or poisonous. An animal with toxins distributed
throughout its body such as certain fish or toads that would cause death to humans after ingesting
the animal is considered poisonous. More simply put, poisons must be ingested, inhaled, or
absorbed. However, only animals with specific toxins and a means to deliver said toxin is
considered venomous. We will continue to discuss venomous bites.

Scope of Discussion of Venomous Animal Bites

It is important to realize that many misconceptions exist regarding envenomation and what
various venoms do. It is falsely understood, for example, by many emergency medical services
(EMS) professionals that a snake is either “neurotoxic” or “hemotoxic.” However, snake venoms
have extremely variable and complex combinations, especially in the Viperidae family.

EPIDEMIOLOGY OF VENOMOUS ANIMAL BITES

The medical burden of venomous animal bites is considerable worldwide but grossly
underestimated. While bites and envenomations constitute a smaller percentage within the
United States, they represent a major health care burden and killer in developing countries.
Conservative numbers vary but indicate a global incidence of over 5 million annually; of those,
over 100,000 patients die, and over 400,000 others sustain permanent disabilities.53-58 A majority
of the world’s envenomations are from snakes that inhabit rural areas where prompt medical care
and documentation is not adequate. A review of native US venomous snake bites reported to the
American Association of Poison Control Centers (AAPCC) from 2009 through 2013 revealed
35,751 cases (averaging about 7,100 per year) with 11 total deaths, which is just over an average
of two deaths per year.59-64
In the United States, there are two basic types of indigenous venomous snakes, namely,
Viperidae and Elapidae. Viperidae, and specifically its subfamily Crotalinae, also known as “pit
vipers,” is most prevalent in the United States. These vipers are present in every state except
Maine, Alaska, and Hawaii, and account for 99% of all venomous snakebites in the country. The
remaining indigenous venomous snakes to the United States are from the Elapidae family. Most
snakes hibernate in the winter plus more people explore the outdoors during warmer months. As
a result, the majority of bites in the United States occur between May and October. Bites occur
most often in southern states where a majority of the species lives. Of all snake bites, 97% occur
on the extremities, with two-thirds being on the upper extremities. This is consistent with the
principle that most bites are actually provoked rather than accidental. The most frequent victims
of snake envenomation are children, intoxicated individuals, snake handlers, and collectors.
Along those lines, many people are importing exotic venomous snakes causing a rise in exotic
snake envenomation. In the past, only research centers, zoos, and herpetologists kept exotic
venomous snakes.

CLINICAL MANAGEMENT OF VENOMOUS ANIMAL

BITES

Venomous Reptiles
The most infamous venomous reptile in the world is the snake. Of the thousands of species of
snakes, only a fraction is venomous. Given that the taxonomy of reptiles continues to be
disputed, it is difficult to say precisely the total number of families that contain venomous
species. However, all of the medically important venomous snakes belong to the families
Viperidae, Elapidae, Atractaspidinae, and Colubridae. Although the Colubridae globally
encompasses a majority of all snake species, there are very few venomous members dangerous to
humans. On a global scale, the Elapidae is common and includes cobras, kraits, mambas, corals,
and sea snakes. All snakes are poikilotherms, like the Crocodilia order mentioned earlier, which
accounts for their distribution and activity because of their inability to self-maintain body
temperatures. All snakes are carnivorous, and their venom apparatus has evolved in order to
gather food, but often is used for defense.

Identification of Venomous Animals and Bites

In the identification of venomous snakes, two principles should always be kept in mind: only
trained experts should handle live snakes, and even dead snakes can envenomate. As mentioned
multiple times throughout this chapter, when traveling or responding to a certain region or area,
one should know locally what local creatures exist and tips on how to identify them. Popular
mnemonics such as “Red on yellow, kill a fellow, red on black, venom lack” are regionally
specific. For instance, this rhyme correctly identifies North American coral snakes; however,
some Brazilian coral snakes have red on black stripes or no red stripes at all, and even some
North American coral snakes have colorings that can complicate this mnemonic (Figure 19.1).
Knowledge of geographic distributions can significantly make snake identification easier.

Classification and Characteristics of Select Specific Venomous Snakes

Crotalin Snakes
Crotalin snakes, or Crotalinae, are also known as pit vipers and are a subfamily of Viperidae.
They account for the greatest number of bites and morbidity in the Americas. Common findings
among venomous crotalins include heavy bodies, triangular heads, elliptical eyes, a single row of
subcaudal plates (scales on the underside of the snake closer to the tail), and heat-sensing pits
located between the eye and the nostril that give them their common name. Although it is true
that these traits can sometimes be found in nonvenomous snakes, specific combination of keeled
dorsal scales and a single row of subcaudal plates is indicative of vipers in the United States and
Canada.65 A subfamily of Viperidae, known as Old World vipers and adders, lack the heat-
sensing pits. A number of books, publications, and field guides list over a hundred types of
“dangerous” North American snakes. However, the taxonomy for many is still debated and
changing. Furthermore, from a clinical aspect, identification of the subspecies level is usually
unnecessary for guiding treatment, with certain exceptions.66 The exceptions to this concept
produce venom with different venom profiles that require specific toxin management. These
exceptions include Mojave rattlesnake (Crotalus scutulatus), timber (Crotalus horridus), and
Southern Pacific rattlesnakes (Crotalus oreganus helleri), among other taxa that produce venoms
with potent presynaptic neurotoxins.

FIGURE 19.1. Eastern Coral Snake, Micrurus fulvius. Note this specimen shows a flaw of the “red on yellow” mnemonic, as
the red bands have a black hue on the top. Courtesy of Lt. Scott Mullin from Venom One.

Crotalins have bilateral venom glands located in the sides of the head behind the eyes,
nestled between muscles that contract and squeeze venom from the glands through relatively
large, retractable needle-like fangs. Although relatively large (up to 20 mm in length in larger
rattlesnakes), the fangs are relatively fragile and can fracture, fall out, and thus also are replaced
over time. Commonly encountered pit vipers include various rattlesnakes (eastern and western
diamondback, timber or canebrake rattlesnake, prairie rattlesnake, pygmy rattlesnake),
cottonmouths (water moccasins), and copperheads. Rattlesnakes account for approximately 65%
of crotalin snakebites, whereas copperheads and water moccasins account for 25% and 10%,
respectively. The diamondbacks are responsible for the greatest morbidity and mortality. Pit
viper contains a mixture of hemolytic and proteolytic enzymes that cause extensive local tissue
damage in addition to systemic effects bringing us to the medically important consequences of
their bites; namely, the injection of these hemotoxic substances creates soft-tissue swelling and
necrosis, local and systemic bleeding, and clotting problems.
As mentioned previously, snake venoms are extremely variable and complex toxin cocktails
that can produce a variety of toxin effects. The toxin constituents are known to vary considerably
between geography within species, or even between siblings.67-69 Examples of these toxin
cocktails include crotoxin, hemorrhagins, and thrombin-like enzymes. Some can lead to paralysis
of muscles by blocking neuromuscular junction neurotransmission, whereas others, such as
thrombin-like enzymes, cause consumptive coagulopathy without directly activating coagulation
factors.70 Disintegrins prevent blood platelets from combining with fibrinogen as needed to form
clots by binding to proteins on them.71,72 Myokimia or muscle fasciculations may also be seen
with certain species, although this is a different biochemical mechanism from other
neurotoxins.73,74
Pit vipers are almost exclusively ambush predators and tend to coil and wait motionless for
prey to enter their strike zone in places such as between rocks. When small prey happens upon an
awaiting viper, it will strike quickly. On the contrary, when a relatively larger victim such as a
human happens upon an awaiting viper, a quick strike accelerating at over 100 m per second
squared can occur out of defense.
Most of pit viper bites are “dry bites” and do not result in envenomation.75 Therefore, it is
important to recognize the signs of pit viper envenomation in order to avoid needless evacuation
and improper therapy. This varies from elapid envenomation. Bear in mind, the clinical
presentation and the progression of such presentation of pit viper envenomation is variable.76
Generally speaking, the degree of envenomation of a crotalin bite is determined by the degree of
swelling, the presence of systemic symptoms, and the progression of pain. The most consistent
symptom associated with pit viper bites is immediate burning pain local to the area of the bite,
whereas pain may be minimal with envenomation from Elapidae and other exotic snakes. Also,
more common among viper envenomations are contusions, blood-filled bullae, and bleeding.
These are more related to the cocktail of specific toxins injects and should not be confused with
early infection. As severity of the envenoming increases, swelling progresses up the affected
extremity and may become quite severe. Even if thought to be a “dry bite,” these patients should
still be evaluated for monitoring and lab testing to ensure no further signs of envenomation
develop.
Common signs of most crotalin bites are as follows:

Typical puncture or fang marks (seen with venomous and nonvenomous)

Venomous wounds tend to bleed more.
If rows are appreciable, one to four larger markings from the front fangs will be apparent
if venomous.
Immediate burning pain at the site. NOTE: may not be present with Mojave rattlesnake.
Swelling at site of bite usually within minutes and possibly becoming quite severe. NOTE:
may not be present with Mojave rattlesnake.
Numbness and tingling of lips, fingers, and toes. If immediate, it is more indicative of
hyperventilation.
Rubbery or metallic taste in the mouth 30 to 90 minutes after bite.
 Systemic findings such as sweating, weakness, nausea, vomiting, and fainting as well as
possibly chest tightness, rapid breathing, rapid heart rate, palpitations, headache, chills, and
confusion.
Bruising and large blood blisters or bullae.
Difficulty breathing and further increased bleeding (bruising, blood in urine or vomit or
bowel movements) and collapse.

Elapid Snakes
The only elapid snakes (family Elipidae) indigenous to the Americas are the coral snake, of
which there are only three within the United States, and the Pacific Sea Snake (Hydrophus
platarus) found mostly around Central America. Other important elapids include sea snakes,
cobras, kraits, and mambas.77 The American Elapids have relatively short, fixed front fangs. The
US coral snakes are identified primarily by color pattern that completely encircle its body;
however, this only works with most US corals. Micrurus and Micruroides venoms are much
simpler than the local Viperidae and have minimal proteolytic activity and thus usually do not
have much local tissue damage or pain. The primary lethal toxin from these snakes is a low-
molecular-weight, postsynaptic toxin that blocks acetylcholine binding sites at the
neuromuscular junction as shown by the neurotoxic clinical effects of envenomation from them
which includes paralysis, ptosis, and other effects of neurotransmitter disruption.78 Some elapids
are known for their cytotoxic effects (see later discussion). The characteristic hood of cobras and
some other elapids is erected only when the snake is rearing up in a defensive attitude (Figures
19.2 and 19.3). In the case of kraits, mambas, coral snakes, most of the Australasian elapids,
some of the cobras, and sea snakes, local effects are usually mild although exceptions do occur.
That being said, patients bitten by African spitting cobras commonly develop tender local
swelling, blistering surrounding a demarcated pale or blackened area of necrotic skin and
regional lymphadenopathy.79 Severe envenomation by the king cobra (Ophiophagus hannah)
results in swelling of the entire limb and formation of bullae at the site of the bite, though local
necrosis is usually minimal or absent.80
Paralytic symptoms as well as preparalytic symptoms may present within minutes of the bite,
or they may be delayed for 10 or more hours. Preparalytic symptoms include nausea, vomiting,
retching, abnormal taste sensations, paresthesias, hyperacusis, blurred vision, drowsiness, and the
feeling of eyelid heaviness. It is important to not attribute repeated vomiting or retching to pain
response or being scared. Muscle paralysis starts centrally as can be seen by ptosis, external
ophthalmoplegia (dysconjugate gaze where eyes do not move together), mydriasis, and paralysis
of other muscles innervated by the cranial nerves ensue, eventually involving swallowing and
respiration muscles, the trunk, and the limbs (Figure 19.4). Autonomic nervous system
symptoms such as hypersalivation, gastrointestinal (GI) symptoms, sweating, and changes in
blood pressure and heart rate are characteristic of most elapids but not of African spitting
cobras.81 The most common cause of death after envenoming of a neurotoxic venom is thought to
be respiratory paralysis, but paralysis of bulbar muscles leading to upper airway obstruction or
aspiration is extremely possible.
FIGURE 19.2. King Cobra with its hood spread. Courtesy of Ryan Martinez.
FIGURE 19.3. A, Defensive cobra. B, Same cobra not acting defensive. Courtesy of Benjamin Abo.

Atractaspidinae
The African and Middle Eastern burrowing asps or stiletto snakes, also known as burrowing or
mole vipers or adders, false vipers, or side-stabbing snakes, have very long front fangs that
protrude out of the corner of the mouth on which they impale their victims by a side-swiping
motion that they encounter underground in a burrow. These snakes are known to bite many
people but more rarely cause severe envenoming. Although all are venomous, fatal envenoming
has only been described by three species: A. microlepidota, A. irregularis, and A. engaddensis.
Locally pain, swelling, blistering, necrosis, and numbness or parasthesia is seen along with
tender local lymph node enlargement. Systemically the most common symptom is fever.

FIGURE 19.4. Example of a Serious Systemic Envenoming of a Coral Snake Showing Here Ptosis and Dysconjugate
Gaze. This patient has now fully recovered. Courtesy of Benjamin Abo.

Prevention of Venomous Animal Bites

The old adage of “an ounce of prevention is worth a pound of cure” could not be more important
to remember when it comes to animal bites and envenomation. It is important to have a basic
knowledge of wildlife indigenous to whatever region one may be visiting or practicing in. That
being said, exotic snakes have become more prevalent. Seeking out resources ahead of time,
such as the World Health Organization, regional toxinology resources, and regional poison
information centers can provide important information regarding well-known local venomous
snakes as well as where to procure antivenin quickly if needed. Furthermore, knowing how to
contact specialized teams such as Miami-Dade Fire Rescue’s Venom One team can help identify
the species as well as provide recommendations on antivenin administration on the basis of
experience (Boxes 19.1 and 19.2).
There is no simple rule to aid in differentiating a dangerous venomous snake from those that
are harmless. Many harmless snakes have evolved to look almost identical to venomous ones.
Examples of this include species of Dryocalamus and Cercaspis. However, some of the most
notoriously dangerous snakes can be recognized by looks as well as behaviors and their sounds
when they feel threatened. Note, for example, the defensive behavior of cobras as they rear up,
spread a hood, and hiss while making repeated strikes. The blowing hiss of a Russell’s viper or
the grating rasp of a saw-scaled viper or the castanet-like rattle of a rattlesnake are all examples
of warning and identifying sounds.

Box 19.1 Helpful Links Regarding Envenomings and Antivenins

• WHO Antivenom Database http://apps.who.int/bloodproducts/snakeantivenoms/database/
• WHO Snakebite Resources http://www.who.int/ipcs/poisons/snakebite/en/
• Unified treatment algorithm for management of crotalin snakebite in the United States
https://bmcemergmed.biomedcentral.com/articles/10.1186/1471-227X-11-2

Box 19.2 Venom One: Profile of an EMS Toxinology Team

The Miami-Dade Fire Rescue Venom Response Program, also known as Venom One, specializes in the response,
management, and treatment of envenoming. Working closely with EMS physician Benjamin Abo and toxicologist Dr.
Jeffrey Bernstein, the Venom Response Team is committed to delivering the highest possible standard of medical
intervention with respect to injuries due to venomous fauna. Venom One currently maintains the largest antivenom bank for
public use in the United States. Over 1,500 vials of antivenin includes both domestic and exotic species, and the team
employs the latest techniques to prevent morbidity and mortality through antivenin intervention 24 hours a day, 7 days a
week locally, nationally, and internationally. The team can be reached via the Miami Poison Control Center or directly at +1
(786) 331-4443.

Treatment and Disposition of Venomous Animal Bites

Excellent supportive care and early proper identification are ultimately important. Safety of the
rescuer remains paramount, and technology can be extremely helpful in proper identification of
the snake at a safe distance by means of a digital picture. If in doubt of the particular species, it is
beneficial to at least determine whether the snake is venomous or not, making the difference
between simple wound care versus a potentially costly and hazardous evacuation. Bites by small
snakes should never be ignored or dismissed and should be taken just as seriously as bites by
larger snakes of the same species.
Nothing in terms of field care should delay rapid transfer to a facility that can safely
administer antivenin.82
Addressing airway, breathing, circulation (the ABCs), removing any jewelry or tight-fitting
clothing bilaterally immediately, and early treatment are a common thread no matter what level
of provider one is. Severe effects from venom can be seen immediately or delayed for even over
15 hours. For this reason, again, early transport without waiting for more severe effects is
extremely important. If possible, mark and note the time of the bite, the bite marks, and the
leading edge of erythema. Without delaying transport, the wound should be cleaned and covered
with sterile dressing. If not delaying transport, a wide compressive bandage can be placed and
the affected extremity can be immobilized with splinting techniques. Depending on the needs of
the evacuation, try to maintain the affected area at the level of the heart. Raising it above the
heart can potentially increase systemic spread of venom, whereas lowering it may cause
increased swelling and local venom toxicity.83,84 Note all local and systemic effects and mark
progression of pain or wounds with time stamps. This can be done more easily with digital
photographs for easier comparison. The ability to assess for further systemic symptoms beyond
major bleeding, angioedema, and neurotoxicity will depend on level of the practitioner.
Unfortunately, there are many myths associated with the care of snake envenomation, as
mentioned before, some of which can be harmful. Techniques that are of no benefit and
potentially harmful to the patient include oral suction, mechanical suction, incising or “bleeding”
the bite site, tourniquet application, and electricity or electrotherapy.52,66,85-90
With certain species of snakes, significant local tissue damage can occur. It is important to
realize that wound infections from venomous snakes are quite uncommon and rarely are
prophylactic antibiotics required.91-93 Should they be required, antibiotics should have broad
coverage. Any intact blisters should not be debrided and should be protected as much as
possible. Blebs, bullae, and necrotic tissue should not be debrided until any coagulopathy is fully
reversed.

First Aid
Aims of first aid include identification, prompt evacuation to where complete medical care and
antivenin can be administered, and, above all, applying the overarching Hippocratic principle of
primum non nocere (“do no harm”). Although the victim may have to be hiked out from an
incident, one should attempt to minimize exertion of the patient as much as possible. The
already-mentioned treatment goals apply for all levels of provider. Studies supporting the use of
pressure bandaging or pressure immobilization via elastic or cohesive bandaging is limited. It is
thought to restrict the blood flow and thus progression of venom to systemic circulation. Only in
neurotoxic envenoming (such as elapids, especially taipans) should pressure bandaging be used,
and for elapids, this has really been shown to be valid only in the Australian elapids.94,95 Other
envenoming that is known to cause severe local tissue damage (such as crotalin) may have
worsened tissue damage.94-98

Basic Life Support

Beyond first aid, victims of envenoming may have anaphylaxis—including anaphylactic shock
simply from exposure to the venom itself. Throughout consistent and frequent reassessments,
consideration for anaphylaxis should remain in the provider’s mind and medications such as
epinephrine should be administered. Anaphylaxis and its treatment are discussed in more detail
in Chapter 22. Some toxins also specifically have the danger of rapidly paralyzing the victim.
Airway management and ventilation assistance can potentially be rapidly required. Basic airway
devices such as oropharyngeal airways (OPA) or nasopharyngeal airways (NPA) can be
lifesaving. Manual ventilation, especially by bag-valve-mask (BVM), is unlikely to be effective
for a prolonged time, especially when trying to evacuate a victim; in these cases, it is more ideal
to utilize a supraglottic airway.
Situations in which victims may require urgent resuscitation:

Profound hypotension and shock

Possibly from direct venom effects, inflammatory mediators, hypovolemia (think blood loss
or persistent vomiting), or anaphylaxis
Neurotoxic respiratory failure
Cardiac arrest precipitated by hyperkalemia from muscle breakdown (rhabdomyolysis) after
 bites by certain kraits, Russell’s vipers, or sea snakes99,100
Sudden release of inappropriately applied tourniquet101

Advanced Life Support

As mentioned previously, special situations such as airway management requirements or
anaphylaxis may occur. Without hesitation and if available, intravenous access should be
obtained as quickly as possible. Anaphylactic treatments such as epinephrine 0.1% (1:1,000; 0.3
to 0.5 mL adults, 0.01 mL/kg children) intramuscularly, steroids, and antihistamines may need to
be provided rapidly. Advanced airway management may also be required. If another provider has
applied a tourniquet, do not remove too hastily! Anaphylaxis treatment is discussed in more
detail in Chapter 22, and tourniquet application and removal is discussed in more detail in
Chapter 21.

Clinician
Recommendations for ALS apply similarly to the wilderness clinician. Furthermore, the clinician
should have familiarization with indications for antivenin in case consultation with trained and
experienced experts cannot be made. These include signs of systemic envenomation, signs of
severe local envenomation, and special other indications (Box 19.3).
Swelling of a bitten extremity can be extremely unsightly, painful, and discolored. However,
actual compartment syndrome and the need for a fasciotomy is extremely rare as most of the
swelling occurs in subcutaneous tissues.66,102

Box 19.3 Warning Signs of Systemic Envenoming

Syncope or near syncope
Altered mental status
Ongoing nausea, vomiting, or retching
Pain or tenderness away from bite site
Central paralysis (eg, ptosis, diplopia, or dysconjugate gaze)
Cardiac dysrhythmias

Equipment Summary
Unless antivenin is needed and carried, no specific equipment is needed for the WEMS provider
that differs from other missions. However, a digital camera may prove to be extremely helpful.

SUMMARY
Every snake’s venom is similar to a different cocktail of toxins with various properties, even
within the same species. In essence, because of this every bite can be quite different, thus
requiring different amounts of antivenin or durations of care. It is important not to underestimate
the toxicity of a venom or overestimate the likelihood of a dry bite. When possible, take a picture
but do not risk more bites by killing the animal especially as even a dead snake can still
envenom.
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INTRODUCTION
The purpose of this chapter is to:

Understand the risks of exposure to infectious diseases while providing wilderness and
remote out-of-hospital emergency care.
Understand and be able to perform universal precautions, also known as body substance
isolation.
Understand the different types of human pathogens.
Understand the human immune system and the body’s defense against pathogens.
Understand the infectious diseases which are of the greatest concern, specifically in the
practice of wilderness and remote medicine.
Recognize the signs and symptoms of infectious diseases.

Part 1 will discuss the prevention and management of infectious diseases arising from
wilderness environments and agents. Part 2 will discuss the treatment of general infectious
diseases that occur in a wilderness setting.

DEFINITIONS AND DESCRIPTION OF PATHOGENS

Before discussing the world of infectious diseases, here is a quick review of some medical
terminology that is used throughout this chapter.
 Disease: an interruption, alteration, or cessation of one or more normal body functions,
systems, or organs. Diseases have recognizable etiologic or causative agents and an
identifiable collection of signs and symptoms, along with consistent anatomic alterations.
Communicable diseases: diseases that can be spread directly from one human to another, or
from an animal to a human via a vector.
Contagious diseases: diseases that are spread directly from one person to another.
Infectious diseases: diseases caused by or resulting from the presence and activity of
microbiological agents: viruses, bacteria, fungi, or parasites.
Pathogen: any microorganism capable of causing disease.
Vector: the method by which an infectious disease is transmitted: waterborne, food-borne, or
insect-borne.
Fomite: a nonliving vector that can harbor or transmit an infectious disease. Examples in the
wilderness include flashlights, toothbrushes, foam pads, etc.
Reservoir: living or nonliving material on which an infectious agent multiplies, develops, and is
dependent upon to survive.
Host: the organism in or on which an infectious agent lives and causes symptoms. The
infectious agent is dependent on the host for its energy.
Symbiosis: the biologic association of two or more species for their mutual benefit. Both the
host and the microbe profit from the relationship.
Parasite: an organism that lives on or in another at the expense of that host. The parasite
benefits and the host suffers.
Commensal: a relationship where one organism benefits from another but not at any cost to the
other. Although the microbe lives in the host, it does not cause the host any harm.

There is a constant life and death struggle taking place on us and in us. As long as we are
winning this battle, we are not even aware of it. Our ability to survive and thrive is totally
dependent upon our ability to constantly and consistently wage war, defeating the enemy we
cannot see. This is the war of our own personal world, the war that is constantly being waged by
infectious disease pathogens and our immune system.
It is imperative that all medical providers understand pathogens, the risk of exposure to
pathogens, and how our immune system protects us from these pathogens. Since infectious
diseases play a role in providing care, it is equally important to understand the pathophysiology,
signs and symptoms, and principles of treatment of infectious diseases.
We are not alone on this planet. With approximately 7 billion people, there are billions of
infectious disease agents trying their best to elude and overwhelm our immune systems—in other
words, to make us part of their food chain. These billions of microbiological agents are
commonly known as “bugs,” “germs,” parasites, viruses, bacteria, yeast, fungi, and microbes.
They come in all sorts of shapes and sizes. Most microbes are harmless to us; they are not
pathogens, and many are very beneficial to us. But, the pathogenic organisms thrive at our
expense, causing infectious diseases.
The key to a long life is actually quite simple: knowing how to avoid the bad bugs, the
pathogens, so that we stay on top of the food chain. In other words, to consume and not be
consumed.
Through the excellent sanitation laws and practices in developed nations, we are virtually
oblivious to the risks of infectious diseases. Although from time to time the media alerts us to
various infectious disease problems, we generally feel that we can trust that the food and water
we are served in restaurants or at home is properly prepared and safe to eat.
 When we hear the news that it is flu season, alarmed, we rush off to our doctors’ offices for
flu shots designed to boost our immune system specifically against certain strains of the
influenza virus in the hope that we not be stricken by “the bug.” This preventive measure is
great. But, in the process, we have become so dependent on a “quick fix” that we are no longer
educated about viruses, and may even be apathetic regarding their risks—cavalier in our
assumption that catching influenza will not happen to us, and if it does, our doctors will take care
of us. Nice thought, but as with the case of most viruses, not necessarily true.
Most infectious diseases are curable, but the experience of enduring the illness may not seem
worth the suffering. Still others are incurable, and they can make us sick for life or even end our
lives prematurely.

Table 20.1.1 Transmission Mechanisms of Infectious Diseases

Direct contact:
Blood-borne pathogens
Body fluid pathogens
Skin pathogens
Indirect contact:
Droplet-borne pathogens
Fomite-borne pathogens
Vector transmitted:
Waterborne pathogens
Food-borne pathogens
Insect-borne pathogens

Infectious diseases can be transmitted in many different ways. Table 20.1.1 describes some
of the ways this transmission can occur.
Direct contact occurs when the care provider comes into direct contact with a body fluid:
blood, urine, feces, vomitus, sweat, tears, cerebrospinal fluid, sputum, phlegm, vaginal
secretions, sperm, or a purulent drainage from a wound or skin infection.
Direct contact contamination is prevented by wearing appropriate personal protection
equipment such as gloves, gowns, and eye protection. We also must be careful to avoid
accidental needle sticks. These precautions are part of body substance isolation.
Indirect contact refers to contact with a body fluid that has been deposited onto a surface,
such as a sleeping pad, cookware, or any camping or rescue gear. Surfaces that can play this role
are termed fomites. Infectious droplets coughed into the air and then inhaled are another example
of indirect contact.
Prevention of indirect contact contamination includes protecting the airway by wearing a
surgical mask, protecting the eyes with glasses or goggles, wearing gloves and gowns, and
handwashing before and after providing patient care.
Vector-borne contact refers to disease that is spread by ingestion (water or food) or by stings
or bites by an arthropod (eg, insect, tick).
Insect-borne contact is a subset of vector-borne contact and refers specifically to the biting,
blood-sucking insects, such as mosquitoes, black flies, sand flies, and others that can spread a
disease from a reservoir in nature to a host.
Prevention of insect-borne diseases requires diligently avoiding insect bites by using insect
repellants/insecticides, dressing appropriately, and sleeping under mosquito netting. Many insect
repellants are ineffective, while insecticides, by definition, kill insects. Diligent research will
reveal what is available in a local wilderness EMS operational environment. In some cases, there
are prophylactic measures that can be taken to prevent certain diseases.

Table 20.1.2 Progression of Infectious Organisms

Prions
Viruses
Bacteria
Mycoses
Parasites
Protozoa
Helminths

Waterborne and food-borne methods of contact describe diseases that are spread by drinking
water or eating food that has been contaminated, usually via the oral-fecal route.
Prevention of waterborne and food-borne illnesses is accomplished by drinking water that
has been properly purified by boiling, filtration, or chemically treated with chlorine, iodine, or
UVC light, and by eating foods that are properly prepared, well cooked, and, if appropriate and
necessary, served hot. Even bottled water is not without risks; although safe if the bottle’s
original seal is intact, there is no way of telling if the water is safe if the container has been
refilled. This is more likely to be a problem in developing countries where water treatment and
restaurant laws are not as strict or strictly enforced.
The next step in the process of understanding infectious diseases is an overview of the world
of microbiology, the biology of animals that are typically only visible with the aid of an electron
or light microscope.
The list begins with the smallest known infectious particles, progresses to single-celled
organisms, and ends with multicellular organisms (Table 20.1.2).

Prions
Standing for proteinaceous infectious particle, a prion is the smallest known entity that can cause
an infectious disease. A nonliving bundle of protein without any genetic material, DNA or RNA,
it cannot self-replicate, and it does not require any source of food or energy to survive. It is heat-
stable, and, therefore, cannot be destroyed by cooking. There is no treatment available and
confirmed diagnosis is made by autopsy.
Prions were first discovered in 1982. They are responsible for six different
neurodegenerative diseases that cause spongiform encephalopathies. Spongiform describes the
appearance of the brain when the prions cause vacuoles: the brain becomes sponge-like; and
encephalopathy refers to a disease of the brain.
These diseases have made the news over the past 10 years in Europe and England, in
particular, due to the occurrence of “mad cow disease” or bovine spongiform encephalopathy
(BSE). The concern is the potential for this fatal disease to spread to people who eat the beef
from an infected cow, which has had a great impact on the beef industry throughout Europe
(mostly in the United Kingdom).
The six neurodegenerative or spongiform encephalopathies caused by prions are BSE (mad
cow disease), scrapie (seen in sheep), kuru (caused by cannibalism in New Guinea), Creutzfeldt-
Jakob disease (which can be inherited or caused by eating beef contaminated with BSE),
Gertsmann-Straussle-Scheinker syndrome, and fatal familial insomnia (the latter two of which
are inherited forms).
Currently, experts believe the only way to acquire one of these six spongiform
encephalopathies is either as an inherited genetic disorder or by eating meat contaminated with
prions.

Viruses
A virus is a single-celled organism that consists of a protective protein envelope surrounding
genetic material, either DNA or RNA. That is all there is to them. They do not contain any
organelles (organized or specialized structures within a cell) or other cellular material.
Viruses are intracellular obligate parasites. In order for them to exist and multiply, they are
obligated to live inside another cell, ie, intracellular. They are parasitic in that they live in a cell
external to them at that cell’s expense.
Since viruses cannot reproduce on their own, they attach themselves to another cell and
inject their genetic material into that cell. That injected DNA or RNA then migrates into the
nucleus of the host cell, where it insinuates itself into the host’s genes and turns the host cell into
a virus factory. The “infiltrated cell” then replicates the viral envelope and the viral DNA or
RNA. Eventually, the host cell fills to the point of bursting, releasing the virus back into the local
environment to spread to other cells.
Because viruses are very tissue-specific, they are looking for certain types of cells to invade
or infect. For example, the common cold virus only invades the respiratory epithelial cells in
your nose, sinuses, throat, and lungs. Thus, the symptoms of a common cold are congestion, sore
throat, dry cough, and general malaise, all caused by the invasion and destruction of the cells that
were infected by the virus.
Other examples are viruses such as Varicella (causing chickenpox) that attack the skin,
mumps (infecting the parotid salivary glands), rabies (infecting nerves), or human
immunodeficiency virus (HIV, attacking T cells, lymphocytes that are responsible for turning on
the immune system).
Viruses do not survive well outside of the host: drying, heat, ultraviolet light, or simple
washing with soap and water easily destroys them. But sneezing, coughing, or dirty hands easily
spreads them.
Despite our belief in the efficacy of antibiotics for essentially any illness, viruses are not
sensitive to the common antibiotics. The body will typically respond with a low-grade fever (less
than 39°C [102.2°F]).
We primarily rely upon our immune system to produce antibodies to destroy the invading
virus. However, there are some antiviral medications that interfere with the virus’s ability to
reproduce which are used to fight potentially life-threatening illnesses such as acquired immune
deficiency syndrome (AIDS).
Vaccines are used to boost the immune system so that it will manufacture the antibodies
against life-threatening diseases such as smallpox (eradicated in 1980), polio, and rabies, as well
as dangerous diseases such as measles, mumps, rubella, etc. If we are exposed to these viruses,
the antibody already exists to destroy the virus before it can cause any harm.
Familiar viruses include Varicella (causing chickenpox), Rhinovirus and Coronavirus
(causing the common cold, which is also sometimes caused by respiratory syncytial virus and
parainfluenza virus); herpes simplex (causing cold sores); HIV (causing AIDs); influenza virus
(causing influenza, also known as “the flu”); hepatitis A, B, and C viruses (causing hepatitis);
West Nile virus (causing West Nile virus infection); hantavirus (causing hemorrhagic fever with
renal syndrome and Hantavirus pulmonary syndrome); rabies virus (causing rabies); Zika virus
(causing Zika virus disease); and dengue virus (causing dengue fever, also known as “break bone
fever” or simply dengue). Another common term is “arbovirus,” which is a more general term
for all those viruses that can be spread by blood-sucking arthropods, including dengue fever,
West Nile virus infection, Zika virus, and others. “Arbovirus” is an acronym for ARthropod-
BOrne VIRUS.

Bacteria
Bacteria are also single-celled organisms, but unlike viruses, they do have the ability to replicate
themselves by binary fission (simply splitting in half). Bacteria have a cell wall to protect them,
contain organelles, and have a nucleus with the genetic material (DNA). Bacteria obtain nutrients
from the surrounding environment (they “eat”) and they excrete waste products.
The rate of multiplication of bacteria is dependent upon the environment. If they are in a
favorable environment—warm, moist, and nutrient rich—they will reproduce rapidly. Bacteria
inside the human body, at a normal core temperature of 37°C (98.6°F), will reproduce or double
every 27 minutes. This may not sound like very much, but if one bacterium divides every 30
minutes, then one at time zero will be two at 30 minutes, four at 60 minutes, and the duplication
proceeds from there.
Imagine this: our initial bug at time 0 hour, becomes 2 at ½ hour and 4 at time 1 hour, 8 in
another ½ hour, and 16 at time 2 hours. Continuing the pattern, there will be 64 at time 3 hours,
256 at time 4 hours, and 1,024 at time 5 hours. In 8 hours, one bug has become 64,000 bugs, and
by 16 hours, that initial bacterium has become 4,096,000,000 bacteria. By 24 hours there are now
more than 256,000,000,000,000 bacteria, meaning about 256 trillion hungry mouths to feed and
pick up after at the end of the first day. What sounded rather trivial in the first hours is now a
very big deal.
The reason for playing this numbers game is to demonstrate how quickly we can become
overwhelmed by a microscopic infectious organism if our immune system is not functioning
properly.
Bacteria are described and classified into families based on their shape, the color they turn
when stained so that they can be seen under a light microscope, and whether they prefer an
environment that contains or does not contain oxygen.

Shapes: Bacteria come in a variety of shapes. These include rods, spheres (cocci), spindle-
shaped (fusiform), and coiled like a spring (spirochetes).
Color: In the lab, technicians will cover a slide with Gram stain to make the bacteria more
visible under the microscope. If the bacteria have a cell wall that absorbs the stain, they turn
blue, known as Gram positive. If not, they will be pink, referred to as Gram negative.
Air: In the lab we can also grow bacteria in a normal atmosphere, rich with oxygen, or in an
environment depleted of oxygen and rich in nitrogen and carbon dioxide.

Bacteria that grow well in a normal oxygen-rich atmosphere are known as aerobes, or
aerobic bacteria. Those that grow well in the oxygen-depleted environment are known as
anaerobes, or anaerobic bacteria.
Unlike viruses, bacteria are not as tissue-specific—they tend to be less discriminating and
will try to stake a claim wherever they can. Typically, the symptoms of a bacterial infection are
more pronounced. The symptoms come on quicker, are more severe, and more painful. Factors
that can cause a temporary elevation in body temperature include age, physical activity,
emotional stress, and ovulation. If a person has a consistently elevated temperature, fever is said
to exist. A low-grade fever is marked by temperatures between 37.5°C and 38.2°C (99.5°F and
101°F) when taken orally. A high-grade fever is considered to be present when the oral
temperature is above 38.2°C (101°F).
The good news is that unlike viruses, bacterial infections are more easily treatable. Most will
respond to appropriate antibiotic therapy. Prior to the days of antibiotics, infectious diseases such
as pneumonia were the most common cause of death, and they are still the number one cause of
death in parts of the world where antibiotics are not easily accessible or affordable.1
Because of the many different types of bacteria, there are many different types of antibiotics,
organized into several different families: penicillins, cephalosporins, macrolides,
fluoroquinolones, tetracyclines, sulfa drugs, and aminoglycosides.

Mycoses
Fungi and yeast cause mycotic infections and are among the most common microorganisms on
earth. They affect us both directly as a source of infectious disease, as well as indirectly by
causing spoilage to crops and stored grains and food. Some mycoses even produce mycotoxins
that are highly carcinogenic (causing cancer), teratogenic (causing birth defects), and poisonous.
These organisms are spread by forming spores that are extremely abundant in the proper
conditions and can cause allergic symptoms. Strangely, they can also be beneficial—for
example, yeast is used in the fermentation process to convert grape juice to wine or to make
bread.
Mycotic infections are classified according to what area of the body they invade or infect.
Typically they invade or infect the skin, causing a variety of dry, itchy rashes, but they can also
invade the lungs and cause systemic disease that will be mentioned later. Common, irritating, but
non-life-threatening infections include “athlete’s foot” (Tinea pedis) and the now well-marketed
and popular nail infection, onychomycosis.
The classes of mycotic infections are superficial mycoses, cutaneous mycoses, and
subcutaneous mycoses.
Superficial mycoses affect only the dead, fully keratinized portions of the skin. Living tissue
is not invaded, and the infection is strictly superficial and cosmetic. An example is Pityriasis
versicolor. Cutaneous mycoses are also limited to the keratinized portions of the skin including
the nails, but can cause chronic disfiguring, and even painful changes of the skin or nails (eg,
athlete’s foot).
Subcutaneous mycoses occur when the fungi are introduced into the layer of skin beneath the
keratinized layer by a wound, such as that caused by a splinter or thorn, and the invading
organism sets up housekeeping. This can provoke a brisk response from our immune system,
causing a localized lesion that has difficulty healing. A simple example is a fungal infection of
the skin known as Tinea corporis but commonly referred to as “ringworm.” The name is a
misnomer because it is not a worm, but the surreptitious red edge of the rash makes it look like
there is a worm under the skin.
Systemic mycoses happen when the infectious agent has entered our bodies below the layer
of the skin. Typically, the fungus will get into our lungs by inhalation. Replication begins in the
lungs and then disseminates or spreads systemically to other organ systems. An example is
histoplasmosis (a potentially fatal disease spread by bird or bat feces).
Protozoa
Protozoa are single-celled organisms that are larger and more complex than bacteria and have a
means of mobility. They vary in size from microscopic (only visible under a microscope) to
macroscopic (visible to the naked eye) and are free-living, in that they survive very well outside
the body. They can live in ponds, streams, and other water supplies, and some even have the
ability to encase themselves in a protective shell when the environment becomes hostile.
Protozoa exist in two forms, as a cyst and as a trophozoite. The living, moving form is the
trophozoite, but when stressed or challenged by a hostile environment the trophozoite will morph
into a cyst form where it encloses itself in a protective shell. Once back in a favorable
environment, it will return to the trophozoite form.
Amoebas can project out part of their cell wall, creating a pseudopod. By then reshaping
themselves around it, they can effectively pull themselves forward. In a similar fashion, they can
surround something they want to eat, engulf it, and digest it. Giardia, an intestinal parasite, have
small suction cups that help them to anchor to the wall of the intestine, as well as long, hair-like
projections called flagella that allow them to swim about freely.
Approximately 10,000 of the species of protozoa are parasitic, but only a small portion of
those are pathogenic to humans. They are classified by their common traits and by their means of
locomotion.

Helminths
With these organisms, things get very interesting. While we might not have a problem imagining
that there are millions of microscopic organisms living on us, in us, and all around us, it is
altogether different to think that there could be WORMS, some many inches long, living in our
intestinal tract, skin, liver, or even lungs. Unfortunately, for the vast majority of the world, that is
reality. Many people live without proper sanitation, and as a result, acquire these worms by oral-
fecal contamination.
Helminthic infections are caused by parasitic worms. Unlike single-celled protozoa, these are
multicellular animals with complex tissues and organs. The classifications of helminths that
parasitize man are: Nematoda, Platyhelminthes (cestodes and trematodes).
Nematoda is a phylum containing non-segmented roundworms. Most members are free-
living, inhabiting soil and water. Most of the 80,000 species are biologically dependent upon a
single host, most of which, fortunately, are not humankind.
Platyhelminthes (flatworms) include both trematodes (flukes) and cestodes (tapeworms). The
flukes are found in the intestinal tract but can migrate into the liver and bladder. Tapeworms are
the largest of human parasites, growing to be many feet long. The largest is the fish tapeworm,
Diphyllobothrium latum, which can grow to be over 50 ft long.
The obsession that our culture has with body weight and wanting to appear sleek and trim is
nothing new. Up until about World War II, we could buy a capsule that contained tapeworm ova
(eggs). By taking one, we would then have our very own tapeworm that would help us stay thin.
This would be the ideal pet—it would go where we went, eat what we ate, and allow us to have
two desserts, one for us and one for our tapeworm.
Now that we know all about the world of infectious diseases, what telltale hints will help us
to determine what type of illness we may be dealing with?

Prion infection: We will not know until it is too late. The chief signs and symptoms of a prion
 disease are a failing central nervous system.
Viral infection: Viruses are very tissue-specific, with low-grade fevers, generalized aches and
pain, and general malaise.
Bacterial infection: Characterized by a rapid onset of symptoms: high fever, fatigue, and rapid
deterioration of general health.
Mycotic infection: Most likely limited to the skin, it presents with a slowly worsening,
nonspecific rash, often appearing as dry, slightly red, slightly itchy, scaly skin.
Protozoal infection: Most likely a diarrheal illness, with worsening symptoms of diarrhea, gas,
and abdominal cramps. As the infection worsens, the patient may develop blood in the stool
(dysentery).
Helminthic infection: Generally we will see worms in the stool. It can take months to years after
getting infected for these to be observed.

Despite some of the distasteful or even dire conditions caused by these various agents, there
is hope. Fortunately, we have within us our own army of cells and an immune system that is just
itching for a good fight.

DEFINITION AND DESCRIPTION OF THE HUMAN

IMMUNE SYSTEM
The purpose of the immune system is self-defense, which includes:

The recognition of SELF versus NON-SELF

The ability to fight off the invasion of foreign pathogens and antigens by producing
antibodies and killer T cells
The ability to fight an acute infection

Table 20.1.3 describes the various parts of the human immune system.
The lymphatic system is part of the circulatory system. A closed loop system, the circulatory
system goes from the heart to the heart and circulates the blood. It is under constant pressure—
blood pressure. But, the circulatory system is designed to leak, so fluid constantly leaks out of
the blood vessels into the surrounding tissues.

Table 20.1.3 Anatomy of the Immune System

Lymphatic fluid
Lymph vessels
Lymph nodes—contain lymphocytes and macrophages
Tonsils and adenoids
Thymus—produces T lymphocytes
Spleen
Peyer patches
Appendix
Bone marrow—produces white blood cells
 Lymphocytes
Leukocytes

Because the circulatory system is under constant pressure, the fluids that have drained out
cannot get back in, which would cause them to accumulate in the tissues if it were not for a
parallel system that drains these interstitial fluids and delivers them back into the circulatory
system.
This parallel system is the lymphatic system, consisting of lymphatic vessels and lymph
nodes. Unlike the circulatory system, it is not a closed-loop system. Instead, it consists of vessels
that dead-end, like the roots of a tree progressing outward, getting smaller and smaller.
Fluids collect in the interstitial space between the cells. Adjacent to the vasculature are the
lymphatic vessels that are not under pressure and are designed to open up and drain fluid as the
pressure builds up around them. This fluid, called lymph, is very similar to the serum of the
blood, except that it also contains white blood cells, known as lymphocytes.
Built into the lymphatic system are filters, the lymph nodes, which capture and kill foreign
invaders, such as bacteria, that may also be in the fluid. The lymph nodes contain lymphocytes
and macrophages that will kill any pathogen in the fluid.
Lymphangitis is the term used to describe swelling and tenderness of lymphatic vessels.
These are the red streaks that are visible and palpable as an infection progresses up an extremity.
Lymphadenitis is also the term used to describe swelling and tenderness of lymph nodes.
These are characterized by the swollen tender nodes felt when an infection reaches the lymph
nodes, such as that seen occurring in the neck when someone has strep throat or mononucleosis.
The tonsils and adenoids are lymphatic tissues found in the back of the throat. They are
designed to protect us from infection by capturing and destroying any pathogens causing a sore
throat.
The thymus is a gland in the center of our chest that produces T lymphocytes—white blood
cells that are produced in the bone marrow and mature in the thymus gland to become killer
cells. They phagocytize (engulf) pathogens and destroy them.
The spleen contains islands of white blood cells that produce antibodies that are recruited to
help invade and destroy pathogens.
Peyer patches are collections of lymphatic tissues in the small intestine. They help to prevent
infection and invasion of pathogens from the small intestines.
The appendix contains lymphatic tissue and helps to fight infection at the junction of large
and small intestines.
The bone marrow produces all of the blood cells including white blood cells, lymphocytes,
and leukocytes.
There are three natural lines of defense against pathogens.

1. The skin: This is a waterproof and pathogen-proof covering familiar to all of us. When
intact and healthy, it provides a mechanical barrier to infection.
2. Nonspecific immune response: This is also known as the innate immune system and is an
inherited, immediate response. There is no delay; it is ready to kill anything that is non-self.
It creates phagocytosis via macrophages and natural killer cells, recruits cells to areas of
inflammation, activates the complement cascade, and triggers adaptive immunity and
antigen presentation.
3. Specific immune response: This is also known as the adaptive immune system or acquired
immunity system, which produces a slow, gradual response, as well as a lifelong memory,
 ie, “immunity.” It stimulates the production of antibodies by B cells (a type of lymphocyte)
in response to specific antigens.

Natural: Passive (maternal) + Active (infection)

Artificial: Passive (antibody transfer) + Active (immunization)
Creates an immunologic memory (eg, vaccination)
Found only in jawed vertebrates
Humoral immunity via antibodies
Cell-mediated immunity via T lymphocytes

The steps involved in a complete immune response are explained below.

1. An antigen/pathogen enters the body and is recognized as non-self and phagocytized

(“eaten”) by a macrophage.
2. The macrophage destroys the antigen/pathogen and displays portions of it on its cell
membrane surface.
3. Helper T cells recognize the display and become activated.
4. Helper T cells activate the cytotoxic T cells and B cells.
5. The cytotoxic T cells divide into active cytotoxic T cells and memory T cells.
6. Activated cytotoxic T cells recognize and kill infected cells, destroying the pathogen.
7. B cells divide into plasma cells that make antibodies and memory B cells.
8. In the future, these plasma cells’ antibodies will deactivate the antigens and pathogens—this
is active immunity.
9. Memory T cells and memory B cells stay in the body for decades and will speed up any
future response to the same antigen/pathogen.
10. Suppressor T cells stop the process once all of the antigen/pathogen has been destroyed.

THE WILDERNESS MANIFESTATIONS OF INFECTIOUS

DISEASES
Consider this scene: An individual falls off a mountain bike, causing a laceration to their lower
leg. Bleeding is easily controlled with direct pressure, but a bacteria, Staphylococcus aureus
(“staph”), that is always on the skin, is introduced into the wound. The wound is not properly
cleaned, and over the next two days the staph bacteria multiply in the wound site, causing a skin
infection referred to as cellulitis.

1. A pathogen, in this case S. aureus, is introduced into the body.

2. Once inside the wound, the staph bacteria find themselves in a very favorable environment,
a place in which they can reproduce and multiply. Being warm, moist, dark, with plenty to
eat, at 37°C (98.6°F), the bacteria will double approximately every 30 minutes.
3. The bacteria are recognized as non-self, phagocytized by macrophages, and the immune
response begins.
4. Natural killer cells and plasma cells are activated, and histamines and other hormones are
produced that call or recruit more macrophages and killer cells into the area to phagocytize
and kill the invading pathogens.
 The histamines also cause vasodilation of the localized vasculature resulting in an
5. accumulation of fluid in the tissue, redness, swelling, warmth, and tenderness.
6. The histamines cause chemotaxis—they attract and accumulate more white blood cells into
the wound that can result in abscess formation.
7. The destruction of bacteria produces waste products that get into the bloodstream. These
waste products are recognized by the part of our brain responsible for thermoregulation. In
response, the brain will increase the core temperature, causing a fever. The fever is good,
because the elevated temperature slows the reproduction of the bacteria, which means there
are fewer bacteria to battle. In this context, treatment of fever in the wilderness is somewhat
controversial. Fever may have an adaptive and healing role in the sense that it fights
pathogenic reproduction. On the other hand, fever causes many unpleasant side effects for
the patient. Our recommendation is that fevers only be treated if the side effects are
extremely unpleasant for patients or reduce their ability to participate in their own rescue in
critical ways. This is consistent with the American Academy of Pediatrics.2 Otherwise,
allowing a fever to run its course may actually be helpful to patient healing.
8. As the battle rages on, the excess fluids, pathogens, and white blood cells will get picked up
by the lymphatic vessels and migrate proximally toward the lymph nodes.
9. If the bacteria overwhelm the immune system, the bacteria will infect the lymphatic vessels,
and they will become red, swollen, and tender—lymphangitis.
10. Once the infection reaches the lymph nodes, they will now go to battle and the affected area
becomes red, warm, swollen, and tender—lymphadenitis.
11. If this process continues up the extremity, it will eventually reach the point where the
lymphatic vessel drains lymphatic fluid into the subclavian veins adjacent to the heart,
resulting in rapid dissemination of the bacteria. All the waste products of the battle will
cause septic shock and possible death.

The classic signs and symptoms that show cellulitis is progressing are abscess formation with
rubor (redness), tumor (swelling), dolor (pain), and calor (fever).
Lymphangitis and lymphadenitis can indicate cellulitic progression outside the local
infection.

References
1. Centers for Disease Control. Achievements in Public Health, 1900-1999: Control of Infectious Diseases. MMWR Morb
Mortal Wkly Rep. 1999;48(29):621-629.
2. Sullivan JE, Farrar HC, the Section on Clinical Pharmacology and Therapeutics, Committee on Drugs. Fever and
antipyretic use in children. Pediatrics. 2011;127(3):580-587.
INTRODUCTION
Treatment of infectious diseases has become a routine practice in medicine. It is easy to take the
lifesaving impact of timely administration of antibiotics for granted. The introduction of mass-
produced penicillin during World War II had a profound impact on both amputations of limbs
due to gangrene, as well as death from overwhelming infections caused by dirty battlefield
wounds. Since that time, the number of antimicrobial choices has exponentially increased, but
new antibiotic-resistant species are emerging constantly. Traditional EMS has only recently
began to place emphasis on the treatment of infectious disease, primarily because rapid transport
to hospitals is the norm, and the time delay, in most cases, is not significant enough to outweigh
the benefit of access to advanced diagnostic and treatment resources in the emergency
department. Providers of wilderness EMS, however, must be able to recognize disease patterns,
anticipate the projected clinical course, and provide early intervention when possible to prevent
clinical deterioration. As increasingly portable and robust technology makes the wilderness feel
less remote and intimidating to some, and more people venture into the wild every year,
wilderness EMS providers will need to be prepared to encounter patients with a variety of
diseases. Due to variable disease progression, patients who felt fine when leaving home can
quickly develop serious illness once in the wilderness, especially if they have underlying medical
conditions.

Definition
Infectious diseases are caused by “infective agents” which are microorganisms such as bacteria,
viruses, fungi, and parasites that are capable of producing illness and death in the host. While
they use various, complex methods for accomplishing this, in general they produce toxins that
cause tissue inflammation and activate the body’s immune system. This results in the classic
symptoms of warmth, pain, swelling, fever, and pus formation. The term “infectious disease” is
often used interchangeably with “communicable disease” or “transmissible disease”; however,
they do not truly have the same meaning. Communicable diseases are those that can be easily
spread from person to person, and not all infectious diseases are easily spread that way.

Scope of Discussion
The field of infectious disease is vast and this chapter is by no means an exhaustive review of all
possible serious infections one may encounter while rendering care in the wilderness. It is
possible that nearly any infection that one could see in traditional EMS could also occur in the
wilderness. Out-of-hospital medicine is inherently limited by, and in essence defined by, a lack
of advanced diagnostic equipment, support, and resources. Wilderness EMS relies on physical
exam, clinical history, and knowledge of epidemiology to guide treatment. This leads to quite a
bit more uncertainty, and differentiating similar infections may not be possible without bacterial
cultures, gram stains, and the support of a microbiology lab that one would have in a hospital
emergency department. Although similar diseases may be indistinguishable to the wilderness
EMS provider, by using a systematic approach it is possible to initiate appropriate treatment
early and prevent patient deterioration. This chapter will cover recognition and treatment of the
most common and life-threatening infections of the skin and soft tissue, gastrointestinal (GI)
system, genitourinary (GU) system, central nervous system (CNS), and pulmonary system.
Finally, this chapter covers sepsis and its management in the wilderness.

EPIDEMIOLOGY
Management of infectious diseases relies on general understanding of disease prevalence in
populations. In general, the population venturing into the wilderness is somewhat healthier and
younger than the population at large. In traditional EMS it is common to treat patients with
severe infections. The actual incidence of illness due to infectious disease in the wilderness is
unknown, as statistics reflecting the prevalence and nature of calls for help in the wilderness are
scarce, and there is no central repository for reporting. The National Park Service reports that
approximately 280,000,000 people a year visit national parks, though only 1.8 million stay
overnight in the backcountry, and 2.96 million in park campsites.1 Between 2012 and 2013, there
were approximately 35 to 40 calls for EMS per million visitors to national parks, with the
majority being for traumatic injuries. Approximately 46% were for noncardiac medical
complaints.2 It is unclear how many of these calls involved infections, or whether they occurred
in the frontcountry or backcountry. While the data are not entirely representative of all travelers
to other backcountry areas such as National Forests or other public lands (the National Park
System includes a considerable amount of frontcountry and even some urban areas), it does show
an overall trend toward a lower utilization of EMS and likely overall healthier population group,
who are engaging in activity more likely to cause injury than illness.
Although the prevalence of infectious disease is less common for wilderness EMS providers,
the impact of infectious disease is far more profound than in the frontcountry. Traditional EMS
providers typically would not need to consider treating a urinary tract infection (UTI) or
pneumonia, but this may be necessary in the wilderness. Pneumonia, for example, is typically
very straightforward to treat in an otherwise healthy person. A visit to an outpatient clinic or an
emergency department with access to testing and expert clinicians makes diagnosis fairly simple.
Treatment can be tailored to the patient with many antibiotic choices to account for allergies and
likely organisms. The same healthy patient in a wilderness environment is much more
complicated to manage. Progression of illness will make self-evacuation difficult due to
shortness of breath, and could exponentially increase the time to diagnosis and treatment if that
required arriving at a hospital. Wilderness EMS crews will likely have limited choices in
antibiotics which may make it difficult to account for every disease and patient-specific allergy.
Providers will need to be equipped to diagnose and treat evolving infections without all of the
resources considered common in the hospital environment. Early recognition and treatment
prevents otherwise mild infections from progressing to life-threatening or fatal processes.

CLINICAL MANAGEMENT OF PULMONARY INFECTIONS

Identification
Infections of the pulmonary system are common and range in severity from very mild to life-
threatening. Although travelers to wilderness areas are at risk of a variety of diseases uncommon
in the frontcountry, they are still much more likely to suffer from the same infections that are
common in the frontcountry. Infections of the pulmonary system are classified by the anatomic
location of the infection, and have characteristic physical exam findings and symptoms.
Bronchitis is one of the most common ailments seen in clinical medicine. It is the infection
of the bronchi, or large airways of the lungs. It is usually caused by viruses, and by definition, is
self-limited in course. Patients present with at least 5 days of dry cough, sometimes with sputum
production, wheezing, and can have mild dyspnea with exertion. Bronchitis has an indolent
course and usually has a gradual onset, worsening over days. Patients with bronchitis may also
have cough productive of rust-colored or blood-tinged sputum, which is a result of inflammation
and irritation of the bronchioles by persistent coughing. During the first few days of illness it is
not possible to distinguish acute bronchitis from other viral upper respiratory infections caused
by the common cold or related viruses. Patients who are smokers or have underlying lung disease
such as chronic obstructive pulmonary disease (COPD) or asthma are more likely to have severe
symptoms, and can have acute exacerbations of their disease triggered by the inflammation
caused by infection.
Pneumonia is the acute infection of the lung parenchyma, the portions of the lung involved in
gas transfer—the alveoli and small bronchioles. It is distinct from bronchitis in both presentation
and significance. While bronchitis may cause annoying symptoms by irritating the large airways
and causing cough, pneumonia can cause difficulty with gas exchange leading to severe
shortness of breath and even hypoxia. Pneumonia is characterized by relatively rapid onset of
fever, chills, cough, malaise, and shortness of breath. Approximately 30% of patients will
experience chest pain. Pneumonia often follows a viral illness in otherwise healthy adults.
Sudden shortness of breath (or worsening of earlier mild shortness of breath), high fever, and
rapid respiratory rate in a patient who has been suffering from cold symptoms for several days
should be an alert that a patient is developing pneumonia. In contrast to bronchitis, pneumonia is
typically a bacterial infection, although viruses can cause pneumonia as well.
Pneumonia is classified as either community-acquired pneumonia (CAP) or health care-
associated pneumonia (HAP) depending on the clinical context. Patients with significant contact
with the health care system are classified as health care-associated, including3:

Intravenous (IV) therapy, wound care, or IV chemotherapy in the past 30 days

Residing in a nursing home or long-term care facility
Hospitalization for more than 2 days in the past 90 days
Attendance at hospital or dialysis clinic in past 30 days

Wilderness EMS providers are unlikely to encounter HAP patients in remote areas, but it is
important to note that they are more likely to be infected with different organisms than patients
with CAP, and will need different antibiotics.
Pneumonia is a common, potentially life-threatening condition that is usually of little
concern in otherwise healthy patients in the traditional EMS context. Standard practice in
hospital-based medicine is to obtain chest x-ray to confirm the diagnosis of pneumonia.
Wilderness EMS providers will need to rely on history and physical exam findings to make the
diagnosis and begin treatment; however, there are no specific sets of clinical symptoms that can
reliably distinguish pneumonia with complete certainty. Additionally, exposure to common
wilderness factors, such as mold and mat, produce conditions that mimic pneumonia. While the
vast majority of patients with pneumonia are febrile (80% according to some studies), accurate
measurement of the patient’s temperature in the wilderness is difficult, and can be affected by the
environment. Exposure to a cold environment can lower the patient’s core temperature and mask
a fever, just as exertion and exposure to heat can raise the core temperature. Portable pulse
oximetry is relatively inexpensive and units are available that are small and lightweight (Figure
20.2.1). These units measure pulse oximetry (SpO2,) a surrogate but usually accurate reflection
of arterial oxygen saturation (SaO2). A significant drop in the patient’s pulse oximetry reading
during ambulation or lower than expected readings accompanied by fever, rapid respirations, and
cough are also strongly suggestive of a severe pneumonia warranting intervention. On
examination, most patients will also have audible crackles on lung auscultation. Despite much
investigation, no constellation of symptoms has ever been shown to reliably predict whether a
patient has pneumonia.4 An assessment of the overall risk of treatment versus that potentially
leaving a bacterial pneumonia untreated should accompany the decision to begin therapy. While
bronchitis is self-limited and unlikely to incapacitate a patient, pneumonia can progress to a life-
threatening and incapacitating illness fairly quickly without treatment. Prior to antibiotics, this
was a leading cause of death in human populations.
FIGURE 20.2.1. Low-cost portable pulse oximeter

Treatment and Disposition

Treatment of respiratory illness can be thought of in three parts: support of the patient’s
breathing and respiratory function, treatment of underlying organism causing illness (if possible),
and relief of symptoms. Not all patients suffering from respiratory illness and infections will
require rapid evacuation or even antibiotics. In general, treatment by wilderness EMS providers
should start with careful risk-assessment considering:

Degree of respiratory distress (examples of worsening respiratory distress include increased

work of breathing, decreased SpO2, and rapid respiratory rate)
Underlying lung disease such as COPD or asthma
Signs of poor perfusion (examples include pale skin, lack of urine output, tachycardia, slow
capillary refill)
Speed of progression: symptoms rapidly worsening over the course of hours instead of days

If in doubt, rapid evacuation should be initiated for patients at high risk of deterioration or
with rapidly progressive illness. When the situation allows, beginning treatment and evacuating
early is preferable when the patient is still able to assist in his or her own rescue.

Basic Life Support

Providing supplemental oxygen by nasal cannula or nonrebreather mask is fundamental basic life
support (BLS) care for nearly all respiratory complaints. While providing supplemental oxygen
may be possible and necessary in wilderness EMS, providers must use a more measured
approach than in the frontcountry. Standard practice is to provide supplemental oxygen by nasal
cannula at 2 to 4 liters per minute (lpm), or high-flow oxygen by nonrebreather mask at 10 to 15
lpm based on subjective degree of difficulty breathing. While short-term application of high-flow
oxygen in otherwise healthy patients has little risk, there is evidence that, at least in patients with
COPD, titrating oxygen therapy to patient response and pulse oximetry may improve
mortality.5–7 The biggest problem with oxygen delivery in the wilderness is physically delivering
an adequate supply of compressed oxygen to the patient due to the weight and size of oxygen
tanks. In general, high-flow oxygen by mask should be avoided if possible. Providers should
start with lower flows of oxygen than is usual in frontcountry EMS, and titrate oxygen rate of
delivery to patient response. There is no need to raise a patient’s SpO2 to 100%. A goal of 92%
to 94% is safe and adequate in patients with respiratory infections, as saturations less than 92%
have been associated with poor outcomes, and over-oxygenation has been shown to be harmful,
even in patients with such severe disease as to require intubation.1–4 Small adjustments to the
flow of oxygen not only significantly increase the percentage of inhaled oxygen (FiO2), but also
dramatically shorten the life of the tank (see Table 20.2.1). It is important to note that as altitude
increases, atmospheric pressure decreases, which makes it more difficult to diffuse oxygen into
the blood. SpO2 is normally lower in healthy people at altitude, and the degree that it is lowered
is relative to the altitude. Providers can check the SpO2 of themselves and other healthy rescuers
and compare it with that of the patient to get a better idea of the severity of respiratory function
compromise.

Advanced Life Support

In addition to providing supportive care, the introduction of advanced life support (ALS)
personnel allows wilderness EMS teams to begin therapeutic interventions typically reserved for
the hospital environment. Upper respiratory infections often cause bronchospasm. On exam,
patients will have characteristic wheezing breath sounds and shortness of breath. Albuterol, a
beta-agonist bronchodilator, works by relaxing bronchiole smooth muscle to relieve
bronchospasm. It is often delivered by nebulization with compressed air, or more commonly in
frontcountry EMS, compressed oxygen. It is more commonly used by patients at home in the
form of a metered dose inhaler (MDI). Many clinicians believe that nebulized albuterol is
superior to MDI; however, head-to-head trials have failed to show any superiority in patients
who are able to use them properly.8 Nebulized albuterol should therefore not be used unless the
patient is too dyspneic (short of breath) to take a full breath to effectively use the MDI. This will
save oxygen, which is usually in limited supply in wilderness environments.
Steroids are familiar to ALS providers in traditional EMS. They are commonly used to
reduce systemic inflammatory response in asthma attacks, COPD exacerbations, and allergic
reactions. There is some evidence that steroids may improve mortality when given to patients
with CAP.8–11 Steroids should be considered for patients with significant symptoms concerning
severe bronchitis or pneumonia. They have a clear role in reducing inflammation and improving
outcomes in COPD and asthma exacerbations, and the actual diagnosis may be unclear to the
wilderness EMS providers. There is no significant difference in the effectiveness of IV or oral
steroids, so IV formulations should be reserved for patients who are unable to take pills by
mouth due to severe respiratory distress, nausea and vomiting, or altered mental status. There is
no clear evidence to suggest that any particular steroid-dosing regimen is superior. Prednisone 50
mg by mouth once daily or methylprednisolone (SoluMedrol) 0.5 mg/kg may be given IV every
6 to 12 hours.
State medical boards approve mediations for use by EMS personnel, and there is significant
variability among states as to the legality of EMS personnel initiating antibiotic therapy without
direct physician involvement. Some states such as Maine and North Carolina do permit the
development of wilderness-specific treatment protocols allowing for antibiotic administration.
Patients suspected to have pneumonia could be started on antibiotics if rapid evacuation is not
feasible. Table 20.2.2 summarizes antibiotic recommendations for CAP.

Clinician
Integrating physicians, PAs, and APRNs into wilderness EMS systems allows for a more
nuanced approach to the management of respiratory infections in the wilderness. Most
physicians, PAs, and APRNs involved in traditional EMS are very familiar with managing
respiratory infections from their usual clinical practice. Some additional consideration must be
given to the possibility of mold or dust-induced respiratory inflammation as well as to other
environmental causes of pulmonary compromise as these are more common in the wilderness
setting. Treatment protocols should be developed that maximize the number of indications for
which a single drug may be used. This limits the number of drugs that must be carried saving
space, weight, cost and minimizing complexity of decision-making. It would be reasonable to
include only levofloxacin, doxycycline, and ceftriaxone in the formulary, and still be able to
provide adequate respiratory coverage. All three antibiotics are useful for treatment of infections
from various other organ systems, and the protocol could still account for drug allergies. It may
not be feasible to carry multiple antibiotics, and one must consider the specific characteristics of
the team’s practice environment and the demographics of the patients they are likely to
encounter. For those teams needing a single antibiotic solution to as many conditions as possible,
we recommend ceftriaxone as parenteral therapy and levofloxacin or clindamycin for oral
therapy.

Table 20.2.1 Hours of Oxygen Delivery by Tank Size and Flow Rate
Flow Rate (L/min)
Tank Sizea 1 1.5 2 2.5 3 4 5 6
ML 6 2.8 1.9 1.4 1.1 0.9 0.7 0.6 0.4
C 4.0 2.7 2.0 1.6 1.3 1.0 0.8 0.7
D 6.9 4.6 3.5 2.8 2.3 1.7 1.4 1.2
E 11.4 7.6 5.7 4.6 3.8 2.8 2.3 1.9

aFor
more information about oxygen cylinder size conventions, see http://bit.ly/oxygen_cylinders.

Table 20.2.2 Suggested Antibiotics

Recommended Antibiotics for Pneumonia in the Wilderness
Able to tolerate pills by mouth, no signs of poor perfusion, hypoxia or RR ≤30
• Azithromycin 500 mg first day, 250 mg daily days 2–5
OR if allergy to macrolide (azithromycin, erythromycin)
• Doxycycline 100 mg daily
Not able to tolerate pills by mouth OR signs of severe disease
• Levofloxacin 750 mg IV (or PO if able to tolerate) daily
OR if allergy to fluoroquinolone (levofloxacin, ciprofloxacin [Cipro], or moxifloxacin [Avelox])
• Ceftriaxone 1 g IV/IM daily PLUS EITHER
• Azithromycin 500 mg IV (or PO if able to tolerate) OR if allergy to macrolide (azithromycin, erythromycin)
• Doxycycline 100 mg PO daily

Adapted from IDSA/ATS guidelines for recommended empiric antibiotics for community acquired pneumonia in adults in
Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44 Suppl 2:S27-72, by
permission of the Infectious Diseases Society of America.

Equipment Summary
Wilderness EMS teams may have vast differences in their ability to care for respiratory
infections depending on their practice environment and ease of transporting equipment to the
patient. Oxygen can be lifesaving and could conceivably help support a patient’s efforts to self-
evacuate with the assistance of the rescuers. Oxygen cylinders made from carbon composite
materials that weigh approximately 50% less than aluminum are available, which could make
carrying significant oxygen supplies feasible. Using tables to calculate the amount of oxygen to
bring can reduce the excess weight carried as well (see Table 20.2.2). If it is not possible to carry
sufficient oxygen to last at least the minimum duration of the expected evacuation, it may not be
worth bringing any at all. Portable pulse oximetry is highly useful, as discussed above, for
conserving oxygen and can be used as a means for objectively monitoring trends in the patient’s
ability to oxygenate their blood. Devices are available that are small, inexpensive, and
lightweight (Figure 20.2.1). Oral or parenteral antibiotics that cover common respiratory
pathogens should be a strong consideration. The specifics of antibiotics are discussed in greater
detail above.

CLINICAL MANAGEMENT OF GENITOURINARY

INFECTIONS

Identification
Complaints of painful urination (dysuria), urinary urgency, flank pain, vaginal or penile
discharge, and lower pelvic/suprapubic pain are suggestive of GU infections. Depending on the
severity of the illness, patients may also have fever, chills, tachycardia, or rapid respirations. As
with all infections, signs of poor perfusion, altered mental status, and low blood pressure are
signs of very severe infection and portend a poor outcome in the wilderness.
Lower UTIs, also known as cystitis, are quite common in females, but relatively uncommon
in men. Approximately 5 to 8 otherwise healthy men per 10,000 will experience a UTI yearly,
compared to 1 in every 2 or 3 otherwise healthy women.12,13 Young women who complain of a
combination of dysuria, suprapubic pain, urgency, and hematuria are likely to have UTIs.
Women of childbearing age should be screened for pregnancy. The diagnosis is usually
confirmed by urinalysis—in the wilderness, necessarily, by urine pregnancy dipstick rather than
serum testing. With regard to UTI, the presence of leukocyte esterase with or without nitrites,
microscopic evaluation of the urine for bacteria and white blood cells, and urine culture
combined with symptoms of UTI is the gold standard for diagnosis. Urine smell is often
associated with UTIs by both patients and clinicians; however, it is reflective of hydration status
and is of no utility in determining whether a patient has a UTI.14 Dipsticks are small and easy to
carry; however, it is not necessary to confirm the UTI diagnosis with urine dipstick to begin
treatment in nonpregnant, otherwise healthy females without vaginal complaints. The likelihood
of a UTI in these patients is 90% and with vaginal complaints is still 50%.15 The only utility of
urine dipstick in this case would be that if negative, it may suggest investigating other causes, or
potentially conserve limited supplies of antibiotics.
Patients presenting with the symptoms of UTI who also have flank pain and/or fever may be
suffering from an upper UTI, also known as pyelonephritis. Bacteria can travel from the bladder
to the kidneys via the ureter and infect one or both kidneys. On exam, patients may have pain
with percussion of the costovertebral angle (Figure 20.2.2), fever, and tachycardia. Although
most otherwise healthy patients do very well if treated early for pyelonephritis, long delays in
initiation of antimicrobials can lead to patient decompensation. Given the relatively low
incidence of UTIs in men, one should strongly consider other diagnoses before settling on
pyelonephritis in an otherwise healthy male. Intermittent sharp pain in flank, which may radiate
to the groin, accompanied by blood in the urine should raise the suspicion for a kidney stone. If
this patient also has a fever, this does constitute an emergency, as infected kidney stones can lead
to serious complications and patients can quickly become very sick.

FIGURE 20.2.2. Costovertebral angle (CVA) tenderness can be elicited by percussing the patient’s back at the junction between
the spine and the lowest ribs, which roughly corresponds to the location of the kidney.
 Complaints of vaginal pain, discomfort, foul-smelling discharge, and suprapubic discomfort
indicate that the patient may be suffering from gynecologic infections. Risk factors include being
sexually active, and not using barrier protection. Mild infections are limited to the cervix, and
generally do not produce severe symptoms. Chlamydia and gonorrhea are common sexually
transmitted infections in developed countries. These infections can ascend to infect the uterus,
fallopian tubes, ovaries, and surrounding pelvic structures. This is known as pelvic inflammatory
disease (PID). Patients with risk factors who complain of symptoms of gynecologic infections,
and who have significant lower abdominal pain, tenderness, and or fever should be treated as
though they have PID. The diagnosis is typically made by a speculum examination of the cervix
and digital examination of the internal reproductive organs. This is very uncomfortable for the
patient, is beyond the scope of practice of most wilderness EMS providers, would add little
useful information in the wilderness EMS context, and is not routinely recommended for the
diagnosis of gynecologic infections in wilderness EMS.
It is critically important to consider ectopic pregnancy when evaluating any female of
childbearing age complaining of pelvic pain. This is a potentially immediately life-threatening
condition that should warrant emergent evacuation. A negative urine pregnancy test makes the
diagnosis of ectopic pregnancy highly unlikely.

Treatment and Disposition

Treatment of GU infections is relatively less complex than pulmonary infections, and in general,
they are less likely to be the primary reason for wilderness EMS calls.

Basic Life Support

For some patients suffering lower UTIs, urination may be very painful. The pain from
uncomplicated UTIs may be alleviated somewhat with phenazopyridine. It is available over-the-
counter (OTC) under various names including Pyridium, Azo-Gesic, and Baridium. It works as a
local anesthetic to the lining of the urethra that can help relieve the symptoms of a UTI. It is
important to note that it will turn the patient’s urine a reddish-orange color. This may be the only
treatment needed for an uncomplicated UTI in a patient who will be able to access definitive
medical care within a day or two.
Without the ability to begin antibiotic therapy, BLS for more severe infections is supportive.
Patients should be hydrated by mouth and pain and fever should be controlled with OTC
medications such as nonsteroidal antiinflammatory drugs (NSAIDs) and acetaminophen. Perhaps
most important is recognizing the severity of the infection and recognizing patients who have the
potential to deteriorate. Although most GU infections are not rapidly progressive, patients who
do not have normally functioning immune systems such as transplant patients and patients with
HIV are at high risk of rapid decline. Once a patient develops unstable vital signs, it is very
difficult to manage them in the wilderness environment.

Advanced Life Support

Uncomplicated UTIs can be treated with oral antibiotics. Although antibiotic-resistant organisms
are common in some areas, most UTIs are caused by bacteria that are susceptible to cephalexin
(Keflex) or trimethoprim-sulfamethoxazole (Bactrim). Note that ciprofloxacin is no longer
recommended as a routine first-line antibiotic for uncomplicated UTIs by the Food and Drug
Administration due to side effects potentially outweighing benefits and by infectious disease
experts due to increasing resistance patterns.11,16 Nitrofurantoin (Macrodantin, Macrobid) is
recommended as first-line therapy; however, it is not a versatile medication, its use is limited to
the urinary tract, it is bacteriostatic rather than bactericidal, and it is ineffective at treating
pyelonephritis. For these reasons, it is of little utility for wilderness EMS unless already carried
by the patient or available in some other way than team-based antibiotic supplies. Patients with
mild symptoms and no signs of pyelonephritis may not need evacuation, and transport decisions
should be made accordingly. High resource utilization rescue operations involving aircraft or any
operation that puts the life or safety of rescuers in danger should be reserved for only the most
critically ill.
Pyelonephritis may also be treated with oral antibiotics. If the patient is able to tolerate pills
by mouth and the infection is early in its course, oral fluoroquinolones such as ciprofloxacin or
levofloxacin are first-line.17 In patients who show signs of severe pyelonephritis or are not able to
tolerate pills by mouth, ceftriaxone is recommended. A single 1 g dose can be given either
intramuscularly (IM) or IV, and is effective for up to 24 hours, at which point they could be
either redosed or switched to oral antibiotics.18,19
Patients with suspected gynecologic infections such as sexually transmitted diseases may be
treated with a single dose of ceftriaxone IM accompanied by daily doxycycline PO.20 If patients
have nausea and vomiting, premedication with antiemetics such as ondansetron—available as
disintegrating tablets (ondansetron ODT)—may help patients tolerate doxycycline, which can
cause GI upset on its own. If still unable to tolerate pills by mouth, or if the patient has high
fever, severe abdominal pain, more aggressive therapy is needed. These more severe infections
may be treated with IV gentamycin and clindamycin, if available.

Clinician
GU infections are unlikely to be a common reason for wilderness EMS missions. Based on the
clinician’s experience and comfort with treating GU infections, it may not be necessary to
evacuate patients with mild infections. Serious consideration should be given to local antibiotic
resistance when designing treatment protocols for GU infections. Although the Infectious
Disease Society of America (IDSA) recommends fluoroquinolones as first-line therapy for
pyelonephritis, depending on the local resistance patterns, it may be preferable to substitute a
first-generation cephalosporin such as cephalexin as oral therapy. Cephalosporins are also more
useful for treating skin and soft tissue infections. It would also be reasonable to limit the
complexity of the decision-making process and number of medications carried by treating all
complicated GU infections with IM ceftriaxone. Oral levofloxacin and/or clindamycin may also
be used.

Equipment Summary
Treatment of GU infections is primarily managed with antibiotics. Recommendations for
antibiotics are summarized in Table 20.2.3.

CLINICAL MANAGEMENT OF INFECTIONS OF THE SKIN

AND SOFT TISSUES
Identification
Skin and soft tissue infections are likely to be among the most common infections encountered
by wilderness EMS providers. They range in severity from very mild, superficial infections that
can be managed conservatively, to deep infections with abscess formation requiring surgical
intervention. Cellulitis is the infection of the dermis and underlying subcutaneous tissue. It
occurs when bacteria are able to breach the skin’s defenses by entering through a break in the
skin. Insect bites, scrapes, lacerations, or minor trauma to the skin open a pathway for bacteria to
invade. Scratching from itchy rashes such as poison ivy, hives, or eczema can also open a
pathway for bacterial invasion. Cellulitis most commonly occurs on the lower extremities and
patients with poor circulation and diabetes are at much higher risk for severe infections.21 The
bacteria that are the usual culprits in cellulitis are normal skin flora. Streptococcus is the most
common bacterium, followed by Staphylococcus aureus. Methicillin-resistant Staphylococcus
aureus (MRSA), once limited to hospital-acquired infections, is becoming more common in
cellulitis acquired in the community, including the wilderness.22

Table 20.2.3 Suggested Antibiotics

Recommended Antibiotics for GU Infections in the Wilderness
Lower UTI: no fever, no back pain
BLS: Phenazopyridine 190 mg TID for 2 d
ALS: Trimethoprim-sulfamethoxazole 1 DS tablet PO BID for 3 d
OR if allergy to sulfa-containing drugs
• Cefalexin 500 mg PO TID for 3–5 d
Pyelonephritis
• Trimethoprim-sulfamethoxazole 1 DS tablet PO BID for 14 d
OR if allergy to sulfa-containing drugs
• Cefalexin 500 mg PO TID for 14 d
OR if not tolerating PO medications or signs of severe infection
• Ceftriaxone 1 g IV/IM daily
Suspected GU infection
• Ceftriaxone 250 mg IM once
AND
• Doxycycline 100 mg PO daily

Adapted from IDSA recommendations for treatment of cystitis and pyelonephritis in Gupta K, Hooton TM, Naber KG, et al.
International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010
update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin
Infect Dis. 2011;52(5):e103-120, by permission of the Infectious Diseases Society of America.

Cellulitis is diagnosed by physical examination. The skin will appear red (erythema), feel
warm to the touch, and be firm (indurated) and painful if palpated. Foreign bodies such as
splinters can serve as a source of infection, as is common on the hands and feet. Patients with
cellulitis and a history of trauma suggesting a foreign body may be present should be carefully
examined.
Abscesses are formed when bacteria invade deep into the skin and form a collection of pus in
the subcutaneous tissue. They have the appearance of cellulitis, but have raised areas that are
movable and compressible when palpated. This is called fluctuance. Some abscesses will
spontaneously drain pus. A rim of cellulitis usually surrounds an abscess. It may be difficult to
distinguish abscess from cellulitis. Deeper abscesses may not raise the skin as much as
superficial abscesses. Both may be associated with painful, swollen lymph nodes near the
infection. Fevers and chills are not normally caused by simple cellulitis or abscess, so its
presence should warn the provider that the bacteria may have spread to the bloodstream, and
should be considered an emergency. Red streaking which tracks centrally is a warning sign of
progressing infection, and these infections should be considered severe.
If the distinction between abscess and cellulitis is unclear and the infection is a safe anatomic
location (generally not on the hands, face, abdomen, or over joints), the provider could attempt to
aspirate its contents with a sterile needle. The return of pus would confirm it is an abscess;
however, the lack of pus does not exclude it, as the needle may have missed the fluid collection,
or the pus may have been too thick to pass through a small needle. Ultrasound is still uncommon
in traditional EMS; however, its use is being investigated, and U.S. military physicians have used
it in the field for years.23,24 Technology advances are making ultrasound portable and inexpensive
enough that it could serve as a valuable tool for wilderness EMS providers in the future.
Ultrasound can be useful in the diagnosis of cellulitis and abscess. Cellulitis has a characteristic
appearance of “cobblestones” on ultrasound, while an abscess will appear as a discreet, dark
fluid collection (see Figures 20.2.3 and 20.2.4).

FIGURE 20.2.3. An abscess is characterized by a discrete anechoic (dark) area. Courtesy of Dr. Casey Glass.
FIGURE 20.2.4. Cellulitis has the appearance of “cobblestones” on ultrasound. Courtesy of Dr. Casey Glass.

Traumatic injuries such as lacerations, avulsions, and open fractures are at high risk of
becoming infected in the wilderness. Patients with large traumatic wounds that develop foul
odor, begin draining pus, or develop signs of cellulitis on the surrounding skin that should be
monitored carefully and treated aggressively. Basic wound care is the mainstay of management,
but even under the best circumstances, approximately 1% to 12% of all wounds will become
infected.25
Soft tissue infections occurring in certain areas are of special concern. Infections of the hands
are at risk of progressing quickly and causing loss of function. They should be considered a
surgical emergency, because infections can quickly spread to deep structures, and often require
emergent surgery to prevent permanent disability. Rapid progression of swelling and pain,
numbness, or loss of function (particularly pain with flexion of the fingers) should trigger
emergent evacuation. Cellulitis surrounding the eye has the potential to quickly invade the orbit,
the space surrounding and behind the eye. Orbital cellulitis is characterized by signs of cellulitis
on the face surrounding the eye, accompanied by pain with eye movements. Because of the
anatomic structure of the orbits, there is a serious risk of spread of infection to the brain, loss of
vision, and stroke. Any patient with signs of cellulitis near the eye should be considered at risk of
progression to orbital cellulitis.

Treatment and Disposition

Basic Life Support
The fundamental treatment for all skin and soft tissue infections is primarily good wound care.
Fresh wounds should be cleaned with soap and potable water. It is unnecessary to carry sterile
saline for wound care and irrigation, as potable water has been shown to be equally effective at
reducing infection rates.26 High pressure and a high volume of fluid should be used.27 Simply
pouring water over the wound is inferior to pressurized irrigation of grossly contaminated
wounds.28 Adequate pressure may be generated using a 20 mL syringe with an 18g angiocatheter
attached. The goal should be to remove as much contaminated material and organic matter as
possible. Wounds should be dressed with clean dressings and kept clean and dry. There is no
evidence that any particular type of dressing is superior for reduction of infection, so dressings
should be made from whatever is most practical to carry and will be easy to apply and
remove.29,30 Antibiotic ointment is a versatile and useful medication for preventing skin and soft
tissue infections. Generally, wilderness medicine authorities recommend bacitracin alone or
bacitracin/polymyxin B (Polysporin) is preferable to “triple antibiotic” ointments such as
bacitracin/polymyxin B/neomycin (Neosporin) due to allegedly frequent allergies to
neomycin.31,32 When applied to areas of skin breakdown such as burns, lacerations, or other
wounds, it provides a physical barrier and prevents bacterial growth. It also serves to keep the
wound moist, which has been shown to aid in wound healing.33,34 When unavailable, wet-to-dry
dressings, moistened with potable water is an acceptable alternative.28
When cellulitis or abscess is suspected, the edges of the area of induration and erythema
should be marked with a pen, and the time noted. This will help identify the rate at which the
infection is spreading. The area should be elevated if possible. This will aid in the reduction of
swelling and will help drain inflammatory substances from the area of infection. NSAIDs such as
ibuprofen and naproxen can help control associated pain. Warm compresses may be applied to
the area of infection to reduce pain and inflammation.
Patients with high-risk wounds (around the eyes or on the hands) should be evacuated
rapidly. Patients with open fractures in the wilderness are at high risk of serious infections due to
the degree of wound contamination. Open fractures should be irrigated, debrided of as much
foreign material as possible, dressed with moist dressing material, splinted, and kept as clean as
possible.

Advanced Life Support

Antibiotic therapy is critical in the treatment of skin and soft tissue infections; however, there is
no evidence to support using them prophylactically except in cases of several particular types of
wounds. All mammalian bites to the hand, open fractures, and any human bites should receive
prophylactic antibiotics. Amoxicillin-clavulanate (Augmentin) is the first-line antibiotic for
human and all mammalian bites in usual practice. In order to limit the number of antibiotics
needed in your team’s pack, a combination of clindamycin and either ciprofloxacin or
trimethoprim-sulfamethoxazole is also suitable. Simple open fractures are often treated with
cefazolin (Ancef) in the hospital setting, but clindamycin and ceftriaxone are more effective for
contaminated, high-grade open fractures, and have the advantage of also being more versatile
drugs. Clindamycin and ceftriaxone can both be given IM, and there is no evidence to suggest
that the IV route is superior.
Uncomplicated cellulitis is treated with oral antibiotics that cover the bacteria most often
implicated in skin infections: Streptococci and Staphylococci species, including MRSA. Oral
clindamycin or trimethoprim-sulfamethoxazole are appropriate for mild and uncomplicated
cellulitis; however, emergent treatment is not necessary unless there will be a very prolonged
time to definitive care. Intramuscular or IV clindamycin may be used to treat patients with high
fever, nausea and vomiting, abnormal vital signs, signs of progressive cellulitis, and signs of
infected traumatic wounds. Cellulitis around the eye should also be treated aggressively with
IM/IV clindamycin. If orbital cellulitis is suspected (pain with movement of the eye associated
with cellulitis around the eye), high-dose ceftriaxone (2 g) should be given IM or IV (Figure
20.2.5). If oral antibiotics are the only option, amoxicillin/clavulanate or ciprofloxacin may be
substituted.35

FIGURE 20.2.5. Ceftriaxone and clindamycin are useful antibiotics for wilderness EMS and may be given either IV or IM

Clinician
If familiar with the procedure, incision and drainage can provide definitive treatment of
cutaneous abscesses. If performed with adequate local anesthesia, it can provide considerable
pain relief to the patient and may allow them to participate more in their own evacuation.
Although debated, there is some evidence of benefit to antibiotics following incision and
drainage for uncomplicated abscesses,36 and this benefit may be even more pronounced in the
wilderness EMS environment where wound cleanliness may be much harder to maintain than the
average population.

Equipment Summary
Traumatic injuries and infections of the skin and soft tissues are common in the wilderness.37
Access to potable water is important for team and patient well-being. It can be used for hydration
as well as to clean dirty wounds. Needles, syringes, and IV catheters are common equipment
needed for fluid and medication administration, and can be used for wound irrigation as well. A
20 mL syringe attached to an 18g plastic IV catheter is capable of producing the high-pressure
stream of water needed for effective wound decontamination, and is far superior to low-pressure
irrigation that can be generated by poking holes in bags and bottles. A splash shield to protect
providers from body fluid exposures can be fashioned from a plastic bag (Figure 20.2.6).
It is important to carry adequate materials for dressing wounds. While no particular type of
wound dressing has been found to be superior for preventing infection, several particular
materials are well suited to the wilderness environment.22 A supply of antibiotic ointment will be
very useful for open wounds, burns, or as a lubricant for areas of skin breakdown. Petrolatum-
impregnated gauze (Xeroform) is useful for keeping wounds moist and preventing dressings
from adhering to the wound, but can be substituted by generously applying antibiotic ointment to
regular medical gauze. Non-adherent, absorbable dressing material (Telfa) is also useful for this
purpose. Elastic self-adherent wrap (Coban) is also very useful in the wilderness. It is able to
stick to itself and does not require adhesion to the patient, which is beneficial if the patient is
sweating or dirty. It also provides a good barrier to keep the wound clean.

FIGURE 20.2.6. 20 mL syringe with 18 g angiocatheter for irrigation, shown with improvised splash shield

A summary of antibiotics for skin and soft tissue infections is included in Table 20.2.4.

Table 20.2.4 Suggested Antibiotics for Skin and Soft Tissue Infections
Recommended Antibiotics for Skin/Soft Tissue Infections in the Wilderness
Cellulitis with or without abscessa
• Clindamycin 450 mg PO three times daily
OR if allergy to macrolide (clindamycin [Cleocin], erythromycin, azithromycin [Zithromax])
• Trimethoprim-sulfamethoxazole DS 2 tablets twice daily
If Signs of Systemic Infection (fever, abnormal vital signs, signs of poor perfusion)
• Clindamycin 600 mg IV/IM every 8 h
Open fractures
• Ceftriaxone 1 g IV/IM daily
OR if allergy to cephalosporin (ceftriaxone [Rocephin,] cephalexin [Keflex])
• Ciprofloxacin 400 mg IV/IV every 12 h
Special situations
Cellulitis around the eye (possible orbital cellulitis):
 • Clindamycin 600 mg IV/IM every 6 h OR if signs of orbital cellulitis—Ceftriaxone 2 g IV/IM daily
All human bites and all mammalian bites of the hands:
• Amoxicillin/clavulanate 875 mg PO twice a day
OR
• Clindamycin 450 mg PO twice a day PLUS EITHER
• Ciprofloxacin 500 mg PO twice a day OR
• Trimethoprim-sulfamethoxazole DS 1 tablet PO twice a day

aIncision and drainage is first-line treatment, if feasible

CLINICAL MANAGEMENT OF GASTROINTESTINAL

INFECTIONS

Identification
Patients with GI infections complain of any combination of nausea, vomiting, diarrhea,
abdominal pain, and fever. These infections are common, and usually due to viral or bacterial
infection of the GI tract, or from bacterial toxins in contaminated food. It is important to
distinguish nausea and vomiting due to GI infection from nausea and vomiting that may be
symptoms of other serious illnesses. Myocardial infarction, head trauma, meningitis, bowel
obstruction, and many other emergencies may cause nausea and vomiting and should be
considered based on the clinical history.
Acute gastroenteritis is one of the most common causes of acute vomiting and diarrhea in
otherwise healthy patients. Patients will have an acute onset of nausea and vomiting with or
without diarrhea. The course of the disease is usually self-limited, but patients are at risk of
becoming dehydrated. Many of the pathogens responsible for gastroenteritis are very contagious,
and are spread through fecal-oral contamination. Several patients with the same symptoms who
are traveling together is suggestive of infectious gastroenteritis. Patients will typically develop
symptoms 12 to 24 hours after being exposed to the pathogens either in food or through contact
with an infected person. (Note that this is much longer than many non-health care providers
understand, and many will look to a meal they just ate as the source of an infection, rather than
one 12 to 24 hours earlier.) Hand hygiene, especially when preparing food, is important to
prevent the spread of infection. More than one patient with an onset of nausea and vomiting
within 6 hours of the ingestion of shared meal is suggestive of contamination with the toxins
produced by S. aureus or Bacillus cereus. The bacteria grow and release toxins in the food, and
even though cooking kills the bacteria, heat does not destroy the toxins they produce. Improper
food storage and lack of refrigeration are usually to blame. Typically symptoms caused by these
toxins are rapid in onset and violent, but do not last very long, as there is no ongoing toxin
production or infection.
Diarrhea caused by GI infections is usually loose or watery in character, but can be bloody
(the definition of dysentery) or contain pus and mucous. For wilderness EMS, it is sufficient to
classify diarrhea as either watery or bloody in order to appropriately treat. Large amounts of
bright red blood per rectum are uncommonly due to infectious etiologies and should prompt the
clinician to consider other causes of GI bleeding. Bloody diarrhea associated with abdominal
pain and fever is suggestive of a bacterial, as opposed to viral, etiology of infection.
Abdominal pain is common with GI illness. Retching and vomiting strains the abdominal
muscles, and can lead to abdominal pain and soreness, usually worse with stretching of the
abdominal muscles. The pain associated with uncomplicated infections is usually mild.
Symptoms of GI infections accompanied by fever, severe abdominal pain, or significant
tenderness with rebound or involuntary guarding are signs of serious infection or a surgical
emergency.

Treatment and Disposition

Basic Life Support
The primary complication of acute GI infections is dehydration and hypovolemia, resulting from
nausea, vomiting, and diarrhea. This can be exacerbated in the wilderness by exposure to heat
and high levels of activity that leads to further fluid loss. Patients who are mildly dehydrated will
have increased thirst, fatigue, and strong-smelling, concentrated, dark urine. Patients who are
moderately dehydrated will have dry mouth and mucous membranes, mild tachycardia,
decreased urine output, and poor skin turgor. Patients who are severely dehydrated will have
signs of poor perfusion, weak pulses and mottled skin, lethargy and altered mental status.
Oral rehydration is the most important therapy in the treatment of acute GI illness. Patients
with acute diarrhea who have not yet developed signs of hypovolemia should be encouraged to
drink plenty of fluids to prevent dehydration. Plain water is acceptable, but sugar-salt solutions
are absorbed far more easily, and while not as necessary when the patient is not yet hypovolemic,
become critical as the severity of dehydration worsens.38–40 In the United States, oral rehydration
is underutilized, and many providers will move quickly to IV therapy, when in reality, oral
rehydration could prevent thousands of hospitalizations annually.41 Oral rehydration solutions
(ORS) contain salt and sugar that aid in the transport of water across the cell membrane in the
small intestines thorough the activation of special transport channels. Sports drinks such as
Gatorade are intended for use as sweat replacement, and are not as effective as rehydration
solutions in patients who are dehydrated.42 The World Health Organization (WHO) recommends
an ORS containing the following per liter of water:

3.5 g sodium chloride (salt)

2.5 g sodium bicarbonate (baking soda)
1.5 g potassium chloride (sodium-free salt substitute)
20 g glucose or 40 g sucrose (table sugar)

A similar, somewhat easier solution can be made with one-half teaspoon of salt, one-half
teaspoon of baking soda, and four tablespoons of sugar per liter of water.43 Patients who have not
yet developed signs of severe dehydration should be given ORS after each loose stool. Patients
who have developed signs of severe dehydration should be given 2 to 4 L of ORS in the first four
hours, unless they are unable to safely drink due to decreased level of consciousness or inability
to drink.
Although controversial, patients with acute-onset watery diarrhea can be treated with
loperamide (Imodium) to reduce the volume and frequency of loose stools by decreasing GI
motility and can significantly decrease the length of diarrheal illness.44 Loperamide should not be
given to patients who have fever or bloody diarrhea,44–47 and in general, is best reserved for those
situations where frequency of bowel movements is dangerously impairing rescue operations or
patient movement. While generally thought to be helpful, there is some risk that actual losses are
masked, as the stool may pool in the intestines, as well as dangers of causing toxic megacolon
and other serious side effects.46 The dose of loperamide is 4 mg initially then 2 mg after every
loose stool, up to a maximum of 16 mg/d. Control of severe diarrhea is helpful in the wilderness
EMS context because with oral rehydration and reduction in the frequency of bowel movements,
a patient may be able to ambulate and expedite his or her own evacuation. It is also important to
note that loperamide abuse has been reported, and a recent trend toward increasing misuse and
abuse has been epidemiologically identified.48–50 Given its overall poor efficacy for acute
diarrhea and potential for harm or abuse, it is rarely indicated in WEMS care.

Advanced Life Support

Sometimes patients are unable to tolerate oral rehydration simply due to severe nausea and
vomiting. Oral antiemetics such as oral disintegrating ondansetron (Zofran ODT) can prevent the
need for IV placement in this case. Tablets are of less utility if the patient has refractory
vomiting. Often after giving one or two doses of antiemetic, patients will be able to tolerate oral
rehydration. It may be appropriate to add this medication to the kits of BLS providers due to its
good safety profile and its ability to prevent progression toward severe dehydration in patients
with persistent vomiting.
Patients who are severely dehydrated with altered mental status, weak pulses, and/or who
cannot tolerate oral rehydration despite antiemetics should be rehydrated with IV fluids. Neither
lactated ringers nor normal saline has proven to be superior, so either fluid is appropriate. Large
volumes of fluids will be needed to resuscitate the truly hypovolemic patient. Over the first 30
minutes patients should receive 30 mL/kg (approximately 2 to 3 L for the average size adult).
Thereafter, fluids should be slowed and titrated to patient response. As volume status improves,
tachycardia will improve, and urine output will increase. IV fluids are heavy and will be in
limited supply, so patients should be encouraged to drink ORS whenever they are safely able to
if their condition improves. Up to 10 L of IV fluids may be needed over the first 4 hours to
resuscitate a severely hypovolemic patient.

Clinician
Empiric antibiotic therapy is rarely indicated in acute GI infections. Patients who may benefit
from empiric antibiotics are those who are severely dehydrated due to watery diarrhea, and who
are likely to need hospitalization.51 Some wilderness protocols suggest empiric antibiotics for
dysentery (bloody diarrhea) associated with fever and abdominal pain, as they are more likely to
be bacterial.52 It is important to consider that patients infected with enterohemorrhagic
Escherichia coli O157:H7 have an approximately 25% increase in risk of hemolytic uremic
syndrome with antibiotic therapy.53 For this reason, clinical judgment and experience should
guide the decision to begin empiric antibiotics, which is one important reason to limit antibiotic
administration to the clinician category of WEMS provider rather than the ALS category.
Ciprofloxacin 500 mg PO twice a day is the drug of choice for empiric coverage of most culprit
bacterial pathogens. Metronidazole (Flagyl) 500 mg PO three times a day can be added if
available, and acute intraabdominal infection such as bowel perforation, diverticulitis, or other
infection leading to peritonitis is suspected.

Equipment Summary
An abundant supply of ORS is important for the care of patients with GI illness. Packets are
available commercially, or can be made from readily available ingredients, premixed, packaged
into zip-top bags or other containers and added to water on-site. Some means for disinfecting
water in the field is critical as well. The simplest method is boiling. Boiling water for 10 minutes
was widely reported and previously recommended for disinfection. This is time-consuming and
uses a considerable amount of fuel. The WHO now recommends that any water brought to the
boiling point should be safe to drink.54 In order to add an extra margin of safety, the Centers for
Disease Control recommends boiling for 1 minute.55 Boiling for a margin of time after boiling
point also can account for altitude changes, as water boils at a lower temperature at higher
altitudes. A multitude of systems are available commercially at outdoor outfitters that are small,
lightweight, and are effective at removing or killing pathogens in water. Filter systems are
convenient because they produce water that is safe to drink immediately. However, they are
bulky and require significant effort to pump large volumes of water through the micro filters.
They are also susceptible to damage in cold weather. As water trapped in the filter freezes, it can
cause serious damage. Iodine and sodium hypochlorite tablets and solutions are commonly used
and are a great backup to filters, but require at least 30 minutes of contact time in clear, warm
water, and up to an hour with turbid water or cold water. It is important to note that ORS or any
other additives should not be added to the water until it has had sufficient contact time to kill any
pathogens, as the additives may inactivate them. They do have the advantage of being small and
lightweight, and can treat large volumes of water at a time without much energy expenditure.
They can leave an unpleasant taste to water that may discourage patients from drinking it.
Ascorbic acid tablets are often sold with iodine tablets, or small amounts of sports drink powders
can be added to improve the taste as well. Other methods of water purification for backcountry
travel are available including devices that use electrolysis or ultraviolet light to purify water,
such as the SteriPen. Strategy for water treatment should take into account likely infective
organisms, personal taste, group size and carrying/weight capacity, location, and available fuel.56
At 1 kg (2.2 lb) per liter, carrying large volumes of IV fluids may not be practical for a small,
fast moving team traveling on foot. Ten liters of IV fluids may be needed for a severely
hypovolemic patient, and would add approximately 22 lb in weight to a pack. But if information
about patient condition is available prior to responding, it may be wise to take a large volume of
IV fluids, which can be split among team members. Likely in this case, other equipment that may
not be needed could be left behind in its place.

CLINICAL MANAGEMENT OF CENTRAL NERVOUS

SYSTEM INFECTIONS

Identification
Meningitis is the infection of the coverings of the brain and spinal cord. It can rapidly progress to
encephalitis, or the infection of the brain tissue itself. Bacterial meningitis typically has an abrupt
onset and progresses rapidly, and can be fatal within 24 to 48 hours of symptom onset without
treatment. Viral meningitis usually is less severe, with a more gradual onset of symptoms, and
rarely causing death or severe disability. Even with treatment, patients with acute bacterial
meningitis may have lifelong disability. Patients with meningitis classically present with fever,
headache, neck stiffness, and altered mental status. One or more of the classic symptoms may be
absent, and in one study, only 44% of patients who were diagnosed with bacterial meningitis had
all four classic findings.57 Nearly all patients will have a fever, so its absence essentially excludes
the diagnosis. Difficulty flexing the patient’s neck on exam (nuchal rigidity) is present 88% of
the time, and altered mental status (usually lethargy, but some will be only responsive to painful
stimuli) is present in 78%.58 Patients may have other neurologic abnormalities such as loss of
balance (ataxia), seizures, or nystagmus. Some patients with bacterial meningitis will develop a
rash that usually begins as small petechiae on the trunk and lower extremities, and can progress
to large, firm, purple lesions known as purpura (Figure 20.2.5). The incidence of bacterial
meningitis is rare, but its early recognition and treatment is so critical that wilderness EMS
providers should be aware of it and prepared to treat it if encountered.

Treatment and Disposition

Basic Life Support
Recognition of patients at risk for meningitis is critical. Patients have the potential to rapidly
deteriorate and may die within 24 to 48 hours of symptom onset. If meningitis is suspected,
patients should be monitored closely for deterioration in mental status and evacuated emergently.
Bacterial meningitis is contagious, and providers should wear a mask and use standard body
substance isolation (BSI) precautions.

Advanced Life Support

If the provider suspects a patient may be suffering from bacterial meningitis, prompt
administration of antibiotics is critical. If the patient has all four classic findings of meningitis
(headache, fever, neck stiffness, altered mental status), meningitis should be presumed and
treatment started if this is permitted under local protocols. Patients with very mild symptoms and
with only fever and headache with or without mild sensation of neck pain or sore throat may be
suffering from any number of viral illnesses and may be managed supportively and monitored
for progression.
IV ceftriaxone should be given in a dose of 2 g, which is higher than the dose used for most
other infections. Ceftriaxone is commonly given IM in pediatric patients for meningitis, although
it is not recommended in adults. Ideally IV steroids should be given prior to antibiotics to
prevent neurologic complications. Dexamethasone (Decadron) is the most studied medication,
and should be given at a dose of 10 mg 15 to 20 minutes prior to the administration of
antibiotics. Methylprednisolone (SoluMedrol) may be more commonly carried, and would offer
the same theoretical benefit.59

Equipment Summary
Meningitis and CNS infections, while uncommon, are among the most serious emergencies that
wilderness EMS providers may encounter. Recognition and rapid evacuation is paramount and
carrying ceftriaxone and potentially a glucocorticoid steroid such as dexamethasone or
methylprednisolone can allow for early treatment of presumed cases. These are highly useful
medications to carry, as they may be used for a multitude of other illnesses.

CLINICAL MANAGEMENT OF SEPSIS

Identification
One of the most feared complications of routine infections is sepsis. The definition of sepsis has
evolved over the years, but currently is defined as any life-threatening organ dysfunction caused
by dysregulated host response to an infection. This may result from the spread of bacteria from
local tissues into the blood, but sepsis also can result from inflammatory substances released by
severe local infections of any organ system. Patients with sepsis have a suspected infection of
any type and present with the following features:

Fever (temperature >38.9°C [101°F])

Tachypnea (rate >20)
Tachycardia (rate >100)

Sepsis can lead to shock, which is a state of poor perfusion of the tissues and organs, and
recognizable by the following features:

Altered mental status

Decreased or absent urine output
Pale skin with slow capillary refill (>2 seconds)
Low blood pressure (<90 systolic blood pressure [SBP] or <70 mean arterial pressure)

There are a few important points to consider when assessing patients in the wilderness
environment for signs of poor tissue perfusion (hypoperfusion). First is that exposure to a cold
environment causes shunting of blood to the core and away from extremities and the skin.
Prolonged capillary refill time is expected when anyone is exposed to the cold, and should not be
considered a sign of hypoperfusion in a cold environment. It has been taught for many years that
SBP can be accurately estimated based on the presence or absence of radial, femoral, and carotid
pulses. Recent studies have shown that these recommendations grossly overestimate SBP.60
There is no evidence that the presence of a radial pulse equates to SBP greater than 90 mm Hg,
femoral pulse 70 to 80 mm Hg and carotid 60 mm Hg. Relying on these estimates for
reassurance that a patient is not hypotensive may allow hypotension and shock to go
unrecognized. On the other hand, absence of a femoral pulse would be an indication of critical
hypotension, and absence of a carotid pulse would be an indication for cardiopulmonary
resuscitation in an unconscious patient.

Treatment and Disposition

Basic Life Support
Sepsis and septic shock are deadly, and have a high mortality if treatment is not aggressive and
early. Early recognition of abnormal vital signs and signs of shock are critical for wilderness
EMS providers. Patients with unstable vital signs and suspicion for sepsis should be evacuated
rapidly while supporting the patient’s airway, breathing, and circulation. Patients with sepsis are
at greater risk of environmental exposure, and care should be taken to protect them from the
elements.

Advanced Life Support

Patients with sepsis benefit from early administration of IV fluids and antibiotics. As soon as a
provider recognizes warning signs of sepsis, IV fluids should be started as soon as is feasible.
Certain operational environments may make this impractical, but if possible, patients should
receive 30 mL/kg of IV crystalloid fluids (2 to 3 L for the average size adult), ideally at a rate of
1,000 mL/hour. Some patients may be profoundly dehydrated due to increased metabolism due
to infection and environmental exposure, so larger volumes may be necessary if heart rate and
blood pressure do not improve. Broad-spectrum IV antibiotics should be started as soon as
possible that are directed at the suspected source of infection. A key element to the hospital-
based diagnosis of sepsis is measurement of serum lactate. Out-of-hospital protocols have been
developed that utilize point of care testing of lactate; such tools might be equally or more
efficacious in a wilderness out-of-hospital environment.61

Clinician
Since the groundbreaking research from Emanuel Rivers in the early 2000s revolutionized the
care of sepsis patients with early goal-directed therapy (EGDT), the focus in sepsis care has been
to optimize oxygen delivery to the tissues. It has relied on monitoring of central venous pressure,
potential administration of vasoactive medications, blood transfusion, and central venous oxygen
saturation monitoring, along with large fluid boluses.62 Since its introduction, subsequent
research suggests that three aspects of EGDT seem to make the biggest difference in sepsis
morbidity and mortality: early recognition, early IV fluid resuscitation, and early antibiotics. The
remainder of the EGDT recommendations, including sophisticated monitoring, vasoactive
medications, and blood transfusions may not improve outcomes at all.63–66 This has a particular
impact on wilderness care for patients with sepsis. Although this might surprise some hospital-
based or traditional EMS providers, it is clear that the most important aspects of sepsis care are
possible in the wilderness environment with specially trained teams and only a modest amount of
equipment.

PREVENTING THE TRANSMISSION OF INFECTIOUS

DISEASE
Despite having somewhat limited resources available, wilderness EMS providers must be
prepared to keep themselves and their patients safe from transmission of infectious disease. BSI
precautions should be observed at all times. Although the greatest risk of transmission of disease
is through blood exposure, all body fluids should be considered potentially infectious. Latex or
non-latex gloves are standard precautions to prevent transmission of blood-borne pathogens
when providing patient care in any environment, and should be carried in sufficient quantities.
When selecting gloves, durable models with textured fingers will help handing zippered bags,
gear, and the abuses of the wilderness environment. Brightly colored gloves are more visible and
are less likely to be left behind on scene, lessening the environmental impact. Although not ideal,
gloves can be disinfected and reused by simply dropping into a water bottle full of a dilute
bleach solution for 10 minutes, and allowed to dry.67 When there is a risk of splashing body
substances, face and eye protection is needed. Face shields and masks can be carried; however, if
unavailable, sunglasses, protective snow goggles, or eyeglasses do provide protection. Gowns
provide an impermeable barrier to protect providers; however, they are impractical for the
wilderness operational environment. Technical outdoor clothing that is designed to be water
resistant or waterproof, such as rainwear, is a practical alternative, and should already be carried
by providers. In patients whom respiratory droplet protection is required, commercially produced
masks are preferable. They are small and lightweight, and should be included as standard
personal protective equipment. If unavailable, a bandana or handkerchief worn over the face can
be substituted.

SUMMARY
Treatment of infectious disease is not usual care in traditional EMS, but the potential benefit of
early treatment makes it worthy of consideration in the right wilderness EMS environment.
Depending on the operational environment, a modest pharmacy of antibiotics, coupled with
training in identification and discrimination of various infectious conditions, allows wilderness
EMS providers to provide early treatment for a wide array of common and potentially life-
threatening infections.

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INTRODUCTION
The management of trauma in the out-of-hospital environment involves rapid identification and
stabilization of life-threatening injuries followed by transport to the closest, most appropriate
facility. In the typical emergency medical services (EMS) system, transport of trauma patients to
definitive care within 1 or 2 hours is often feasible either by ground or air transport. In the
wilderness setting, delayed patient access, limited resources, and prolonged transport times
present unique challenges to the out-of-hospital provider. Complications of traumatic injury that
are not typically seen in the traditional EMS setting might not only be encountered in the
wilderness EMS (WEMS) setting, but might also prompt intervention given the delay to
definitive care in ways not seen in traditional EMS. Fractures and dislocations may require
reduction, open injuries may require antibiotic coverage, and tourniquets may need to be
converted, all outside of the hospital.
Another challenging aspect of WEMS trauma care involves patient transport. Traditional
EMS transport decisions revolve around the need for emergent transport or routine transport, the
need for transport to a trauma center, and whether air resources are needed to facilitate that
transfer. Patient transport in WEMS, however, must take into account not only patient condition,
but also the safety of rescuers, resources available, and terrain/environmental considerations. For
example, fully immobilizing an otherwise ambulatory patient may pose significant risks to both
the patient and the rescuers due to hazardous terrain or impending inclement weather. The risk of
further harm to the patient or team members with little documented benefit of immobilization
favors having the patient assist in self-evacuation.
In traditional EMS, the provider usually makes patient contact with a full set of EMS
equipment on their person or nearby in a response vehicle (ie, ambulance). In the WEMS setting,
however, the first EMS providers making contact with the patient may have only limited supplies
on hand, and therefore must decide how much medical equipment to carry as hasty teams and
how to initially manage potentially severely patients with their limited supply. In other
situations, however, the patient’s location and general status is known and a team can deploy
with a relatively complete medical kit and resources required for transport.

Scope of Discussion
The purpose of this chapter is not to provide a comprehensive resource in the management of
trauma, but to provide a framework with which to approach and manage patients with traumatic
injuries, to cover injuries most likely to be encountered by a WEMS provider, and to highlight
areas where patient care may differ from traditional EMS care. It is assumed that the reader has
some prior training in out-of-hospital emergency care, and this chapter is intended to serve as a
reference for such responders who will be providing care in a wilderness environment. Many of
the existing wilderness medicine texts regarding trauma discuss considerations of evacuation
versus continuing the wilderness activity. In the context of this book, it is assumed that the
patient is being evacuated and discussion will focus mostly on the urgency of evacuation and
field management.

EPIDEMIOLOGY
Incidence
Traumatic injuries are very likely to be encountered by the WEMS provider. Approximately 52%
of search and rescue (SAR) operations involve at least some traumatic injury,1–3 and is actually
the cause of SAR operations in approximately 28% to 51% of cases.1,3,4 Data from state and
national parks show that the incidence of injury or illness in the wilderness is approximately 1.3
to 9.2 per 100,000 visitors,5,6 and data from the NOLS showed an injury rate of approximately
1.07 to 2.3 per 1,000 person-days during their activities.7,8 Males typically account for the
majority of injured patients in the wilderness, with percentages ranging from 55% to 66.7% of
injuries.1–3,5,6,9 It is unclear if this reflects a higher rate of participation, a higher rate of risk-
taking, or a higher rate of injury. Limited data published by NOLS showed a slightly higher rate
of injury in female participants compared to men, but a similar rate among male and female
instructors.7

Mechanism of Injury
The mechanism of injury and injury pattern varies by the activity being undertaken by the
patient. General data show that the most common mechanism of injury in the wilderness setting
is slipping or falling (42% to 70%),1,2,4,5 and the most commonly injured body part is the lower
extremity (38% to 56%).6–8 The most common injuries are soft tissue (10% to 49%)1–3,5–8 and
musculoskeletal injuries (28% to 82%).1–3,5–8 In contrast, upper extremity injures predominate in
kayaking with 5% to 15% of injuries involving shoulder dislocations.10 Similarly, while earlier
studies suggested lower extremity injuries were more common in climbers and mountaineers in
general, more recent studies including sport climbers and boulderers as well as more traditional
climbers have shown that upper extremity injuries are the most common in climbing sports.11
The most common activity being undertaken at the time of injury is hiking (48% to 74%),
followed by activities that vary from park to park but include climbing, mountaineering, winter
sports, and water sports.1–5,8,12
The mechanism of injury is important to consider in the evaluation and management of
trauma patients. It can clue the provider into the most likely injury. Twisting motions on knees
and forced rotation on abducted arms are common mechanisms for dislocations, while direct
blows are more likely to cause fractures. With more severe mechanisms of injury, the provider
should have a higher suspicion for injury even in the absence of obvious external injuries.
The mechanism of injury may also clue the provider into certain patterns of injury. For
example, a patient who fell and has sustained what appears to be calcaneal fractures has a high
risk of concomitant pelvic and/or lumbar spinal fractures as force is transmitted up the axial
skeleton. Patients who fall landing on their sides and appear to have rib fractures may also have
significant risk of concomitant splenic or liver lacerations and subsequent hemorrhage.

CLINICAL MANAGEMENT

Prevention
A comprehensive review of injury prevention in the wilderness setting is outside the scope of
this text and relies on hazard recognition and mitigation. Information regarding safety and injury
prevention for most outdoor activities is abundant. In addition to books and online material,
many organizations actively promote safety for specific outdoor activities. The American Alpine
Club, for example, has published Accidents in North American Mountaineering annually since
1948 (although it was renamed Accidents in North American Climbing in 2016), which allows
readers to analyze many climbing incidents.13 The American Canoe Association also offers
multiple safety and rescue courses.
Fatigue often plays a role in injury, with most accidents (54%) occurring during the second
half of an activity.3–5,7,9 The second half of hiking, climbing, and mountaineering often includes
descent, where less ergonomic movements combine with previously mentioned fatigue resulting
in six times as many injuries occurring during descent as compared to ascent.4,5 It is important
while participating in wilderness activities (and rescues!) that participants be cognitive of fatigue
and the increased risk of injury as fatigue develops.

Identification
Examination of the trauma patient begins the moment visual and/or auditory contact is made
with the patient. The patient should be assessed for life-threatening hemorrhage, which should be
fairly obvious as the patient is approached. This should be managed immediately, but is usually
already accomplished prior to arrival of formal medical responders. The patient should then be
evaluated systematically to avoid missing any potentially life-threatening injuries. This exam is
traditionally split into primary and secondary surveys. The primary survey is performed rapidly
with the goal of identifying and treating any immediate life-threatening injuries while the
secondary survey is intended to be more thorough and to systematically evaluate the patient in
their entirety in order to identify all injuries.
The primary survey is easily remembered by the mnemonic ABCDE.
The provider should first assess the airway for patency, foreign body, injury, swelling, etc. If
the airway is not patent, corrective actions should be taken prior to continuing the primary
survey.
The next step is to assess breathing. The patient should be assessed for the presence of lung
sounds bilaterally, symmetry of chest excursion, and work of breathing. If the patient requires
assisted ventilation, this should begin as soon as possible.
The patient’s cardiovascular status should then be rapidly assessed by palpating pulses for
both strength and rate (determining an actual rate, or simply evaluating for excessively fast or
slow) and assessing his or her skin for capillary refill time. In certain situations, for example a
cold or wet environment, capillary refill can be unreliable as an indicator of cardiovascular
status.
Disability is then assessed by obtaining the patient’s mental status and assessing gross motor
and sensory function in all four extremities.
The trauma patient should then be exposed as much as possible to assess for traumatic injury.
In the wilderness environment, exposure should also include protecting the patient from
environmental exposure. Full exposure might not necessarily be practical in every circumstance,
as hypothermia is detrimental to the trauma patient. For example, removing a mountaineer’s
protective clothing could expose him or her to the elements and could actually cause harm.
Diligence should be taken to evaluate the patient in entirety as much as possible while protecting
him or her from the elements. The provider should also avoid cutting clothing in most wilderness
situations, as clothing may be technical and necessary for comfort and survival in the
environment for an extended period after the initial assessment.
In traditional EMS, a transport decision is made after the primary survey regarding rapid
transport with further evaluation and management en route to the hospital versus more extensive
evaluation on scene. In the wilderness setting, the primary survey will give the provider a general
impression of illness severity, but a secondary survey will still generally be performed unless
transport by ambulance or helicopter is immediately available and the patient is critical. The
primary survey will key the provider early into the urgency of evacuation and necessary
resources can then be summoned. While the primary survey is taught in a linear fashion, several
components can often be performed simultaneously. The provider can palpate a pulse while
talking to the patient, evaluating airway, breathing, circulation, and mental status all at the same
time.
The secondary survey includes a full set of vital signs. The patient is then systematically
assessed in a head-to-toe fashion for evidence of traumatic injury. See Table 21.1 for a list of
exam components by body part. With the exception of controlling hemorrhage, managing the
patient’s airway or breathing, or reassessing after a change in condition, every attempt should be
made to complete this examination uninterrupted, as it is easy to miss or skip part of the exam if
distracted.
Other pitfalls in examining a trauma patient include lack of exposure and not examining the
patient’s back. A wound on the posterior thorax, and possibly subsequent pneumothorax, would
easily be missed without moving the patient to examine his or her back. It is also easy to become
distracted by impressive-appearing injuries such as large open wounds or deformed extremities,
missing a more immediately life-threatening injury, and the provider must be diligent in not
becoming distracted by these injuries and focus on systematically evaluating trauma patients.

Table 21.1 Trauma Exam Components

Body Part Pertinent Exam Components
Head • Assess face and cranium for DCAP-BTLS
• Assess for fluid or blood from the ears or nose, raccoon eyes, Battle signs
• Assess eyes for pupillary response, extraocular motion, evidence of trauma, gross visual
function
 • Assess face for any mid-face instability or tenderness
• Assess jaw for any malocclusion, trismus, tenderness
• Assess mouth for any intraoral or tongue lacerations, loose or missing dentition
Neck • Assess for DCAP-BTLS, subcutaneous emphysema, jugular venous distension
• Assess posterior neck for any midline tenderness
• Assess range of motion
Chest • Assess for DCAP-BTLS, subcutaneous emphysema
• Assess bilateral lung sounds, equal and normal chest excursion
• Assess heart tones (muffled or clear)
Abdomen • Assess for DCAP-BTLS, guarding on examination
• FAST examination if ultrasound is available
Pelvis • Assess for pelvic stability and pain on testing
Back • Assess for DCAP-BTLS, flank hematoma
• Assess for midline tenderness to palpation
Rectal/GU • Examine perineum, rectum, and external genitalia for DCAP-BTLS
• Examine for rectal tone
Extremities • Examine for DCAP-BTLS
• Examine distal pulses in all extremities
• Examine range of motion of all joints
• Examine motor and sensory function in all extremities (see orthopedic section for further
details)

DCAP-BTLS, deformities, contusions, abrasions, puncture wounds, burns, tenderness, lacerations, swelling; FAST, focused
assessment with sonography for trauma; GU, genitourinary.

Conditions
Hemorrhage and Shock
The loss of blood from the body is referred to as hemorrhage. Hemorrhage may be very minor
and stop on its own or it can be significant and continue until a large quantity of blood is lost
from the body. Shock is defined as inadequate tissue perfusion and occurs when the circulatory
system fails to deliver adequate oxygen and other nutrients to tissues. The most common type of
shock associated with trauma is called hemorrhagic shock and results from the loss of a large
amount of blood or other body fluids. Hemorrhage can be massive, particularly if the injury
involves an artery. Shock can often be prevented or mitigated by controlling hemorrhage.
There are several techniques that can be used to control hemorrhage. In most cases, bleeding
can be controlled by firm and well-aimed direct pressure to the bleeding site. If this fails or is
inadequate, it has classically been taught that the next step should be elevation of the bleeding
site above the level of the heart followed by applying pressure to an artery proximal to the injury
followed by application of a tourniquet as the last resort. More recent military data, however,
have shown that tourniquets can be used safely for hemorrhage control with minimal adverse
effects.14,15 Many organizations now recommend application of a tourniquet if direct pressure
alone does not stop bleeding in an extremity, or immediately if bleeding is obviously arterial and
potentially life-threatening in its volume.15 Hemostatic dressings can also be very useful for
hemorrhage control as they promote coagulation in addition to providing a physical barrier.
The best treatment for shock is prevention. Hemorrhage should be identified early and
treated as detailed above. In some cases, hemorrhage can be brisk or the patient may not be
found until shock has developed. Look closely for signs and symptoms of shock. These include:

Cool and clammy skin

 Pallor (pale skin)
Rapid pulse
Rapid breathing
Nausea
Vomiting
Dilated pupils
Dizziness/fainting
Fatigue/weakness
Altered mental status

Any of these findings should increase your index of suspicion for shock. Once shock
develops, it may progress rapidly, making it important to intervene as soon as possible. As shock
worsens, the patient’s blood becomes more acidotic and coagulation factors do not work as well,
called coagulopathy, making it more difficult to stop bleeding. Summon any additional resources
available and provide basic first aid measures including control of hemorrhage and supporting
the airway, breathing, and circulation as needed. The patient should be protected from the
environment in order to minimize heat loss as hypothermia worsens coagulopathy. Plans should
then be made to extract the patient as quickly as possible to a higher level of care.
FIRST AID
The first step for any patient who has significant bleeding is hemorrhage control. In most cases,
bleeding will stop on its own with the application of a dressing and bandages to the wound.
However, in severe cases, especially those that involve arterial bleeding, pressure must be
applied to the bleeding area to control hemorrhage. In many instances once bleeding has been
controlled with compression, a pressure dressing and bandage can be applied. If bleeding
continues despite the application of direct pressure, consider a hemostatic dressing or tourniquet.
Studies have shown that many improvised tourniquets fail when loaded or take too long to
construct that they are not useful, and commercial tourniquets should be the part of medical kits
for wilderness responders. It is important to document the time of tourniquet application. Once
the tourniquet is applied, it should remain in place until the injury is evaluated by more
experienced providers.
Certain injuries may result in shock. Oftentimes the source of bleeding may not be readily
identifiable because it is covered with clothing or is internal. Any patient who sustained an injury
and who exhibits the signs or symptoms of shock should be considered to have shock until
proven otherwise. Following recognition or suspicion of shock, the patient should be placed in a
supine position. Although commonly practiced in the past, there is no evidence that elevation of
the feet and legs improves outcomes in patients who are in shock.16 It is best to place the patient
in a level position and protect them from the environment (eg, blankets, pillows). Initially, assess
the airway, breathing, and circulation, and provide any necessary interventions. Because shock is
a progressive process, it is important to continually reassess the patient’s condition including the
airway, breathing, and circulation to detect and intervene upon any deterioration noted. Care
should be continued until more advanced providers arrive. Patients in shock or who have
multiple injuries should be evacuated as soon as practical. Injured patients do better when cared
for in a trauma center that has significant resources and capabilities. Unfortunately, trauma
centers tend to be located in urban areas and some distance from more austere settings. A
community hospital or similar facility may be closer than a trauma center and it is often prudent
to first transport the patient there for stabilizing care and later transport to the trauma center if
necessary.
BASIC LIFE SUPPORT
Basic life support (BLS) providers should initially provide the same care as detailed above for
first aid providers. Depending on the equipment available, the patient should be prepared for
evacuation and transport to definitive care. Supplemental oxygen is likely beneficial to a patient
in shock, as they have decreased tissue oxygenation by definition. In patients with adequate
oxygen saturation who are not in shock, routine application of supplemental oxygen is unlikely
to provide additional benefit, and may actually cause harm through production of free radicals.17
It is important to remember that, in many cases, the definitive care for hemorrhagic shock may
be surgical and planning should be initiated to route the patient to the proper receiving facility so
that necessary emergency care can be provided as quickly as possible.
ADVANCED LIFE SUPPORT
Emergency personnel with advanced skill capabilities should quickly identify shock and plan for
subsequent care and disposition. Hemorrhage control, in addition to maintenance of the airway,
adequate respirations, and appropriate circulatory status, should be initiated. These measures are
typically BLS interventions, but advanced life support (ALS) interventions for hemorrhage
control may include medications such as tranexamic acid (TXA), discussed further in the
clinician section. If extrication and extraction are prolonged, additional treatment modalities may
be useful. Fluid resuscitation for shock may be beneficial if available, though the appropriate
amount of fluid to administer to a hemorrhaging patient remains unclear. Administration of
intravenous (IV) fluids must balance the benefits of volume expansion and improved tissue
perfusion with the detrimental effects of acidosis, dilutional coagulopathy, and hypothermia, all
of which may worsen bleeding and shock. Traditional resuscitation strategies focused on large
boluses of fluids with a target blood pressure near normal. More recent guidelines, however,
recommend small 250 mL boluses titrated with a goal of palpable radial pulses or improved
mental status.18,19 Fluids like normal saline and lactated ringers, however, cannot carry oxygen—
this can only be accomplished with blood. Some WEMS teams are capable of deploying blood
into the field and this may be beneficial in some WEMS trauma operations. The military, for
example, now recommends blood as the primary fluid for resuscitation in the field and has been
taking steps to make blood available as close as possible to the point of injury.20,21
With significant injuries, such as open fractures and partial or complete amputations, arterial
bleeding may be present and difficult to stop. Certainly the standard application of direct
pressure and pressure dressings may not be adequate to control hemorrhage. The military
experience has shown tourniquets to be particularly beneficial in both life and limb salvage and
commercial tourniquets work best in these situations. These are typically wide enough (greater
than 1 inch) to prevent any significant tissue pressure necrosis. Note that tourniquets in this
setting must occlude arterial flow—“venous tourniquets” sometimes referenced in medical
techniques are not an appropriate intervention to stop bleeding. It is important to document the
time of tourniquet application as this will assist in subsequent care and surgical planning. Most
appropriately applied tourniquets will cause significant pain in conscious patients and analgesia
should be considered. It is important to remember that certain opioid medications, such as
morphine, may adversely affect the blood pressure while others, such as fentanyl citrate, tend to
have less effect on blood pressure. These should be administered with caution in the setting of
shock, and in situations of potential or confirmed hypotension, fentanyl may be a preferable pain
agent. Furthermore, medications such as ketamine may be a valuable alternative since ketamine
has minimal effects on hemodynamics and respiratory drive while offering similar analgesia to
opioid medications. While some systems may restrict this to clinician providers, some systems
may allow for subdissociative pain dosing of ketamine at the ALS level. Note is made that per
trauma combat casualty care (TCCC) guidelines, ketamine is the preferred pain agent in these
settings.22
CLINICIAN
The field management of hemorrhage and shock does not differ significantly at the clinician
level, aside from the availability of certain medications that a system may restrict to clinician-
only care. As mentioned previously, internal hemorrhage typically requires surgical management
and most external hemorrhage can be managed by direct pressure, pressure dressings, or
tourniquet use. Two key areas that are likely to be addressed at the clinician level through direct
or indirect medical direction are tourniquet conversion and antifibrinolytic therapy.
Tourniquet conversion is the process of reevaluating the need for tourniquet use and
“converting” to a more traditional method of hemorrhage control. “Safe” tourniquet time, or the
time past which adverse effects from tourniquet placement occur, is typically regarded as 2 hours
though is likely longer.14 In traditional EMS, the patient is often delivered to definitive care
under 2 hours, and there is no need for conversion in the field. In the wilderness setting,
however, transport times are prolonged and safe tourniquet use may dictate conversion in the
field. This should be accomplished as soon as possible. In the tactical environment, this means
conversion should be attempted soon after the “care under fire” phase is completed and other
life-threatening injuries have been addressed. In the WEMS environment, the provider is more
likely to encounter a tourniquet that was applied prior to patient contact. In this situation,
tourniquet conversion should be attempted shortly after initial assessment, if indicated. If the
tourniquet was applied by the WEMS provider, or if the initial attempt failed, it is reasonable to
attempt conversion in approximately 15 to 30 minute intervals. The process is outlined in Figure
21.1. If the tourniquet is in place longer than 6 hours, it should be left in place until the patient
arrives at an emergency department (ED), given the significant risk of reperfusion injury,
hyperkalemia, and possibly cardiac arrest if removed.23,24
Patients with hemorrhage significant enough to cause vital sign abnormalities often develop
significant coagulopathy, worsening their bleeding.25 Resuscitation of severe hemorrhage in the
hospital environment typically includes administration of coagulation factors in addition to
RBCs and platelets. Routine transportation of blood products into the wilderness environment is
impractical and a poor use of resources, although some teams may be capable of deploying blood
for specific patients. Military operations and even some cruise lines have utilized “walking blood
banks” to allow for transfusion of whole blood that is complete with platelets and clotting
factors. While not utilized by most WEMS teams, it is a viable option for certain austere
environments.
FIGURE 21.1. Tourniquet Conversion. A, The original tourniquet in place proximal to the site of injury. B, First, place a
second tourniquet in addition to the original, but do not tighten. This is in case bleeding cannot be controlled and the first
tourniquet breaks as it is being retightened. C, Slowly release the tourniquet while evaluating the wound for bleeding, attempt to
control with direct pressure or pressure dressing if needed. If hemorrhage is controlled, leave tourniquets in place in the event that
severe bleeding resumes. If hemorrhage is not controlled, tighten tourniquet and reassess at a later time, if possible. Courtesy of
Matthew Horbal.

Table 21.2 Tranexamic Acid (TXA) Guidelines

Patient Selection Given the risk of venous thromboembolism, TXA should be given only to patients with the
following:
• Hemorrhage that is unable to be controlled on scene (ie, internal injuries or non-
compressible sites).
• Evidence of shock such as tachycardia or hypotension.
These criteria should be formalized in a protocol.
Timing Patients should only receive TXA if the time from injury to time of administration is less than 3
h.
Contraindications Known allergy, isolated head injury, known venous thromboembolism, time from injury
greater than 3 h.
Dosing 1 g over 10 min followed by 1 g infusion over 8 h.
Destination Patients receiving TXA should be transported to a facility capable of continuing the required
TXA infusion, preferably a level I or II trauma center.

Antifibrinolytic therapy with TXA, however, has recently shown mortality benefit, if given
early, in both the civilian and military environments with minimal adverse side effects. It also
has the advantageous property of storing well at a wide range of temperatures for an extended
period of time.26 At the time of publication, there is ongoing research regarding the use of TXA
in the out-of-hospital environment, and recommendations for use of TXA are summarized in
Table 21.2. Administration of TXA in the WEMS setting should be formalized in a protocol and
done so in conjunction with receiving trauma facilities to ensure both bolus and maintenance
dosing occur.27

Soft Tissue Trauma

Soft tissue injuries are among the most common injuries that will be encountered in the
wilderness setting. Soft tissue injuries are those that affect the skin and associated tissues.
Injuries to the skin may present as either open injuries or closed injuries. Generally speaking,
soft tissue injuries rarely pose a threat to life, although they may endanger the blood vessels,
nerves, and other associated tissues. Uncontrolled bleeding from soft tissue injuries can result in
significant hemorrhage and possibly shock. Infection is also a delayed consideration, but if not
managed appropriately can become a WEMS concern leading to unnecessary evacuation.
Soft tissue injuries are generally classified as follows:

Closed injuries:
Contusion. A contusion is a blunt, non-penetrating injury that results from the
compression and crushing of the skin and associated tissues causing damage to small
blood vessels. These typically have an area of discoloration that eventually becomes a
bruise.
Hematoma. A hematoma is an injury that occurs when blood vessels are damaged
resulting in the pooling of blood within a pocket of connective tissue. Hematomas can
vary significantly in size depending upon their location. They are often characterized by
 swelling and bruising.
Crush injury. A crush injury is a closed wound (although there may be an open
component) that occurs when a body part is compressed, often by a heavy object, that
causes a deep injury to the muscles, blood vessels, bones, and other internal structures.
The damage can sometimes be massive despite minimal external signs and symptoms.
Open injuries:
Abrasion. An abrasion is a minor injury that violates the protective barrier of the skin. It
is usually due to the scraping or abrasive loss of the outer skin layers. Bleeding can be
present although it is typically easy to control. Large abrasions can occur causing a
significant risk for infection as well as pain.
Laceration. A laceration is an open wound that penetrates more deeply into the skin
than an abrasion. It generally affects only a small surface area, though underlying
structures may be damaged. Full-thickness lacerations penetrate all the way through the
dermis and into varying depths of the subcutaneous tissues and possibly deeper
structures. Advanced WEMS providers may elect to close (ie, suture) these wounds or
leave them open until they can be adequately cleaned at a later time to prevent early
infection.
Incision. An incision is a type of laceration that is very smooth. These injuries are often
caused by sharp objects such as a knife, razor, or a piece of glass.
Puncture. A puncture is a type of laceration that involves a very small entrance wound
with damage extending to the deeper tissues. Sometimes the entrance actually seals itself
making an evaluation of the injury below difficult. Punctures also carry an increased risk
of infection because bacteria and other contaminants can be trapped within the wound.
Impaled object. An impaled object is not a specific wound, but rather a wound
complication associated with either a puncture or a laceration. In this case, the object that
caused the puncture laceration remains in the wound either below the skin surface or
above. It is hard to determine the amount of underlying injury and removal of an impaled
object can be problematic if adequate surgical resources are not available.
Avulsion. An avulsion occurs when a flap of skin that is cut or torn is not completely
loose or free from the body. This injury is commonly encountered and can vary
significantly in terms of severity and depth.
Amputation. An amputation is the partial or complete severance of a digit or a limb.
These injuries can be devastating and can often result in the loss of the affected body
part. They are often associated with significant bleeding and can result in hemorrhagic
shock or even death.

The goals of soft tissue injury treatment include the control of hemorrhage, the protection of
injured tissues, and the prevention of infection. This is sometimes difficult in the austere
wilderness setting. When practical, a sterile dressing should be applied to the wound. This is
typically held in place by bandage that is not sterile, but is fashioned to hold the sterile dressing
in place. The purpose of the bandage and dressing is to control hemorrhage and to prevent
further tissue damage and to minimize the chances of infection. Unfortunately, in the austere
setting, it is sometimes difficult to effectively dress and bandage soft tissue injuries. If treatment
will be prolonged, attention should be directed at cleansing the wound to remove any secondary
contaminants and minimize infection. This is often performed with a sterile saline solution, but
irrigation with potable water is equally effective in reducing the risk of infection.28–30 In some
instances, splinting may assist in minimizing secondary tissue damage and can also be effective
in the control of hemorrhage and pain. The vast majority of soft tissue injuries can be treated
with simple wound care followed by the appropriate dressing and bandage. Providers who have
additional medical skills may be able to repair the wound using standardized techniques such as
suturing and similar methodologies.
FIRST AID
Soft tissue injuries should be treated by first aid providers as detailed above. After bleeding has
been controlled, the wound should be inspected. If the wound is dirty or contaminated, it should
be irrigated with clean water. Following this, a dressing should be applied and affixed by an
appropriate bandage. If the wound is complex or if there is suspicion of an associated fracture,
consider applying a splint. If the patient has significant pain, over-the-counter analgesics such as
aspirin, acetaminophen, or ibuprofen may be administered.
BASIC LIFE SUPPORT
The treatment of soft tissue injuries by BLS personnel is essentially the same as for first aiders.
This involves control of hemorrhage, application of appropriate dressings, and cleansing and
decontamination of the wound. If care is prolonged, it may be necessary to remove and replace
the dressing if bleeding oozes through the initial dressing. In some cases, the older dressing can
be removed and replaced. If bleeding is brisk, the best practice is to simply apply a second
dressing atop the first and then reapply the bandage. The application of specialized splints such
as vacuum splints can both immobilize associated fractures and can help with compression of the
bleeding site. It is important to always check pulses and capillary refill distal to the injury. If
significant pain is noted, consider the administration of an over-the-counter analgesic as
described above.
ADVANCED LIFE SUPPORT
Generally speaking, soft tissue injuries can be adequately managed by BLS procedures as
outlined above. ALS personnel should examine the injury to try and determine whether there is a
significant threat to the affected area. This would include such things as vascular or neurologic
compromise, the presence of a foreign body, or the presence of a time-sensitive condition such as
compartment syndrome. Some ALS personnel may have had the training and have the
appropriate equipment to repair the wound in order to prevent additional hemorrhage and to
minimize the chances of infection. In the austere setting, the primary goal is to simply close the
wound to protect the underlying tissues. The wound can be later revised to improve the cosmetic
effect, if necessary. It is very important to remember that the wound should be adequately
cleansed and irrigated before closing with suture or a similar technique as failure to do this may
cause the entrapment of debris and bacteria in the wound increasing the chance of infection.
CLINICIAN
Management of soft tissue trauma, especially laceration care, is an aspect of wilderness medicine
where the clinician brings skill and expertise above and beyond other certification levels. This
can be either in the context of performing wound care or training other providers to perform
wound care in the austere environment. The details of wound repair are outside the scope of this
textbook and only differ from hospital or clinic management in a few small ways. The two major
decisions in wilderness laceration care are deciding what equipment to bring and whether or not
to repair the laceration primarily. Tissue glue and tissue adhesives are lightweight, store well,
and can be used successfully for many lacerations. Lacerations with higher tension may require
staple or suture repair. Small, lightweight staplers may be a useful addition to a wilderness
medical kit (see Chapter 7 [WEMS Equipment] for further discussion of staplers available to a
WEMS provider). Suture material itself is lightweight, but also requires carrying additional
surgical equipment. The provider must weigh the likelihood of performing laceration care with
the weight and pack space of advanced laceration care equipment.
The two factors affecting whether or not to perform primary closure acutely are the time
from injury and the level of wound contamination. A grossly contaminated wound or a high-risk
wound should be debrided, irrigated, packed, and left to heal by secondary intention or delayed
primary closure. A relatively clean wound can typically be closed with acute primary closure.
The data regarding timing of wound closure are conflicting and thus there is no clear time after
which acute primary closure increases the risk of wound infection. The Wilderness Medical
Society recommends that most clean wounds can be safely closed up to 6 hours after injury, and
up to 10 hours for face and scalp wounds.30 If repairing a wound primarily, it is important to
copiously irrigate the wound and to explore for any foreign bodies or damage to underlying
structures such as tendons or nerves. The optimal volume of fluid with which to irrigate wounds
is unknown, but the Wilderness Medical Society recommends at least 1 liter (grade 1C
recommendation).30 Prophylactic antibiotics are generally not necessary in most soft tissue
injuries with the exception of human bites anywhere and mammalian bites to the hand.30
Amoxicillin/clavulanic acid is recommended as a first-line agent for prophylaxis. See Chapter 11
(Pharmacology) and Chapter 20 (Infectious Diseases) for further discussion of antibiotics in
WEMS operations.

Burns
Burn injuries are a type of soft tissue injury that results from exposure to heat. The human body
is predominantly water and, thankfully, does not readily combust. However, exposure to heat can
cause irreversible damage to the skin and deeper structures that subsequently changes the
integrity and chemistry of the skin and associated tissues through the evaporation of water and
the subsequent denaturing of proteins. These injuries can result in extensive damage to the skin
and other structures. Most burns result from thermal exposure but can also can result from
exposure to certain chemicals, electricity, and lightning. Ultraviolet radiation, typically from
exposure to the sun, can also cause a burn injury (eg, sunburn). Ionizing radiation, although
uncommon, can result in burn injuries as well.
Burn injuries are fairly common and can vary in severity. Some burn injuries can be life-
threatening. Those at risk of serious burns include those at the extremes of age (children and
older adults), those with concomitant medical disabilities, and those who work in certain
occupations (eg, firefighters, steelworkers, chemical factory workers). In the austere
environment, burns can come from wildland fires, fires used for cooking and heating, and
exposure to environmental heat sources such as geysers and similar formations.
Burns are generally classified by the layers of skin and deeper structures affected by the
injury. The least severe burns are superficial burns. Superficial burns, also called first-degree
burns, tend to affect only the outermost layers of the skin—typically the epidermis in the upper
layers of the dermis. These burns normally heal without problem. A minor sunburn is an
example of a superficial burn.
Partial-thickness burns, also referred to as second-degree burns, involve more of the dermis
layer and cause greater skin destruction. With this injury the skin is red, painful, and edematous.
The hallmark of a partial-thickness burn is the presence of blisters on the skin. Both superficial
and partial-thickness burns tend to be quite painful. With superficial and partial-thickness burns,
the deep dermis layer remains intact and skin regeneration (healing) can occur.
The most severe type of burn is the full-thickness burn—also called a third-degree burn. This
burn injury penetrates both the epidermis and dermis skin layers and often extends into the
deeper tissues including the subcutaneous tissues, muscles, bones, and even the internal organs.
Full-thickness burns are typically leather-like in appearance and vary in color (white, brown,
dark red, or even black). Full-thickness burns extend through the dermis layer and generally do
not regenerate. In these cases, the grafting of skin from other unaffected body areas is often
necessary for healing. In many instances, full-thickness burns are often less painful than
superficial or partial-thickness burns because the nerve fibers are often destroyed. Blisters are
generally not seen, except at the margins.
FIRST AID
The first approach to treating a burn injury is to assure your safety and the safety of those in the
area. The next step is to stop the burning. Remove any rings, leather, clothing, or other items that
may continue to smolder and burn the patient. Also, remove anything that is tight or restrictive
(eg, rings, jewelry) before swelling makes it difficult to remove.
For minor burns, the next step is to cool the burn, which will also help to alleviate the pain.
The burned area can be placed in cool (not cold) running water for 10 to 15 minutes or until the
pain is significantly improved. This may be difficult in the austere environment, and as an
alternative you can use a towel dampened with cool water then applied to the area of injury. If
available, consider using a moisturizer or an aloe vera lotion or gel to help with pain relief. Pain
may also be treated with over-the-counter analgesics such as acetaminophen, aspirin, or
ibuprofen.
For major burns, first protect the injured patient from additional harm, then assure adequacy
of the airway, breathing, and circulation. Be prepared to provide rescue breathing and/or
cardiopulmonary resuscitation (CPR) as needed. Remove any smoldering material or products
that may continue to burn the patient. Pay particular attention to the presence of jewelry, belts,
and other restrictive items. Do not immerse the patient with major burns in cold water. If
possible, cover the areas that are burned with a clean or sterile cloth. These may be moistened
with cool water to help with pain relief if less than 10% of the body surface area (BSA; a good
guide is that the palm is about 1% of a patient’s BSA). As soon as the severity of the burn is
identified, plans should be made for proper evacuation to definitive care.
BASIC LIFE SUPPORT
The care of burn injuries by BLS personnel is largely the same as that for first aid providers. If
you have additional medical supplies, commercial burn dressings may be available and they may
help to cool the wound and mitigate pain. Pain is a major factor associated with burns and should
be addressed. In the austere setting, all that may be available are over-the-counter analgesics.
These can help to mitigate pain until stronger medications are available. See Chapter 11
(Pharmacology) for a more complete discussion of WEMS analgesics. For major burns, it is
important to begin to plan early for evacuation and transport to a designated burn center or other
facility capable of managing the initial resuscitation of the seriously burned patient.
In the process of field care, it may be helpful to unroof a blister if it appears likely to burst
traumatically or unexpectedly. This can be done by sterilizing any sharp object—preferably
something the size of a pin—and inserting it at the base of the blister near where it interfaces into
intact skin. This can drain off fluid and decompress the blister while retaining the protective
viability of the roof of the blister over otherwise exposed skin. However, this should only be
done if traumatic bursting of the blister seems inevitable (which would be more disruptive to the
protective roof). Otherwise, leaving a blister intact may be most advisable as the fluid between
the roof and otherwise exposed skin has healing and protective properties.
ADVANCED LIFE SUPPORT
Fluid resuscitation and maintenance is an important consideration in patients with major burns.
To adequately determine fluid resuscitation rates, it is important to estimate the percentage of
BSA burned with partial- and full-thickness burns. Do not include superficial (first-degree) burns
in your BSA calculations. The BSA can be estimated using the “rule of nines” as outlined in
Figure 21.2. Then, if IV fluids are available, begin administration of a crystalloid solution,
typically lactated Ringer’s or normal saline, according to one of the standardized burn
resuscitation protocols such as the Parkland Formula.* If operations are prolonged and it is
possible to measure urine output, fluid resuscitation should be titrated to urine output of at least
0.5 mg/kg/hr.
Pay particular attention to the airway, breathing, and circulation. Inhalation burns can also
occur outdoors and should be suspected in any patient who has stridor, difficulty breathing, or
singed nasal hairs or soot in the upper airway. The patient with major burns may or may not have
significant pain. If possible, provide adequate analgesia, preferably with an opioid such as
morphine, hydromorphone, or fentanyl. If opioids are unavailable, consider an alternative agent
such as ketamine. Traditionally in systems capable of rapid sequence (RSI) by ALS providers, it
has been felt to be necessary to prophylactically intubate any patient with burns to the airway or
soot around the nares or mouth due to concern for airway swelling. Clearly this is very
contextual in a wilderness setting, and even in a traditional setting traumatologists and
emergency physicians are beginning to think prophylactic intubation may not always be
necessary.31 However, vigilance for any potential airway swelling, and anticipating steps that
might be taken to secure an airway over the course of field care, should be considered early in
ALS care.
FIGURE 21.2. Rule of Nines. The rule of nines for estimating total body surface area burned. The area of a patient’s palm is
approximately 1% and can also be used to estimate surface area. From Roberts JR, Hedges JR, eds. Hedges’ Clinical Procedures
in Emergency Medicine. 6th ed. Philadelphia, PA: Saunders/Elsevier; 2013.

CLINICIAN
Burn care in the wilderness setting is managed primarily through local wound care and fluid
resuscitation as noted above. Airway evaluation for inhalation injury and management are
imperative. As noted above, ongoing evaluation of the airway will be necessary, and there may
be difficult medical decision-making regarding the risks of prophylactically securing an intact
airway that is at risk of abrupt inadequacy due to swelling versus trying to secure an airway too
late.
At the clinician level, one must diligently monitor circumferential burns for signs of
compartment syndrome and chest burns for signs of respiratory impairment. In the wilderness
setting, with prolonged patient care, it may become necessary to perform an escharotomy.
Despite a paucity of data specific to wilderness burn care, the Wilderness Medical Society gives
a level 1A recommendation (“strong recommendation with high quality evidence”) for
performing an escharotomy for circumferential burns with risk of compartment syndrome.30 The
procedure itself is quite simple, requiring only a scalpel. A longitudinal incision is made down to
the subcutaneous fat and should be extended just into healthy tissue on either end. Vascular
function should be reassessed distal to the burn after performing an escharotomy to determine
success and need for extending the incision.

Head, Face, Neck, and Spinal Trauma

Injuries of the head, face, neck, and spine can be devastating. It is estimated that approximately 4
million people experience significant head injuries each year. These include such injuries as falls,
being struck by objects, assaults, vehicle collisions, and other similar mechanisms. A review of
wilderness mortalities in Pima County, Arizona found that the majority of fall-related deaths
were secondary to head injuries or cervical spine injuries.32 The persons at increased risk for
these types of injury are males between the ages of 15 and 24, infants and young children, and
the elderly. Injuries of the head, face, neck, and spine are particularly problematic because these
structures contain the central nervous system. In addition, these critical structures are often
enclosed within a rigid protective structure, such as the skull, which can limit the ability of the
brain and spinal cord to swell following the injury.
The head and face are supported by the rigid structure of the skull and the brain lies within
the closed cranial vault. The face consists of various facial bones that serve as the skeletal base.
The brain is well protected by the meninges which consist of the dura mater, pia mater, and the
arachnoid membrane. The brain itself is supported within the protective cerebrospinal fluid that
serves to cushion it during movement. While these structures are protective, they can also be a
source of bleeding during trauma, ultimately putting pressure on the brain itself. Blood supply to
the brain and face is provided by the two carotid arteries as well as the two vertebral arteries.
These structures are vulnerable to injuries that involve both the head and neck. Venous drainage
of the brain is through the jugular veins. The vertebral column consists of 26 different bones that
extend from the base of the skull to the lower part of the trunk. The top seven bones are the
cervical vertebrae (C1–C7), the next twelve bones are the thoracic vertebrae (T1–T12), while
five bones make up the lumbar vertebrae (L1–L5). The sacrum and coccyx consist of nine bones
that have fused to form a single structure. The vertebral column protects the sensitive spinal
cord. Injuries to the vertebral bodies above the mid lumbar region can cause secondary injury to
the spinal cord. Below the first or second lumber vertebrae the spinal cord separates into
individual nerves.
The signs and symptoms of head and neck injuries vary significantly. Typically, with a
serious head injury, there will be some alteration in mental status. This may range from
confusion to unconsciousness. There may be some repetitive questioning. In many instances, the
patient will complain of severe pain in the head and/or neck. With neck injuries, often the patient
will not voluntarily move their neck and they may have tenderness in the posterior aspect of the
spine. The patient may also complain of weakness, numbness, or the inability to move their
extremities. Urine or stool incontinence is highly suspicious for a spinal injury. Injuries of this
nature are typically permanent and can be devastating. The care provided on scene has a
significant impact on the subsequent outcome of the patient.
FIRST AID
The first aid level care of patients with suspected head, face, neck and spinal injuries is primarily
supportive. If a patient with suspected injury of these regions is encountered, it is important to
summon additional help as soon as possible and to begin planning for safe removal to definitive
care. First assess the status of the patient’s airway, breathing, and circulation. If CPR must be
provided, attempt to open the airway without extending the neck with techniques such as the
modified jaw thrust. Any noted hemorrhage should be controlled as soon as possible as
hypotension may worsen head and spinal cord injury. Patients who have an adequate airway,
adequate respirations, and strong pulse should be encouraged to remain still and providers should
attempt to maintain their spine in a neutral position.
The routine application of cervical collars for patients with potential cervical spine injury has
been taught for decades despite the lack of any proven benefit. Their use is centered around the
idea that if a patient has sustained a spinal injury, further motion might cause additional injury to
the spinal cord or nerves. This theory persists without any documented cases of neurologic
deterioration in the out-of-hospital setting secondary to inadequate spinal cord protection.33
While cervical collars have not demonstrated any clear benefit, they have been shown to increase
intracranial pressure, cause pressure ulcers, compromise respiration, impede airway
management, and in certain patients, such as helmeted skiers or snowboarders, worsen cervical
spine alignment.34,35 These detrimental effects may be even more problematic in the WEMS
environment given the prolonged nature of care. Thus, the exceedingly small potential benefit of
placing an awake patient, who can otherwise protect their own spinal cord, in a rigid cervical
collar is likely outweighed by the risks. Additionally, placing that patient in a collar may
interfere with the patient’s ability to assist in their own rescue. With an obtunded patient, care
should be taken to avoid any excessive motion as damage could occur with motion outside of
physiologic range. This is best accomplished by using a full-body vacuum mattress, or in its
absence, by soft, supportive padding around the patient’s head and neck. Rigid cervical collars
are not a required component of patient care in a WEMS operation even in the case of suspected
spinal injuries. Not only are rigid cervical collars not useful for general WEMS operations, the
lack of utility for cervical collars has also been shown for teams in specific WEMS
environments, such as ski patrols.35 For a more complete discussion of packaging for spinal cord
protection, see Chapter 24 (Principles of Technical Rescue, Patient Care Integration, and
Packaging).36
BASIC LIFE SUPPORT
BLS care of patients with suspected head, face, neck, and spinal injuries is essentially the same
as first aid providers. Initial attention should be directed toward assurance of the airway,
breathing, and circulation. Any hemorrhage noted should be rapidly controlled. Management of
the cervical spine is the same as is discussed above for first aid level care. Immobilization on a
long spine board is no longer recommended under any circumstance for medical purposes. If the
patient must be extracted, consider use of a scoop stretcher or a Stokes basket for the rescue.
Long spine boards may also have utility for extrication, but not for spinal cord protection. For a
more complete discussion of packaging for spinal cord protection, see Chapter 24 (Principles of
Technical Rescue, Patient Care Integration, and Packaging).
ADVANCED LIFE SUPPORT
The out-of-hospital care of head, face, neck, and spinal injuries by ALS providers is essentially
supportive. However, if additional medical equipment is available, there are certain interventions
that may aid the patient. Pain can be treated with opioid analgesics or acetaminophen. If
intracranial or internal hemorrhage is suspected, aspirin and other nonsteroidal antiinflammatory
medications should be avoided; if not, these agents may also be helpful. Patients who are
agitated may benefit from sedation. Nausea and vomiting is common with head injuries and the
administration of an antiemetic may be of benefit. See Chapter 11 (WEMS Pharmacology) for a
more complete discussion of analgesics, antiemetics, and sedatives available in the WEMS
setting. Patients with a Glasgow Coma Scale score ≤8 may benefit from endotracheal intubation
and mechanical ventilation if the appropriate medications and equipment are available.
Management of a suspected spinal cord injury is the same as the BLS and first aid care described
above. If the index of suspicion is high for intracranial injury or a spinal cord injury, the patient
should be routed to the closest trauma center as soon as possible, even if this bypasses closer
non-trauma hospitals.
CLINICIAN
The management of head, face, neck, and spinal injuries is not significantly different at the
clinician level. There are little data specific to head injury in the wilderness, but data from the
ED setting can likely be translated to the wilderness environment. Multiple clinical decision rules
exist which can safely identify patients who do not require imaging for intracranial hemorrhage.
It may be extrapolated that patients who do not need imaging acutely in the ED may not need
emergent evacuation, and safer methods of transporting patients out of the wilderness may be
acceptable in lieu of more emergent, higher risk methods (ie, ground rescue vs. helicopter
extraction). The Canadian Head CT and New Orleans criteria have emerged as the most sensitive
rules for identifying clinically important intracranial injury. In studies, both rules identified
100% of patients who require neurosurgical intervention, but unfortunately both have poor
sensitivity, meaning many patients without significant injury would have imaging performed.37
The Canadian Head CT rules have a higher specificity than the New Orleans criteria and may be
more applicable to the wilderness setting, as fewer patients would unnecessarily be evacuated
emergently. These decision rules are listed in Table 21.3. Keep in mind that these rules excluded
patients who were younger than 16, using anticoagulant or antiplatelet agents, had neurologic
deficit, unstable vital signs, penetrating trauma, or obvious depressed skull fractures. These
patients obviously need imaging and should be evacuated expeditiously. While field
management may not change at the clinician level, the clinician may be responsible for direct or
indirect medical direction utilizing these decision rules.
Similar rules exist regarding spinal cord protection. These have been well studied in the out-
of-hospital setting, and the Wilderness Medical Society gives a grade 1A recommendation that
appropriately trained personnel can safely and effectively make decisions in the out-of-hospital
setting as to whether or not cervical spine should be immobilized using either the NEXUS
criteria or Canadian C-spine rule.38 See Table 21.3 for these clinical decision rules. As discussed
above, the risks of routine application of rigid c-collars in otherwise alert, ambulatory, and
neurologically intact patients likely outweigh the exceedingly small potential benefit, and routine
application is not recommended. With an obtunded patient, care should be taken to avoid any
excessive motion as damage could occur with motion outside of physiologic range. This is best
accomplished by using a full-body vacuum mattress, or in its absence, by soft, supportive
padding around the patient’s head and neck. For a more complete discussion of packaging for
spinal cord protection, see Chapter 24 (Principles of Basic Technical Rescue, Patient Care
Integration, and Packaging).36

Chest Trauma
The chest contains many essential structures including the heart, great vessels, esophagus,
tracheobronchial structures, and the lungs. Injuries to the chest can sometimes be life-
threatening. As with other types of injuries, injuries to the chest are typically classified as being
open or closed. Open injuries are particularly problematic because these can affect the negative
intrathoracic pressure that drives the normal respiratory physiology. Also, significant injuries to
the heart and great vessels are often rapidly fatal. Fortunately, the structures within the chest are
well protected by the ribs and associated musculature.
Blunt injuries to the chest can result from falls, deceleration type injuries, and being struck
by objects. Penetrating injuries to the chest can result from projectiles, such as bullets or knives,
and can occur secondary to falls or vehicular trauma when contact is made with a sharp object
that penetrates the integrity of the chest. It is often difficult to determine the severity of
underlying chest injuries by simply examining the external chest wall, especially in children.
Many chest injuries encountered in the austere setting primarily involve the chest wall. These
can range from a contusion of the chest wall to rib fractures. The lower ribs, ribs 9 through 12,
are the most commonly fractured, and these ribs can also cause injury to important
intraabdominal structures such as the liver and spleen. When two or more ribs are broken in two
or more places, the central segment (flail segment) can begin to move freely—typically opposite
of normal chest movement (paradoxical movement). This condition is referred to as a flail chest
and can adversely affect respiration and can be life-threatening—particularly in patients who
have preexisting pulmonary disease. Chest wall injuries can also involve the sternum and
associated structures or concomitant pulmonary contusions. However, sternal injuries generally
result from high-energy type trauma and are often associated with underlying structural injuries
involving the heart, lungs, and/or great vessels.
Injuries of the lungs and associated structures are common with chest injuries and may
include collapse of the lung, referred to as a pneumothorax. With a pneumothorax, air becomes
trapped outside of the lung but within the chest. If air continues to enter the area of entrapment, it
will eventually compress the lungs and heart resulting in a condition referred to as a tension
pneumothorax, which is life-threatening and requires emergent treatment (decompression). Some
chest injuries can cause bleeding inside the chest. This collection of blood in the pleural cavities,
referred to as a hemothorax, can also be life-threatening. Either side of the chest can hold a
considerable amount of blood, and blood loss into the chest can result in shock through either
volume loss or as a tension hemothorax. Some injuries can also result in both a pneumothorax
and hemothorax.

Table 21.3 New Orleans and Canadian Head CT Rules

New Orleans Canadian Head CT
Applies to GCS 15 with LOC, amnesia, or disorientation GCS 13–15 with LOC, amnesia to head injury
event, or confusion.
Criteria CT required for patients with any of the CT required for patients with any of the
following: following:
• Headache • GCS <15 at 2 h post injury
• Vomiting • Suspected open or depressed skull fracture
• Older than 60 yr • Any sign of basilar skull fracture
• Drug or alcohol intoxication • 2 or more episodes of vomiting
• Persistent anterograde amnesia • Age greater than or equal to 65
• Visible trauma above the clavicle • Retrograde amnesia to the event greater than 30
• Seizure min
• “Dangerous” mechanism
• Pedestrian struck by motor vehicle
• Occupant ejected from motor vehicle
• Fall from >3 ft or 5 stairs
Excluded Patients Age <18 • Patients taking oral anticoagulant or antiplatelet
 GCS <15 agents
• Age <16
• Seizure after injury

GCS, Glasgow Coma Scale; LOC, loss of consciousness.

Injuries to the chest can also affect the heart, great vessels, and associated structures. These
injuries can be catastrophic and oftentimes fatal. It is very difficult to detect these types of
injuries in the out-of-hospital setting. Patients with blunt chest trauma who develop cardiac arrest
in the out-of-hospital setting have a very poor prognosis and should be considered candidates for
withholding or early termination of resuscitation.39 Patients with penetrating trauma to the chest
who develop cardiac arrest tend to have somewhat better outcomes than blunt trauma patients,
but only if they are afforded rapid WEMS treatment and access to a trauma center and
emergency surgery. This is often difficult in the wilderness and austere setting, but even severe
injuries can be survivable with emergent evacuation to appropriate facilities.40
FIRST AID
First aid level care of patients with potential chest trauma is supportive. Care should include the
assessment of the airway, breathing, and circulation. Obvious bleeding should be controlled. If
shock is suspected, it should be treated by positioning and protection from the environment. The
patient should be kept in a neutral position while additional resources are summoned. If the
patient is pulseless and apneic, consider CPR unless it is clear that the injury is not survivable.
See Chapter 22 (General Management of Medical Conditions in the Wilderness) for a more
complete discussion of CPR, when it should not be initiated, and when it can be terminated.
BASIC LIFE SUPPORT
BLS care of chest injuries is essentially the same as that detailed above for first aid providers.
However, it is important, if possible, to obtain vital signs in patients with suspected chest trauma.
These should be monitored over time to detect any possible deterioration of the patient’s
condition. In addition, BLS providers should look for specific injuries that require emergent
treatment. An open or sucking chest wound can be treated by covering the wound with a
nonocclusive dressing taped to the chest on three sides (leaving one side loose as an emergency
pressure relief valve). Commercial dressings that accomplish this task are available, are easier to
apply, are small and lightweight, and recommended as part of a medical kit for a wilderness
responder. See Chapter 7 (WEMS Equipment) for a more complete discussion of such tools.
Alternatively, an occlusive dressing may be applied as the three-sided technique may be
technically difficult or may poorly adhere to a diaphoretic patient. The dressing may be
occasionally removed (allowing for “burping”) as needed to relieve any pressure from a
developing pneumothorax, and higher levels of care may perform a needle thoracotomy to
relieve pressure if needed. As with first aid care, the primary goal of BLS here is maintenance of
an adequate airway, breathing, and circulation. Transport should be arranged as soon as possible.
ADVANCED LIFE SUPPORT
While BLS techniques are the primary treatment of chest injuries in the out-of-hospital setting,
ALS providers should implement a more detailed assessment with a presumptive field diagnosis
of the potential injury or injuries. It is important, if possible, to obtain vital signs in patients with
suspected chest trauma and monitor these over time to detect any possible deterioration of the
patient’s condition. Certain conditions require prompt interventions such as decompression of a
tension pneumothorax. This can be diagnosed by hypotension, worsening tachycardia, and
decreased breath sounds on the affected side. Sometimes tympanic sounds to percussion or
tracheal deviation away from the affected side can been noticed on physical exam. Traditionally,
needle thoracotomy has been performed at the second intercostal space in the mid clavicular line,
but more recent data have shown the procedure to be more successful when performed at the
fifth intercostal space of the anterior axillary line. A large-bore (preferably 14 g) needle is
inserted perpendicular to the chest wall just superior to the lower rib (to avoid injuring the
neurovascular bundle). Once in the pleural cavity, the angiocath is advanced into the pleural
cavity and the needle removed. If successful, the provider will likely hear a rush of air, and
hemodynamics should improve rapidly.
Significant injuries that may involve the heart and great vessels require standard emergency
support. It is important to recognize that some of these injuries are invariably fatal, and given the
specific situation and local protocols, termination of resuscitation may be indicated.39 Certainly,
pain management and limited fluid resuscitation may have a role in the treatment of patients with
chest trauma. Planning should be started early in terms of extraction and subsequent transport.
CLINICIAN
While diagnosing thoracic injuries clinically can be challenging, the clinician can utilize
handheld ultrasonography to accurately diagnose pericardial effusion, pneumothorax, and
hemothorax. This is a skill that can potentially be taught to providers at different levels (such as
ALS providers), and has even been used with remote interpretation.41 Free fluid around the heart
is easily visualized on ultrasonography, indicative of a pericardial effusion. A pneumothorax is
readily identifiable by finding a transition point where the “bar-code sign” shows no lung sliding.
Finally, a hemothorax is readily visible on ultrasound as a dark fluid collection in the thoracic
cavities. In terms of management, the clinician adds the ability to perform a rib block, tube
thoracostomy and, under extreme circumstances, a pericardiocentesis.
Patients with rib fractures can experience extreme pain, and management of uncomplicated
rib fractures relies on adequate analgesia. In addition to oral and IV pain medication, the properly
trained clinician can perform an intercostal nerve block which can relieve pain to the point that
the patient may be able to assist in their own extrication. For patients with flail segments, the
analgesia provided is one of the best treatments available. The procedure is typically performed
on the posterior thorax. The skin overlying the rib to be blocked is cleansed, and a 22 gauge
needle is then inserted until it hits the rib. The needle is slightly retracted, and using two fingers
the provider will pull inferior traction on the skin and advance the needle. It is important to pull
negative pressure on the syringe to ensure the provider has not entered an artery, vein, or the
pleural space. Increasing inferior traction is applied until the needle no longer hits bone. At this
point, the needle is advanced approximately 2 mm, and 3 to 5 mL of lidocaine is injected. This
may need to be repeated one rib above and below the suspected rib fracture. This will anesthetize
the rib anterior to where the block is performed.
A tube thoracostomy is a procedure that rarely needs to be performed in the field, and there
is no literature specific to chest tube placement in the wilderness setting. Traditional chest tubes
used in the ED are relatively large, require surgical equipment for placement, and should be
placed in a sterile manner. Because of this, it is likely not reasonable to routinely carry full chest
tube equipment. There are, however, commercially produced kits that include a 14 gauge
catheter with introducer needle, tubing, and Heimlich valve. These small kits are likely more
practical for the wilderness provider than a traditional chest tube, and may be the most
appropriate method for managing a pneumothorax in the field.
 Another rare condition that could be encountered in the wilderness setting is a pericardial
tamponade. This can be difficult to diagnose without ultrasound, as the classic Beck’s triad of
hypotension, jugular venous distension, and muffled heart sounds is present in only a minority of
cases. Definitive management is performed in the operating room, but an out-of-hospital
clinician may be able to perform a pericardiocentesis to relieve the tamponade as a temporizing
maneuver while emergent transport to a trauma center is being sought. The procedure is
performed by inserting a 16 to 18 gauge catheter over a long needle. The skin just below the
xiphoid is prepped, and the needle is inserted at a 45 degree angle and directed toward the left
scapula. Negative pressure is pulled on the syringe until pericardial fluid is returned. The catheter
is then advanced over the needle and left in place. Draining only 15 to 20 mL of blood can
significantly improve hemodynamics and may be able to preserve cardiac output until transfer
can be made to definitive care.

Abdominal/Pelvic Trauma
The abdominal cavity is one of the body’s largest compartments and contains many essential
organs. Although technically a separate cavity, the pelvic cavity readily connects with the
abdomen and these are often considered together when assessing trauma. The pelvic cavity
structures are well protected by the bony pelvis. In contrast, the abdominal contents are not as
well protected. The anterior portion is protected only by the muscles of the abdomen and thus,
injuries to the abdomen and pelvis can easily occur. These are most commonly seen with blunt
trauma, although penetrating trauma certainly can cause significant intraabdominal and pelvic
injuries.
The organs of the abdomen are generally divided into solid and hollow structures. The liver,
spleen, kidneys, and pancreas are all solid organs, and the stomach, small intestine, large
intestine, gallbladder, and urinary bladder are all considered hollow organs. These different
structures respond to external forces differently. Bleeding tends to be more significant when
solid organs are affected. The organs of the pelvis are generally well protected. In the female,
these include the urinary bladder, vagina, uterus, fallopian tubes, ovaries, and the rectum. In the
male, the only organs in the pelvis are the urinary bladder, the prostate, and rectum.
While the bony pelvis provides significant protection for the pelvic organs, it is subject to
injury. It is a circular structure made up of several different bones. Fractures of the pelvis can
occur with falls, vehicular trauma, and similar events. Pelvic fractures can be complicated by
significant bleeding which can sometimes be life-threatening. Most pelvic fractures will involve
more than one fracture site. Thus, there may be a fracture anteriorly with a similar fracture
posteriorly as is typical for any bony ring structure. Patients with an unstable pelvis or who have
significant pelvic tenderness should be suspected of having a pelvic fracture. These patients have
a significant risk of hemorrhage and shock and warrant rapid extraction and transport. The pelvis
has a rich venous plexus on its anterior aspect, and the pelvis should be splinted if there is
suspicion of a pelvic fracture, as movement of fracture segments can worsen bleeding.
As with other forms of trauma, injuries to the abdomen and pelvis can result from blunt
forces and can also occur with penetrating injury. Virtually any organ can be injured in trauma.
The diagnosis of specific organ injury is often difficult—even in the ED setting. Oftentimes, the
external findings of patients with abdominal and/or pelvic trauma are subtle or nonexistent.
While pain and tenderness are some of the most common findings in these patients, nausea,
vomiting, and loss of appetite may also give a high level of concern for injury. Bruising to the
abdominal wall may be noted as time passes and can be an reassessment finding of more
significant injury. In cases of abdominal and pelvic trauma, the vital signs are an important
indicator of trauma severity. A change in respiratory rate, pulse rate, and blood pressure may
indicate hemorrhage within the abdomen and/or pelvis. As with chest injuries, patients with both
blunt and penetrating abdominal trauma can bleed to death with little, if any, external blood loss.
Because of this, the provider should always maintain a high index of suspicion for significant
injury in patients with sustained abdominal or pelvic trauma.
FIRST AID
First aid level care of patients with potential abdominal or pelvic trauma is primarily supportive.
Care should include the assessment of the airway, breathing, and circulation. Obvious bleeding
should be controlled. If shock is suspected, it should be treated by laying the patient flat and
protected from the environment while additional resources are summoned. If the patient is
pulseless and apneic, consider CPR, described further in Chapter 22 (Management of General
Medical Conditions in the Wilderness).
BASIC LIFE SUPPORT
BLS care of abdominal and pelvic injuries is essentially the same as that detailed above for first
aid providers. It is important, however, to obtain vital signs in patients with suspected abdominal
or pelvic trauma if possible. These should be monitored over time to detect any possible
deterioration of the patient’s condition. In addition, BLS providers should look for specific
injuries that require emergent treatment. For example, a suspected pelvic fracture can be
stabilized with pelvic binding. This may be accomplished with commercial pelvic splints (eg,
SAM [structural aluminum malleable] splint, T-POD [an independonym]), but hasty teams and
other rescue teams may not find it practical to routinely carry commercial pelvic binders.
Methods for improvising pelvic splints are outlined in figure 21.3. Penetrating trauma of the
abdomen and pelvis is typically a surgical condition and providers should arrange for rapid
transport of these patients to a facility that can provide stabilizing surgery and/or angiography.
These wounds should be covered with sterile gauze. If abdominal contents protrude through the
abdominal wall (termed evisceration), these should be gently rinsed and covered with moistened
gauze and then a vapor barrier. Attempts to replace the abdominal contents should be avoided as
this increases the risk of intraabdominal infection. As with first aid care, the primary goal of BLS
care here is maintenance of an adequate airway, breathing, and circulation. Transport should be
arranged as soon as possible.
FIGURE 21.3. Improvised Pelvic Splints. A, First, cut two slits at both ends of the splint. The same concept can be
accomplished using zip-ties through holes cut at both ends of the splint. Find two small sticks to help provide more structural
integrity. B, Next, fold both ends around the stick and line up the slits. C, Loop the tourniquet through the slits. It may be easier
to slide the splint under the patient prior to looping the tourniquet through the splint. D, Position the splint around the patient’s
hips, centering over the greater trochanters and use the tourniquet to tighten the splint. Courtesy of Matthew Horbal.

ADVANCED LIFE SUPPORT

BLS techniques are the primary treatment of abdominal and/or pelvic injuries in the out-of-
hospital setting. However, ALS providers should provide a more detailed assessment with a
presumptive field diagnosis of the potential injury or injuries. It is important, if possible, to
obtain vital signs in patients with suspected abdominal and pelvic trauma and monitor these over
time to detect any possible deterioration of the patient’s condition. Pain management with
opioids and fluid resuscitation may have a role in the treatment of patients with abdominal and/or
pelvic trauma. It is important to remember that abdominal and pelvic trauma is often a surgical
condition, and that delays in out-of-hospital care can delay potentially lifesaving surgery.
Planning should be started early in terms of extraction and subsequent transport. Antibiotics
should be considered for any penetrating injuries.
CLINICIAN
As outlined above, the field management of abdominal and pelvic trauma relies on recognizing
significant internal hemorrhage, stabilizing any unstable fractures, and transporting to a trauma
center. If ultrasound is available, a Focused Assessment with Sonography for Trauma (FAST)
exam may be helpful in identifying intraabdominal free fluid. While a patient with unstable vital
signs requires emergent evacuation regardless of FAST exam, a positive FAST examination in
the presence of normal vital signs may alter disposition and be a cause for more emergent
evacuation.

Orthopedic Trauma
Orthopedic injuries are those injuries that involve the bones, joints, muscles, and related
structures. These are extremely common in the austere and wilderness medicine setting. These
injuries include fractures, dislocations, sprains, strains, and contusions. They can result from
falls, direct trauma, twisting mechanisms, or overuse. It is often difficult to determine the exact
nature of an orthopedic injury in the austere setting. Certainly some fractures and dislocations
may be obvious. However, injuries to joints can range from complicated fracture/dislocations to
simple sprains. Injuries to muscles are common and are generally limited to strains although
complete muscle/tendon disruptions can occur. Fractures are generally classified as being either
open or closed. With an open fracture, the bone has pierced the skin or the skin is otherwise
disrupted over the site of the fracture. Open fractures can result in significant hemorrhage,
particularly if a major blood vessel is affected. Furthermore, these wounds tend to be prone to
infection and require specialized care.
The signs and symptoms of orthopedic injury vary significantly. They can range from mild
pain to significant deformity. With open injuries there may be heavy bleeding. The goal of
treatment for these injuries is primarily supportive. That is, bleeding should be controlled and the
affected structure stabilize through bandaging and splinting. Open wounds should be dressed and
bandaged, if possible, to protect against infection. In many instances, the type of care provided is
limited by the supplies and equipment available. Personnel arriving as part of hasty teams or
search teams may not have a full set of medical equipment, and thus should be well versed in
methods of improvising splints.
FIRST AID
First aid level care of orthopedic injuries is primarily supportive. Strategies include controlling of
bleeding, bandaging and dressing of wounds, and immobilization of the affected structure. In
first aid care, fractures and dislocation are generally splinted in the position found, though gentle
traction of angulated and deformed long bones may be necessary to allow for splinting. It is
important to stop any intervention if pain increases significantly or if there is significant
resistance. Fractures should be immobilized from the joint above the suspected fracture to the
joint below the suspected fracture. Dislocations should be immobilized from the bone above the
suspected dislocation to the bone below the suspected dislocation. Distal pulses and neurologic
function should be evaluated both before and after splinting and then periodically thereafter. If a
deficit in the pulse is found, the splint may need to be readjusted or the fracture or dislocation
may need to be reduced to ensure adequate perfusion. It is important that first aid providers not
be distracted by seemingly grotesque orthopedic injury when the patient may have a more
threatening condition involving the airway, breathing, or circulation.
BASIC LIFE SUPPORT
Bleeding should be controlled using standard techniques and open wounds should be dressed and
bandaged. Fractures and dislocations should be splinted. The type of splinting varies
significantly based upon the supplies available. In an austere wilderness setting, straight branches
or sticks can be used as a splint and disposable splints such as the SAM splint are effective and
lightweight. In general, WEMS splinting needs to be more robust with increased stability and
padding over most front county EMS settings. Operationally specific protocols may allow for
reduction of fractures or dislocations by BLS providers (see Clinician section for further
discussion). If treatment and transfer will be prolonged, consider the administration of an over-
the-counter analgesic such as acetaminophen, aspirin, ibuprofen, or naproxen. The patient then
should be transported for appropriate definitive care.
ADVANCED LIFE SUPPORT
Suspected fractures and/or dislocations should be treated with effective splinting. As above,
splinting can be accomplished using sticks, SAM splints, or other improvised tools to support the
injured extremity. Bleeding should be controlled and any open wounds should be dressed and
bandaged. Operationally specific WEMS protocols may be established to include fracture and
dislocation reductions It is important to always assess distal neurovascular function before and
after reduction, and before and after splinting. These techniques can help alleviate pain and
maintain distal neurovascular function. Orthopedic injuries are often painful and the patient may
benefit from the administration of available pain medications including opioids and non-opioids.
Antibiotics should be considered for all open fractures.
CLINICIAN
Initial clinician care should mirror those described for other practice levels above. While there
are little published data regarding the safety and efficacy of reduction of joints and fractures in
the wilderness, studies have shown that shoulder reductions can safely be performed in the field
even by nonmedical providers,42,43 It seems logical that reduction of other less complicated joints
can also be safely reduced by non-clinician providers. Clinicians whose regular practice includes
such reduction will bring much more experience to any field reduction; these will be rare
interventions for nearly all non-clinician WEMS providers. Obviously, fractures and dislocations
that result in vascular and/or nerve injury or result in skin tenting should have reduction attempts
performed as soon as possible. In the setting of significant deformities that are difficult to splint,
fracture or dislocation reduction for pain control and facilitation of evacuation is reasonable.
Suspected fractures without significant deformity or neurovascular injury should simply be
splinted.
Although fracture dislocation and reduction in the wilderness may be performed by BLS or
ALS personnel, the techniques are discussed here as they are advanced skills and typically part
of an operationally specific scope of practice for those personnel. Research surveying the
National Association of EMS Officials Medical Directors Council in 2014 suggested that more
than 60% of states do not permit dislocation reduction by non-clinician EMS provider types.44
Reduction of obvious long-bone fractures is relatively simple using traction/countertraction
technique. One provider holds the bone proximal to the fracture while the other provider simply
pulls gentle and increasing traction on the distal part. The injury is then “re-created” with an
exaggerated motion and the bones aligned. Neuromuscular function should be documented both
before and after reduction and splint placement.
Most dislocations are relatively easy to reduce. Finger dislocations are reduced by simply
pulling traction on the distal finger. As the force is gently increased, a “clunk” will be felt as the
more distal phalanx aligns with the more proximal one (see Figure 21.4). The finger should then
be “buddy taped” to the adjacent finger.
Shoulder dislocations are easily reduced most of the time, but they can be quite challenging
and require multiple attempts, and the ease of reduction is often due to procedural sedation and
other pharmacological adjuncts available in a hospital but potentially not in a wilderness area.
There are many methods to reduce shoulder dislocations and all essentially apply
traction/countertraction. The key is to apply continuous traction to fatigue the muscles, resulting
in muscle relaxation enough to allow the shoulder to reduce. A few methods are shown in Figure
21.5. Once reduced, the affected arm should be placed in a sling until further orthopedic
evaluation can be performed at a health care facility.

FIGURE 21.4. Finger Dislocation Reduction. A, Third digit dislocated at the proximal interphalangeal joint. B, Reduction
using traction/countertraction. Courtesy of Paul Nicolazzo, with permission. Originally published in the Art & Technique of
Wilderness Medicine, © 2010, 2014 Wilderness Medicine Training Center.
FIGURE 21.5. Shoulder Reduction Methods. A and B, Scapular manipulation: the shoulder is flexed to 90 degrees and traction
is applied. This can be accomplished by having the patient hang their arm off a flat surface with weights, a person pulling, or
standing against a tree with a person pulling. Sometimes, this is all that is required for reduction. The scapula is then rotated
inward until reduction is achieved. C and D, External rotation: the shoulder is abducted and externally rotated to 90 degrees with
the elbow at 90 degrees of flexion (like throwing a baseball). Lateral traction is then pulled at the level of the elbow as
countertraction is pulled at the patient’s chest by an assistant (countertraction by assistant not demonstrated in image). Courtesy
of Paul Nicolazzo, with permission. Originally published in the Art & Technique of Wilderness Medicine, © 2010, 2014
Wilderness Medicine Training Center.

Hip dislocations usually occur in the posterior direction as the result of axial load on a flexed
and adducted hip. This results in a shortened-appearing, adducted, internally rotated, flexed hip
on examination. In contrast, an anterior dislocation is caused by forced abduction of the hip
resulting in a flexed, abducted, externally rotated leg. Hip dislocations may also result in femoral
neck fractures which are difficult to recognize clinically. Hip dislocations have a significant risk
of avascular necrosis of the femoral head and posttraumatic arthritis. The risk of these
complications increases with increasing severity of the injury, concomitant fractures, and length
of time to reduction. Patients whose dislocation is reduced more than 12 hours after injury have a
fivefold increase in risk of complications.45 Because of this, it is imperative to rapidly extricate
patients with hip dislocations because they are true orthopedic emergencies. There is little
literature specific to hip dislocations and fracture/dislocations in the wilderness, but it is
reasonable to attempt reduction if estimated time to definitive care will be greater than 12 hours.
Given the risk of underlying fractures that could become more displaced, only a single attempt at
reduction should be performed. The procedure is outlined in Figure 21.6.
Patellar dislocations are readily diagnosed on physical exam, as the patella can be seen
displaced laterally. This is usually the result of turning on a partially flexed knee. The patient is
usually found with their knee in partial flexion. To reduce the patella, the knee is extended fully
while gently pressing the patella medially (see Figure 21.7). Sometimes the patella reduces itself
simply by knee extension. The patient should have their knee splinted in extension, and if they
can bear weight with the splint in place, it is reasonable for them to assist in evacuation.

FIGURE 21.6. Hip Reduction. With the patient supine or near-supine, both the knee and hip are flexed to 90 degrees. Upward
traction is pulled while an assistant exerts countertraction by pushing down on the pelvis. The hip is then externally and internally
rotated as needed for reduction. Courtesy of Paul Nicolazzo, with permission. Originally published in the Art & Technique of
Wilderness Medicine, © 2010, 2014 Wilderness Medicine Training Center.
FIGURE 21.7. Patella Reduction. The knee is extended fully as the patella is gently pressed toward midline. The patella will
sometimes reduce spontaneously as the knee is extended. Courtesy of Paul Nicolazzo, with permission. Originally published in
the Art & Technique of Wilderness Medicine, © 2010, 2014 Wilderness Medicine Training Center.

Knee dislocations typically involve large forces and are the result of motor vehicle collisions.
Significant ligamentous injury must occur to dislocate a knee. The neurovascular bundle on the
posterior knee is easily injured with a knee dislocation, and close attention must be paid to distal
neurovascular function. Given the high risk of injury, knee dislocations are true emergencies.
They can be reduced by pulling traction from the ankle with countertraction pulled on the femur.
These injures are extremely unstable and should then be splinted. Evacuation should be
performed emergently given the high risk of underlying vascular injury and delayed
complications such as compartment syndrome.
Ankle dislocations are usually associated with fractures of the tibia, and/or fibula, and are
usually the result of twisting or rolling with significant force (eg, jumping down onto an uneven
or slanted surface). They are generally obvious on exam (Figure 21.8). They can result in
neurovascular injury, and thus a detailed exam should be performed both before and after
reduction. To reduce ankle fracture/dislocations, one hand is placed behind the patient’s heel and
the other on top of the midfoot. Gentle, steady traction is then applied while an assistant supports
the knee in flexion. An alternate method of reduction is to place the leg in Quigley’s traction,
where the leg is suspended by a fabric tube and the weight of the leg provides continuous
traction until the fracture is reduced (Figure 21.9).46 The fracture/dislocation should then be
splinted.
FIGURE 21.8. Ankle Fracture/Dislocation. Fracture dislocation of left ankle. Notice the skin tenting over the anterior tibia,
indicated by the white color. This is high risk for skin necrosis and requires prompt reduction to avoid converting a closed
fracture into an open fracture.
FIGURE 21.9. Quigley’s Traction. Place the patient’s leg in a tubular piece of clothing and hang the leg in elevation. The
constant traction will fatigue the muscles of the leg, allow for relaxation, and help reduce the fracture/dislocation. Courtesy of
Matthew Horbal.

Management of open fractures has received much research in the hospital environment that
translates well to the wilderness setting. Given the significant risk of infection and poor
outcomes, open fractures should be thoroughly irrigated as soon as possible. While wounds are
typically irrigated with sterile saline in the hospital, results of a multicenter, randomized control
trial found no significant difference in wound infection rates if irrigated with tap water.28,29 It
seems reasonable, therefore, that filtered or disinfected water should likely offer similar efficacy
in wound irrigation.
It is also well established that antibiotic therapy significantly reduces risk of infection,
osteomyelitis, and morbidity in open fractures.47,48 Antibiotics should have broad gram positive
coverage, typically a first-generation cephalosporin such as cefazolin, with clindamycin
recommended for penicillin-allergic patients.48,49 For type III fractures (those with an open
segmental fracture, extensive soft tissue damage, or a traumatic amputation), it is suggested to
add gram negative coverage with an aminoglycoside such as gentamicin. For patients with
wounds contaminated by soil or near farms, anaerobic coverage should be added with penicillin
or metronidazole. The recommendations for additional antibiotic coverage above cefazolin and
clindamycin are based on limited data, and it may be reasonable to delay double coverage until
the patient is delivered to definitive care as these infections are often nosocomial.
The clinician also offers more options for analgesia. Intraarticular lidocaine injections have
been shown to have similar analgesic effects to procedural sedation for both shoulder reductions
and ankle fracture dislocations.50,51 Similar results have been produced using ultrasound-guided
hematoma blocks in distal radius fractures.52 Regional blocks and digital blocks can also safely
offer significant pain relief for fractures, dislocations, and lacerations when administered by
trained clinicians.

Equipment Summary
Deciding what equipment to bring for WEMS trauma responses can be difficult. The provider
must weigh the utility of his or her medical equipment, the likelihood of its use, and its weight
and pack space. Hasty teams or search teams might carry minimal medical equipment if
embarking on foot, but may be able to carry a more robust medical kit if they are utilizing all
terrain vehicles (ATVs) or snowmobiles. For foot teams, lightweight equipment that can serve
multiple purposes is ideal. Moldable splints such as SAM splints can be used to splint most
fractures and can be combined with a commercial tourniquet to fashion a pelvic binder. For
teams responding to a patient at a known location with identified injuries or mechanism, it may
be easier to carry a more complete medical kit. Items to be included in a medical kit for trauma
are outlined in Table 21.4, and more complete information on WEMS medical kits and
equipment in general is discussed in Chapter 7 (WEMS Equipment).

Table 21.4 Equipment List

Level of Care Light Pack Full Pack
First Responder/BLS Selection of Band Aids Stethoscope
4 × 4 gauze Sphygmomanometer
2–6 inch roller gauze Oropharyngeal airways
Large ABD pad Nasopharyngeal airways
2 inch tape ± Oxygen tank
Petroleum gauze ± Nasal cannula
SAM splint ×2 ± NRB mask
ACE wrap ×2 Supraglottic airway device
Triangular bandage ×2 BVM
 CAT ×2 Commercial traction splint
Trauma shears Medications:
Pulse oximeter Ibuprofen, tylenol
Gloves
ALS In addition to the above: In addition to the above:
14 gauge angiocath ×2 IV supplies—selection of angiocaths
Steri-strips 1 L normal saline
Dermabond Endotracheal tubes
Gum elastic bougie
Laryngoscope blades and handle
Colorimetric EtCO2 detector
10-blade scalpel
Medications:
Morphine, fentanyl, midazolam, ketamine, tranexamic acid
(per protocol)
Provider As above In addition to the above:
Suturing supplies—needle driver, forceps, scissors, hemostats
Skin stapler
Various sutures—absorbable and nonabsorbable
Commercial thoracostomy kit with Heimlich valve
± handheld ultrasound depending on operational environment
Medications:
Lidocaine, cefazolin, clindamycin, amoxicillin/clavulanate

ACE wrap, all cotton elastic wrap; ALS, advanced life support; BLS, basic life support; BVM, bag valve mask; CAT, combat
application tourniquet; EtCO2, end tidal CO2; IV, intravenous; L, liter; NRB, non-rebreather; SAM splint, structural aluminum
malleable splint.

SUMMARY
Traumatic injury in the wilderness can range from trivial injures to life-threatening, multi-system
trauma. Assessment should be performed in a systematic manner to identify all potentially life-
threatening injuries. Physical exam findings together with consideration of mechanism of injury
will help determine the severity of injuries and the urgency of evacuation. Providers are most
likely to encounter orthopedic trauma and protocols may be established to expand scope of
practice to include fracture and dislocation reduction. For most major trauma, emergent
evacuation is indicated, and the WEMS provider may be responsible for performing limb- or
life-saving procedures that might not otherwise be performed in the traditional EMS system.
With appropriate management, even patients with severe traumatic injuries and prolonged
evacuation have survived wilderness trauma with minimal sequelae.

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16. Johnson S, Henderson SO. Myth: the Trendelenburg position improves circulation in cases of shock. CJEM. 2004;6(1):48-
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17. Stockinger ZT, McSwain NE. Prehospital supplemental oxygen in trauma patients: its efficacy and implications for military
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18. Cotton BA, Jerome R, Collier BR, et al. Guidelines for prehospital fluid resuscitation in the injured patient. J Trauma.
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19. Revell M, Porter K, Greaves I. Fluid resuscitation in prehospital trauma care: a consensus view. Emerg Med J.
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20. Butler FK, Holcomb JB, Schreiber MA, et al. Fluid resuscitation for hemorrhagic shock in tactical combat casualty care:
TCCC guidelines change 14-01–2 June 2014. J Spec Oper Med. 2014;14(3):13-38.
21. Cap AP, Pidcoke HF, DePasquale M, et al. Blood far forward: time to get moving! J Trauma Acute Care Surg.
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23. Drew B, Bennett BL, Littlejohn L. Application of current hemorrhage control techniques for backcountry care: part one,
tourniquets and hemorrhage control adjuncts. Wilderness Environ Med. 2015;26(2):236-245.
24. Drew B, Bird D, Matteucci M, Keenan S. Tourniquet conversion: a recommended approach in the prolonged field care
setting. J Spec Operations Med. 2015;15(3):81-85.
25. Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma. 2003;54(6):1127–1130.
26. de Guzman R, Polykratis IA, Sondeen JL, et al. Stability of tranexamic acid after 12-week storage at temperatures from
-20°C to 50°C. Prehosp Emerg Care. 2013;17(3):394-400.
27. Fischer PE, Bulger EM, Perina DG, et al. Guidance document for the prehospital use of tranexamic acid in injured patients.
Prehosp Emerg Care. 2016;20(5):4557-4559.
28. Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012;2:CD003861.
29. Moscati RM, Mayrose J, Reardon RF, et al. A multicenter comparison of tap water versus sterile saline for wound
irrigation. Acad Emerg Med. 2007;14(5):404-409.
30. Quinn RH, Wedmore I, Johnson EL, et al. Wilderness Medical Society practice guidelines for basic wound management in
the austere environment: 2014 update. Wilderness Environ Med. 2014;25:S118-S133.
31. Romanowski KS, Palmieri TL, Sen S, Greenhalgh DG. More than one third of intubations in patients transferred to burn
centers are unnecessary: proposed guidelines for appropriate intubation of the burn patient. J Burn Care Res.
2016;37(5):e409-e414.
32. Goodman T, Iserson KV, Strich H. Wilderness mortalities: a 13-year experience. Ann Emerg Med. 2001;37(3)279-283.
33. Oto B, Corey DJ II, Oswald J, Sifford D, Walsh B. Early secondary neurological deterioration after blunt spinal trauma: a
review of the literature. Acad Emerg Med. 2015;22:1200-1212.
34. Hauswald M. Did you ever have to make up your mind? spine care and decision making when there is not adequate data.
Acad Emerg Med. 2015;22(10):1197-1199.
35. Murray J, Rust DA. Cervical spine alignment in helmeted skiers and snowboarders with suspected head and neck injuries:
comparison of lateral c-spine radiographs before and after helmet removal and implications for ski patrol transport.
Wilderness Environ Med. In press.
36. Hauswald M. A re-conceptualisation of acute spinal care. Emerg Med J. 2013;30(9):720-723.
37. Stiell IG, Clement CM, Rowe BH, et al. Comparison of the Canadian CT head rule and the New Orleans criteria in patients
with minor head trauma. JAMA. 2005;294(12):1511-1518.
38. Quinn RH, Williams J, Bennett BL, et al. Wilderness Medical Society practice guidelines for spine immobilization in the
austere environment: 2014 update. Wilderness Environ Med. 2014;25:S105-S117.
39. National Association of EMS Physicians, American College of Surgeons Committee on Trauma. Withholding of
resuscitation for adult traumatic cardiopulmonary arrest. Prehosp Emerg Care. 2013;17(2):291.
40. Hill JG, Hardekopf SJ, Chen JW, Krieg JC, et al. Successful resuscitation after multiple injuries in the wilderness. J Emerg
Med. 2013;44(2):440-443.
 41. Nelson BP, Melnick ER, Li J. Portable ultrasound for remote environments, part I: feasibility of field deployment. J Emerg
Med. 2011;40(2):190-197.
42. Ditty J, Chisholm D, Davis SM, Estelle-Schmidt M. Safety and efficacy of attempts to reduce shoulder dislocations by non-
medical personnel in the wilderness setting. Wilderness Environ Med. 2010;21:357-361.
43. Bokor-Billmann T, Lapshyn H, Kiffner E, et al. Reduction of acute shoulder dislocations in a remote environment: a
prospective multi center observational study. Wilderness Environ Med. 2015;26:395-400.
44. Hawkins SC, Smith W, Wolfson D. Wilderness dislocation reductions by EMS. Unpublished manuscript currently in
submission.
45. Kellam P, Ostrum RF. Systematic review and meta-analysis of avascular necrosis and post traumatic arthritis after
traumatic hip dislocation. J Orthop Trauma. 2016;30(1):10-16.
46. Dean DB. Field management of displaced ankle fractures: techniques for successful reduction. Wilderness Environ Med.
2009;20(1):57-60.
47. Patzakis MJ, Harvey JP Jr, Ivler D. The role of antibiotics in the management of open fractures. J Bone Joint Surg Am.
1974;56(3):532-541.
48. Lane JCE, Mabvuure NT, Hindocha S, Khan W. Current concepts of prophylactic antibiotics in trauma: a review. Open
Orthop J. 2012;6:511-517.
49. Quinn RH, Macias DJ. The management of open fractures. Wilderness Environ Med. 2006;17:41-48.
50. Wakai A, O’Sullivan R, McCabe A. Intra-articular lidocaine versus intravenous analgesia with or without sedation for
manual reduction of acute anterior shoulder dislocation in adults. Cochrane Database of Systematic Reviews. 2011;
(4):CD004919.
51. White BJ, Walsh M, Egol KA, Tejwani NC. Intra-articular block compared with conscious sedation for closed reduction of
ankle fracture-dislocations. A prospective randomized trial. J Bone Joint Surg Am. 2008;90:731-734.
52. Fathi M, Moezzi M, Abbasi A, et al. Ultrasound-guided hematoma block in distal radial fracture reduction: a randomised
clinical trial. Emerg Med J. 2015;32(6):474-477.

*The Parkland Formula: 4 × weight in kg × percent BSA burned = total fluids to be given in the first 24 hours, with half given in
the first 8 hours and the remainder given in the next 16 hours.
INTRODUCTION
As noted in Chapter 1, wilderness medicine is defined as medical care delivered in those areas
where fixed or transient geographic challenges reduce availability of, or alter requirements for,
medical or patient movement resources.1–4 Many medical emergencies that occur in a wilderness
setting are directly related to the environment, such as altitude illness, heat or cold exposure,
traumatic injuries, and animal bites. However, everyday medical conditions, similar to those seen
in a front country setting, can and do occur.

Definition
Everyday medical conditions include chronic illnesses such as diabetes, heart failure, asthma,
and emphysema, as well as acute problems such as myocardial infarctions (“heart attacks”),
strokes, seizures, infections, abdominal pain, and genitourinary complaints. The wilderness
medicine practitioner must be able to recognize, diagnose, and treat these medical conditions in
an unfamiliar environment. Furthermore, environmental exposures and stress can precipitate
medical conditions in those with underlying comorbidities.

Scope of Discussion
This chapter will cover a broad range of medical conditions, from asthma to abdominal pain to
stroke to diabetes and beyond. A good wilderness emergency medical services (WEMS)
practitioner should be able to identify and understand basic medical conditions, and to prevent
those conditions from becoming acute problems in a wilderness environment when possible.
Some conditions, however, are unavoidable, and we will discuss different treatment options in
the wilderness setting, paying attention to what types of equipment might be at your disposal (as
well as what types of equipment you normally use to help diagnose and treat these conditions
that might be missing).
By the end of this chapter, you should be able to recognize basic medical conditions in a
wilderness environment, know how to treat these conditions, know what types of equipment to
consider having access to as a wilderness medicine provider, and have an understanding of how
to prevent certain medical conditions from becoming more severe or life-threatening.

EPIDEMIOLOGY
Wilderness recreation has become an increasingly popular activity over the past 40 years.
According to the National Park Service (NPS), 307 million recreational visits occurred in 2015
nationwide, up from 198 million recreational visits in 1979.5 In addition to increases in outdoor
recreation, our population is living longer and becoming more active later in life.6 Many older
individuals have comorbid health conditions with the potential to cause medical emergencies. An
analysis of emergency medical services (EMS) activations in Shenandoah National Park over a
5-year period showed that almost half of the calls were due to a medical illness, and the majority
of those patients had comorbid health conditions.7 Likewise, a review of search and rescue
incidents over a 10-year period in Yosemite National Park and a 4-year period in Utah National
Parks showed at least one-third of these calls were due to nontraumatic medical causes.8,9 As
more people continue to engage in wilderness activities, there will likely be an increase in the
number of EMS system activations due to medical reasons.

CLINICAL MANAGEMENT

Cardiac/Chest Pain
Heart disease is the leading cause of death among both men and women in the United States.10
Common risk factors for the development of heart disease include high blood pressure, high
cholesterol, diabetes, obesity, poor diet, and sedentary lifestyle. While cardiac conditions such as
coronary artery disease and congestive heart failure are more often seen in older populations, the
prevalence of heart disease in younger individuals is not uncommon.10 The first step when
assessing a patient with chest pain in the wilderness is to determine if they have a known history
of cardiac disease, or have cardiac risk factors. This helps determine the etiology of the patient’s
symptoms.

Identification
Angina pectoris is chest pain that occurs from inadequate blood flow to heart muscle, most
often due to a blockage within the vessels supplying the heart. The pain is often described as a
squeezing, pressure-like sensation to the middle of the chest. It is sometimes associated with jaw
pain, arm pain, diaphoresis, or nausea.11 Older individuals, those with diabetes, and females often
present with atypical angina symptoms—their cardiac disease may present with nausea,
weakness, or shortness of breath as the only symptom. Chest pain that occurs with exertion and
improves with rest is termed stable angina. Unstable angina is pain that occurs at rest, usually
described as severe, and often occurring in a crescendo-like pattern.12 While any angina is
concerning in a wilderness environment, unstable angina is considered a medical emergency and
needs to be immediately evacuated to a hospital setting.
Myocardial infarctions (MIs) occur when blood flow to the heart muscle is blocked,
causing tissue ischemia and cell death. Often patients will have symptoms classically described
as crushing, heavy, pressure-like substernal chest pain. Other patients may be asymptomatic, or
experience mild or atypical symptoms from their MI. Once the heart muscle dies, it no longer
functions and may cause dysrhythmias due to abnormal electrical conduction over damaged
myocardium. This can lead to malignant arrhythmias such as ventricular tachycardia or
ventricular fibrillation. It can also lead to poor myocardial squeeze and decreased cardiac output,
resulting in cardiomyopathy and congestive heart failure.13
The leading cause of congestive heart failure (CHF) in the United States is coronary artery
disease and myocardial ischemia. CHF can originate as either right ventricular or left ventricular
dysfunction, but ultimately leads to poor heart squeeze and fluid backup in the heart, lungs, and
peripheral vasculature. Clinically, this most commonly manifests as lower extremity edema,
pulmonary edema, orthopnea (shortness of breath while lying flat), and dyspnea on exertion.
CHF can be managed as a chronic condition, controlled with medications such as
antihypertensives, rate controlling agents, and diuretics,14 and only becomes a problem when it
becomes “decompensated,” meaning the body’s metabolic demands outweigh the heart’s ability
to function. A person who has well-controlled CHF may find themselves with worsening heart
failure symptoms if they exert themselves at altitude or in extreme environments, where the heart
has to work harder than it is capable of doing.
Another medical emergency that causes chest pain is aortic dissection. The aorta is
comprised of three layers—the intima, media, and adventitia. A dissection occurs when a tear in
the intima allows blood to enter the media layer. The high pressure of this blood then propagates
along the media, creating a false lumen with a weakened wall (Figure 22.1). The most common
causes are hypertension and connective tissue disorders such as Marfan’s syndrome. A thoracic
aortic dissection will classically present with severe, tearing chest pain, radiating to the back.11,15
Often the patient will have extremely high blood pressures and more than 20 mm Hg measured
systolic blood pressure differences between the upper extremities. Aortic dissection should be
considered in any patient who presents with chest pain and an associated neurologic complaint
such as upper extremity numbness or weakness, as dissections can disturb the blood flow to
arteries supplying the central nervous system, creating both chest pain and neurologic symptoms.
FIGURE 22.1. Two Common Patterns of Aortic Dissection. Blood is pumped through the intimal tear to create a false channel
with a weakened wall. From Morton PG, Fontaine DK. Critical Care Nursing. 11th ed. Philadelphia, PA: Wolters Kluwer; 2018.

The most extreme cardiac dysfunction that can occur is cardiopulmonary arrest.
Cardiopulmonary arrest occurs due to a wide variety of factors. Massive MI can lead to large
territory cardiac muscle ischemia and pump failure. Fatal arrhythmias can develop due to
underlying cardiac disease, heart failure, medications, metabolic disorders, and congenital
cardiac abnormalities. Respiratory failure can lead to cardiopulmonary arrest by causing
hypoxemia, which in turn leads to severe metabolic derangements and ultimately inability to
sustain cardiac function.
The major causes of cardiopulmonary arrest can be remembered with the pneumonic of “the
Hs and Ts.” These include Hypoxia, Hypovolemia, Hypothermia, Hydrogen ion (acidosis),
Hypo/hyperkalemia, cardiac Tamponade, Tension pneumothorax, Toxins, Thrombosis (MI),
Thromboembolism (pulmonary embolism), and Trauma. The cause of cardiopulmonary arrest is
most often based on the history and particular situation. If someone has sustained a traumatic
injury causing hemorrhagic shock, the most likely cause of his or her arrest is hypovolemia,
which is unlikely to respond to on-scene cardiopulmonary resuscitation (CPR). If a patient was
complaining about calf swelling and chest pain with breathing prior to his or her collapse,
pulmonary embolism becomes a likely culprit. Unfortunately, in the wilderness setting, most of
these conditions change from potentially reversible to likely fatal, as they are highly time and
resource dependent. Screening for risk factors and prevention of these conditions is therefore of
much higher yield than carrying defibrillators or performing CPR in the wilderness.

Prevention
Preventing cardiac morbidity and mortality in the wilderness setting is most often about pre-
participation planning. Anyone with known cardiac disease should consult with their physician,
preferably their cardiologist, before participating in a wilderness activity. Someone with a history
of angina needs a full cardiac evaluation prior to participation, including provocative testing that
will mimic the proposed activity, ie, a “stress test.” Those with known CHF should be medically
optimized with good blood pressure control and a stable diuretic regimen prior to any sort of
exercise activity. Participants should have all of their medications with them at all times, and
others in the group should be aware of their underlying medical conditions, particularly group
leaders. Many cardiac conditions such as MI and aortic dissection are acute emergencies that
cannot always be prevented. Therefore, it is important that all wilderness medical providers are
able to recognize the warning signs of these conditions and know how to evacuate these patients
appropriately.

Treatment and Disposition

Treatment of any cardiac condition begins with the basics of airway, breathing, and circulation.
All providers should be able to recognize the warning signs of impending cardiac pathology and
to initiate treatment.
FIRST AID
First aid providers should begin treatment by assessing the patient. When a person complains of
chest pain, shortness of breath, appears pale, cool, clammy, and diaphoretic, the first step is to
stop whatever the patient is doing, and have him or her sit down and rest. Attempt to take a set of
vital signs (at a minimum check for pulse, respiratory rate, and estimate systolic blood pressure
based on pulse pressure—requiring no equipment) and recognize any abnormalities. Any vital
sign abnormalities should be documented and rechecked frequently while determination of
proper evacuation method is initiated.
BASIC LIFE SUPPORT
The basic life support (BLS) provider should also frequently assess vital signs and be prepared to
provide supportive care as needed. If symptoms are concerning for MI, give four tablets of 81
mg chewable aspirin. Patients presenting with signs of decompensated heart failure such as
worsening dyspnea, orthopnea, or significant extremity swelling or signs of aortic dissection
need to be evacuated immediately to the nearest hospital for further evaluation.
ADVANCED LIFE SUPPORT
For those with more advanced training such as advanced cardiac life support (ACLS), you are
dependent on the equipment and medications present. For patients with signs or symptoms of MI
or heart failure, give aspirin, establish intravenous (IV) access, monitor clinical exam including
vital signs, resuscitate as needed, and evacuate rapidly. Patients with a suspected aortic
dissection need IV access, close blood pressure monitoring, and evacuation.
CLINICIANS
Similar to advanced life support (ALS) providers, clinicians are also dependent on the equipment
and medications present. If a patient appears to be having signs of a MI, give 324 mg chewable
aspirin. For patients with signs of decompensated heart failure, medications that may be
beneficial include diuretics such as furosemide and vasodilators such as nitroglycerin to reduce
preload and afterload. For patients with signs of aortic dissection, blood pressure control and
rapid evacuation are essential. 12-lead electrocardiogram (ECG) capability is becoming
increasingly miniaturized and portable, and some WEMS systems have begun deploying ECG-
capable machinery into the field. If an ST-segment elevation MI (STEMI) is identified, and
access to the nearest percutaneous interventional facility for catheterization is known to be
greater than 2 hours, some systems are electing to administer thrombolytics in the wilderness
setting. All medications need to be given with extreme caution in the wilderness, as they have the
potential to cause clinical decline without appropriate monitoring and resuscitative equipment.
For any level of provider, if you encounter a patient in the wilderness in cardiopulmonary
arrest, assess their level of responsiveness, determine if the patient is breathing, and if the patient
has a pulse. If he or she does not have a pulse, begin CPR. The American Heart Association
(AHA) guidelines currently recommend providers initiate CPR in a C-A-B (circulation-airway-
breathing) approach to minimize delay in compressions in order to provide adequate circulation
of blood to the brain.16 If an automated external defibrillator (AED) device is available, attach the
pads to the patient as soon as possible, taking care to minimize interruptions in chest
compressions, and follow the instructions on the device. The AHA guidelines recommend early
defibrillation, as it can reduce morbidity and mortality associated with cardiac arrest. It is
critically important in a wilderness setting to remember this approach does not apply in lightning
strike or drowning subjects, as rescue breaths should be delivered immediately in these
conditions. Care of lightning patients and drowning patients is discussed in more detail in
Chapters 18 and 16, respectively. Assistance or definitive care may be hours away; therefore,
when considering CPR in the wilderness, one must weigh the risks to the rescuer(s) versus the
potential outcome and benefit to the patient. Someone who has had a massive heart attack, is in
cardiac arrest, and is multiple hours away from definitive care, may be unlikely to survive this
event. If they do survive, their outcome is likely to be far more severe in morbidity than if it had
occurred close to definitive care. If there is a potentially reversible cause of arrest, such as
hypoxia, hypovolemia, or tension pneumothorax, and there are resources available to treat those
accordingly, these measures can be life saving. However, providing prolonged CPR can be both
physically and emotionally exhausting to the rescuer. CPR in a wilderness setting may be
discontinued after 30 minutes if the patient does not have return of spontaneous circulation. The
potential exception to that 30-minute time frame is a hypothermic patient, as decreased body
temperature is neuroprotective, thus patients may have partial, if not full, neurologic recovery
despite a prolonged resuscitation. Again, the rescuer must weigh the risk of prolonged CPR to
the providers, especially in a cold environment. In the wilderness, CPR should not be initiated
for patients with obvious signs of death (rigor mortis, lividity, decapitation), frozen chest wall,
ice in the airway, submersion in cold water for longer than 60 minutes, and any situation that
would put a rescuer in excessive danger.17

Equipment Summary
There is a plethora of equipment to consider having when working or recreating in a wilderness
environment. The amount and size of equipment will depend on the type of activity and the
location. If backpacking in a remote location, you are likely to have less equipment than if
camping near a road. Everyone, with medical training or not, should carry a basic first aid kit
with them at all times. BLS-trained providers may consider carrying a stethoscope and
sphygmomanometer to assist in taking vital signs; however, a seasoned provider will be able to
ascertain a good blood pressure estimate with simple palpation. Medications that one should
have in the wilderness are again highly dependent on the activity and location of the patient, the
makeup of the responding EMS team, as well as the practitioner’s scope of practice. Chewable
aspirin is easy to carry, has multiple potential uses, and has been shown to reduce morbidity in
MI. Nitroglycerin is a medication carried by many patients with angina. It causes vasodilation to
the coronary arteries, thereby increasing blood flow. Nitroglycerin should be used with caution
because it can cause hypotension in the setting of a right ventricular MI (which is unknown
without an ECG). Other medications such as atropine, epinephrine, and vasopressors (which may
be carried by some WEMS systems) are rarely carried in wilderness settings. If you have access
to these medications, they should be administered per ACLS guidelines (Figure 22.2).
In the event of cardiopulmonary arrest, practice to the best of the provider’s capabilities and
scope of practice. If you have advanced airways, AEDs, resuscitation medications, IV fluids, and
IV supplies, they should be used as indicated by training level and situation. Overall treatment of
cardiac emergencies in the wilderness involves identifying the potential etiology of symptoms,
treating to the best of the provider’s ability, and evacuating the patient in a timely manner to
definitive care.

Respiratory/Shortness of Breath
Respiratory emergencies are commonly encountered in a wilderness setting. Many people have
underlying respiratory diseases, which can limit exercise tolerance or be exacerbated by
environmental factors. In addition, respiratory infections can be potentially life threatening if not
recognized and treated.

Identification
Asthma is one of the most common respiratory conditions. In 2014, the Centers for Disease
Control (CDC) found that 8.6% of all U.S. children (defined as younger than 18 years of age)
and 7.4% of all U.S. adults (defined as older than 18 years of age) are currently diagnosed with
asthma.18 The condition is caused by chronic bronchial inflammation that limits airflow and can
lead to airway obstruction. Asthma is identified by the presence of wheezing, a prolonged
expiratory phase, and diminished air movement on auscultation. A patient experiencing an
asthma exacerbation will often complain of shortness of breath and chest tightness. In severe
exacerbations, patients may be tachycardic, tachypneic, and speaking in short sentences due to
difficulty breathing. Even patients with well-controlled asthma can experience exacerbations in a
wilderness setting. A prospective study of 203 wilderness travelers with known asthma showed
that 43% experienced an asthma attack while engaging in a wilderness activity.19
FIGURE 22.2. ACLS pulseless arrest algorithm. Adapted from Cardiac Arrest Algorithm: Algorithms for Advanced Cardiac
Life Support 2017. ACLS Training Center website. https://www.acls.net/aclsalg.htm. July 27, 2017 and Neumar RW, Otto CW,
Link MS, Kronick SL, Shuster M, Callaway CW, Kudenchuk PJ, Ornato JP, McNally B, Silvers SM, Passman RS, White RD,
Hess EP, Tang W, Davis D, Sinz E, Morrison LJ. Part 8: Adult Advanced Cardiovascular Life Support. Circulation.
2010;122:S729-S767.

Chronic obstructive pulmonary disease (COPD) is a condition of limited air movement

that occurs either secondary to diminished elasticity of the alveoli (emphysema) or chronic
inflammation of the airways (chronic bronchitis).20 The most common cause of COPD is long-
term tobacco use, but other causes such as interstitial lung disease and α-1-antitrypsin deficiency
can cause similar symptoms. Most patients are aware of their chronic lung conditions, but this
should also be suspected in those with a history of long-term cigarette smoking. Similar to
asthma, wheezing, prolonged expiration, and diminished air movement can also be appreciated
in COPD. Patients experiencing a severe COPD exacerbation may present with pursed lip
breathing, cyanosis, agitation or anxiety, and tripod positioning (bent over with hands on knees
to help with breathing). Environmental allergens, altitude, infections, and increased exercise can
all exacerbate COPD symptoms.
The respiratory tract can be divided into upper (nares, nasal cavity, oropharynx, larynx) and
lower (trachea, bronchi, bronchioles, alveoli). Both upper respiratory infections (URIs) and
lower respiratory infections such as pneumonia can be problematic in a wilderness environment.
URIs are most commonly caused by viruses and are often referred to as “the common cold.”
Symptoms can include cough, congestion, rhinorrhea, sinus pain, fever, and sore throat.
Pneumonia can present similarly to URIs and it can be difficult to differentiate between the two
clinically. Classically, pneumonia presents with fever, cough productive of green or yellow
sputum, and “crackles” on lung auscultation (Figure 22.3). Both viruses and bacteria can cause
pneumonia. Bacterial pneumonia often needs evaluation and possibly treatment in a hospital
setting, as these patients may require supplemental oxygen and have a potential to decompensate
and become systemically ill without timely and appropriate antibiotic treatment.
A pulmonary embolism (PE) is a blood clot that travels (most often from deep leg veins) to
the pulmonary blood vessels. Blockage in the pulmonary vessels causes a mismatch between
ventilation and perfusion in the lung sections supplied by the occluded vessels. The incidence of
PE has been reported to be approximately 60 to 70 per 100,000 individuals.21 Certain populations
are predisposed to thromboembolic disease such as those with clotting disorders, recently
postoperative patients, those on estrogen or other hormone replacement therapies, cancer
patients, and pregnant women. PE often presents with chest pain on inspiration, termed pleuritic
pain. When the blockage is large or obstructs a major pulmonary vessel, it can cause significant
heart strain, hypoxemia, and cardiopulmonary arrest. Indicators of possible PE are shortness of
breath, pleuritic chest pain, unilateral leg swelling (indicating deep vein thrombosis),
tachycardia, hypoxia, and pulseless electrical activity leading to cardiopulmonary arrest.

FIGURE 22.3. Chest radiograph of a right middle lobe pneumonia (marked by arrows). From Webb WR, Higgins CB. Thoracic
Imaging. 3rd ed. Philadelphia, PA: Wolters Kluwer; 2017.
 Another cause of sudden respiratory distress is a spontaneous pneumothorax. A
pneumothorax occurs when air becomes trapped in the pleural space and creates increased
pressure on the lung, causing a “collapsed lung.” Most often, these are encountered in the setting
of trauma. However, a pneumothorax can occur spontaneously, caused by a ruptured air sac in
the lung, termed a “bleb.” These most often occur in young, thin males and in patients with
underlying lung disorders such as COPD/emphysema. A pneumothorax presents with sudden
onset of dyspnea and diminished breath sounds to the affected side. If a pneumothorax becomes
large enough, increased pressure in the pleural cavity will shift the mediastinum away from the
affected side causing a tension pneumothorax (Figure 22.4). This can cause compression of the
superior vena cava and decreased diastolic filling in the heart, leading to decreased cardiac
output. Clinically, patients present with tracheal deviation, absent breath sounds on the side of
the pneumothorax, and Beck’s triad (jugular venous distention, hypotension, and muffled heart
sounds).

FIGURE 22.4. Open Pneumothorax (top) and Tension Pneumothorax (bottom). During inspiration air enters the pleural
cavity. In an open pneumothorax, air exits during expiration. In a tension pneumothorax, air is unable to exit; creating increased
intrathoracic pressure and subsequent shifting of the mediastinum. From Grossman SC, Porth CM. Porth’s Pathophysiology:
Concepts of Altered Health States. 9th ed. Philadelphia, PA: Wolters Kluwer Health Lippincott Williams & Wilkins; 2014.

Prevention
Many respiratory conditions in the wilderness can be prevented by planning and preparation.
Anyone with a known underlying lung disorder, such as asthma or COPD, should have a full
pulmonary evaluation to ensure he or she is well-controlled with or without medications before
participating in any wilderness activities. These patients should ensure they have access to all
daily medications and rescue inhalers at all times in a wilderness environment. In addition, there
should be a response plan in place, such as increasing dosages of home medications, if
respiratory function worsens.22 Some triggers for flares of reactive airway disease include
environmental irritants such as pollen or grass, temperature (both extreme heat and cold) and
humidity, strenuous activity, and altitude changes. Knowing the anticipated environment prior to
partaking in wilderness activities will help prevent worsening of underlying pulmonary disease.

Treatment and Disposition

Treating a respiratory emergency in the wilderness can be a very stressful experience, since
many of the diagnostic and therapeutic tools medical providers are accustomed to having may
not be available (such as supplemental oxygen, chest radiographs, and advanced airway
equipment).
FIRST AID
Basic first aid goals are to recognize worsening respiratory status, attempt to remove whatever
exacerbating factor is causing the symptoms, and determine if the patient needs immediate
transport to a higher level of care. If someone with a known history of asthma is having shortness
of breath, encourage home medication (such as albuterol) administration to help with these
symptoms.
BASIC LIFE SUPPORT
For BLS providers, the goals of care are to provide supplemental respiratory support when
possible, such as oxygen and albuterol, and recognize when patients need to be evacuated to a
higher level of care.
ADVANCED LIFE SUPPORT
ALS providers can intervene most aggressively in respiratory distress if medications and other
equipment are available. For asthma and COPD patients, bronchodilators and steroid
medications are indicated. If there is concern for PE or pneumothorax, the provider should
ensure the patient has adequate IV access and close monitoring of vital signs and respiratory
status until hospital evaluation. If there is concern for a tension pneumothorax, the ACLS
provider can perform needle decompression (Figure 22.5) and obtain an advanced airway if
needed.
CLINICIANS
Clinicians providing care in the wilderness can administer medications such as albuterol,
steroids, and antibiotics if there is concern for respiratory infection, and can work to obtain
advanced airways if indicated. A wilderness clinician should anticipate the limits of his or her
capabilities outside a hospital environment and act accordingly (eg, if a patient is in respiratory
distress and you are able to intubate them, you need to ensure you have a self-inflating bag valve
mask and staff to manage respirations until definitive care is reached).

Equipment Summary
Much of the treatment for respiratory conditions is dependent on the equipment a provider has at
his or her disposal, or those the patient has brought with them. While a solo wilderness provider
may not carry supplemental oxygen, most EMS systems will have the ability to provide
supplemental oxygen. However, with the possibility of prolonged extrication and transport times,
EMS providers need to be cognizant of having adequate supplies to maintain a patient’s
oxygenation for prolonged periods of time. In addition, the presence of advanced airway
equipment such as a laryngoscope blade and endotracheal tube will be dependent on the level of
training of the responding wilderness EMS providers. Providers working in high altitude settings
should carry diagnostic equipment such as pulse oximetry and peak flow meters to aid in the
evaluation of respiratory impairment as well as provide monitoring of response to treatments.
Having an albuterol inhaler for asthma and COPD exacerbations and a large bore IV catheter for
emergent needle decompressions are potentially the most portable and important respiratory
supplies for a wilderness provider.

FIGURE 22.5. Technique for needle decompression. From Cohen BJ, DePetris A. Medical Terminology: An Illustrated Guide.
8th ed. Philadelphia, PA: Wolters Kluwer; 2017.
Neurologic
Neurologic conditions can occur at any time and often without warning. Headaches and
migraines, seizures, and ischemic events are a few of the neurologic complaints that can be
encountered in a wilderness setting.

Identification
Headaches and migraine headaches are common in the general population. The World Health
Organization estimates that 50% of adults worldwide suffer from at least one headache per
year.23 Headaches occur for a variety of reasons including dehydration, decreased sleep,
hormonal changes, stress, medications, stimulant use and withdrawal (eg, caffeine) to name a
few; often, providers have no etiology for a headache. Migraine headaches differ from other
headaches in that they are many times preceded by an aura and have a set of associated
symptoms that can include nausea, vomiting, photophobia, phonophobia, and vision changes.
Others may have frank weakness or numbness as part of their migraine aura. Migraines are
usually recurrent and lifelong; in 2009, the CDC reported approximately 20% of females and
10% of males suffered from some type of migraine or severe headache.24 Often, a patient
presenting with a headache will have experienced similar symptoms in the past. Headaches that
are sudden in onset or “thunderclap,” described as the worst headache of one’s life or in a patient
who has never experienced a headache, or headache associated with neurologic deficits or
changes in mental status need to be evaluated immediately in a hospital setting.
Seizures are the result of overactive neuronal activity in the brain. Seizures can be classified
as focal or generalized. Focal seizures can involve isolated motor groups, sensory systems,
vision, or olfaction. During these types of seizures, the patient remains responsive. Generalized
seizures include tonic–clonic, myotonic, absence, or atonic seizures. Generalized tonic–clonic
seizures are the most recognized type of seizure. Common causes of seizures include medication
noncompliance, sleep deprivation, fever and infection, electrolyte abnormalities (hyponatremia
and hypoglycemia), benzodiazepine or alcohol withdrawal, and trauma. Depending on the cause
of the seizure, the presentation may differ slightly. Many seizures occur with little to no warning,
except in those with epilepsy who experience auras. It is important for providers to take a
thorough history to recognize any warning signs of increased seizure risk.
Ischemic events such as a transient ischemic attack (TIA) and cerebral vascular accident
(CVA or “stroke”) can also occur at any time. A TIA is often referred to as a “mini-stroke”
because patients experience a neurologic deficit indistinguishable from a CVA, but the
symptoms of a TIA resolve within 24 hours, while CVA symptoms persist. Therefore the
difference between a TIA and a CVA cannot be determined in the field for the first 24 hours of
symptoms. Patients who have TIAs, in other words who have stroke-like symptoms that last less
than 24 hours, are at increased risk of having a subsequent full stroke, and thus need a full
evaluation urgently.25 Both TIAs and CVAs can present with a wide variety of symptoms.
Classically, a stroke causes unilateral motor weakness, associated with symptoms such as
difficulty speaking, changes in sensation, dizziness, or difficulty walking. Anyone with new
neurologic complaints such as focal weakness, numbness, dizziness, or difficulty speaking needs
evacuation for hospital evaluation.

Prevention
Neurologic conditions can be preventable with appropriate preparation and management of risk
factors. Those with known headache disorders or headache triggers should be careful to avoid
irritants or behaviors that will increase their likelihood of developing headaches. Many patients
who have migraines can feel the beginning of a migraine developing and have abortive
medications that can control symptoms before they become too extreme. Patients with seizure
disorders are often aware of precipitants that will trigger their seizures and try to avoid them.
Many will be maintained on antiepileptic medicines, but he or she must be diligent about
compliance to avoid having a seizure. Anyone with a seizure disorder should be fully evaluated
by his or her neurologist prior to wilderness activity, and should never participate in activities
alone such as swimming or involving potential fall from height, such as rock climbing. Patients
with a known history of TIA or CVA should also be fully evaluated by a neurologist before
participating in wilderness activities. Many of these patients can be medically optimized to
reduce their risk of stroke or subsequent stroke; however, some of these medications may
increase risk of bleeding in trauma, which should also be factored in the decision to participate in
wilderness activities. If a patient has known neurologic deficits from a previous stroke, care
should be taken in regard to choice of wilderness activity, as they may have specific limitations.

Treatment and Disposition

The acute treatment of neurologic conditions often depends on the underlying etiology. Minor
conditions such as headaches may be easily amenable to treatment in a wilderness setting, while
treatment of seizures and strokes depends upon training level and availability of medications and
supplemental equipment.
FIRST AID
The first aid provider should begin by assessing the patient’s chief complaint. Patients with
simple headaches can be treated with acetaminophen or ibuprofen for pain relief. Those with
other home medications or specific migraine medications should be instructed to bring a supply
and take those as directed. Actively seizing patients should be supported, so they do not cause
trauma to themselves or others. This can be achieved by placing a soft surface such as a pillow,
sleeping bag, or sleeping pad underneath the patient and removing any hard objects, such as
rocks, from the area. Any patient with signs of a TIA or CVA needs to be evacuated
immediately.
BASIC LIFE SUPPORT
BLS providers should perform a basic neurologic examination and history for any patients with
new or concerning headache symptoms. This attempts to rule out potentially life-threatening
causes of headache such as intracranial bleeding, tumor or mass, or intracranial infection. For
actively seizing patients, BLS providers should support the patient to minimize trauma from the
seizure as well as attempt to determine the seizure etiology when possible. For patients with
neurologic symptoms concerning for stroke, the provider should document the time of onset,
monitor diligently for any clinical changes, and document vital signs closely while arranging
rapid evacuation.
ADVANCED LIFE SUPPORT
ALS providers should obtain a detailed neurologic history and examination for any concerning
headache complaints. For seizing patients, if the provider has access to benzodiazepines (such as
lorazepam or diazepam), these should be given first line to stop seizure activity. Ideally these
medications are given via the rectal (PR), IV, or intramuscular (IM) route, as these patients are
unable to take oral medications. Particular attention should be paid to the airway to ensure that
the patient is maintaining appropriate oxygenation and ventilation. If the patient is not
maintaining adequate ventilation, he or she will require supplemental oxygen and advanced
airway placement, if available. Most importantly, the cause of the seizure should be identified if
possible and addressed. If there is concern for hypoglycemia, glucose should be administered
immediately, either intravenously or sublingually (if a paste or powder form of glucose is
available; exercise gels or packets can be used for this purpose and are often available). If the
suspected cause is environmental such as heat stroke, the patient should be cooled as quickly as
possible. More information about heat stroke is available in Chapter 14 (Heat Illnesses). If the
suspected cause is drug or alcohol withdrawal, give benzodiazepines. If the cause is a missed
dose or two of antiepileptic medication in a patient with a known seizure disorder, give oral
doses as soon as possible. Most likely seizure patients will require evacuation and transport to a
hospital for further evaluation.
Any patient with TIA or CVA symptoms requires emergent evacuation to a hospital.
Treatment of a CVA with thrombolytic therapy is time sensitive and therefore in a wilderness
setting, all providers should focus their efforts on rapid and safe transport. If evacuation is
delayed or prolonged, providers can give 325 mg of oral aspirin initially and then 81 mg orally
every day subsequently, monitor blood pressure to maintain a goal of less than 140/90 (avoid
extreme hyper- or hypotension), and monitor the neurologic exam closely.26,27
CLINICIANS
Clinicians should take a thorough history and perform a detailed neurologic exam on any patient
presenting with headache, seizure history, or stroke-like symptoms. Providers can administer
pain relief for headaches, benzodiazepines for seizures (see ALS section), and antiplatelet agents
for CVA symptoms (see ALS section). Most patients with headaches will not require evacuation
unless there are concerning signs or symptoms for a serious cause such as intracranial bleeding,
mass, or infection. All patients displaying any TIA or CVA symptoms require immediate
evacuation. Clinicians should make informed decisions about evacuation for seizure patients.
Any patient with a first-time seizure or a seizure without a clear etiology will require evacuation.
If a patient has a known seizure disorder and an identifiable and easily treatable etiology for his
or her seizure, the clinician can decide whether evacuation is needed. A clinician should be
mindful that he or she is in a resource-poor environment and proceed cautiously with disposition
decisions.

Equipment Summary
No major equipment is required in the wilderness setting to deal with most neurologic
complaints. Recommended medications include pain relievers such as acetaminophen and
ibuprofen for headache management, benzodiazepines for seizure, and aspirin for TIA/CVA.
Advanced airway supplies, IV supplies, and cardiopulmonary monitoring will be necessary in
critically ill patients, all of whom will require emergent evacuation from a wilderness
environment to a hospital for further evaluation and management. Due to the need to rule out an
intracranial hemorrhage as the source of a CVA and the controversy of the risk–benefit analysis
of thrombolytics in CVA, no system of which we are aware currently utilizes thrombolytics in
the wilderness for CVA treatment. The need to rapidly consider this treatment modality
exclusively in a hospital setting (along with the possibility of interventional procedures) is the
primary reason why speed of evacuation is particularly important for CVA patients.

Diabetes
Diabetes mellitus is a disease of dysregulation of normal glucose metabolism. Approximately 20
million people in the United States are currently diagnosed with diabetes; this is a 4-fold increase
from 1980.28 In the normal physiologic state, glucose stimulates the pancreas to produce insulin,
which assists in the cellular uptake of glucose for energy and metabolic functioning. Type 1
diabetes occurs when the pancreas does not secrete enough insulin. Type 2 diabetes occurs when
peripheral cell receptors become desensitized to insulin, and therefore the body has impaired
glycemic control. Patients with type 1 diabetes are treated with insulin, while patients with type 2
diabetes may be treated with some combination of diet and exercise, oral medications, and
insulin. Patients with type 2 diabetes may eventually require exogenous insulin because their
pancreas has essentially “burned out.”

Identification
In the wilderness setting, a provider may see patients presenting with both low blood sugars
(hypoglycemia) and elevated blood sugars (hyperglycemia). Hypoglycemia is seen most
frequently in those with insulin-dependent diabetes. Causes of hypoglycemia include increased
metabolic rate (eg, strenuous exercise such as on a backpacking trip), taking too much
medication (either insulin or an oral glycemic agent), decreased oral intake (such as decreased
appetite while hiking or decreased palatability of food on a backpacking trip), infection, and
adverse effect of certain medications such as indomethacin, pentamidine, and quinine.29,30
Hyperglycemia, on the other hand, usually arises from medication noncompliance, high-sugar
diet, or infection.
Symptoms of hypoglycemia include tremulousness, diaphoresis, nausea, and altered mental
status. This can occur fairly suddenly and can progress rapidly to seizure, coma, and death if not
treated appropriately. Hyperglycemia most commonly presents with increased thirst (polydipsia),
increased urination (polyuria), and increased appetite (polyphagia). Both hypoglycemia and
hyperglycemia can be identified by history and evaluation of blood glucose level. Many diabetics
are aware of their symptoms of hyperglycemia or hypoglycemia and can regulate their insulin or
intake accordingly.

Prevention
Prevention of diabetes has become a major global public health campaign, with education
focused on recognition, diet control, weight control, and close monitoring of those at risk. In the
wilderness setting, prevention is focused on being prepared to treat patients who have a known
history of diabetes. Patients are encouraged to increase their exercise regimen prior to any
wilderness activity, to mimic their wilderness energy expenditure so they are able to anticipate
metabolic changes, and to control their blood sugar appropriately. All patients with diabetes
should monitor their blood sugar with a glucometer while in a wilderness environment. This
means having a temperature-regulated place to store the glucometer, extra test strips, and extra
batteries. Patients with diabetes should carry two to three times the amount of medication and
supplies needed in case of emergency or delays in travel.31 In addition to appropriate amounts of
medication, patients must have the ability to store that medication effectively. Insulin, for
example, should be refrigerated at 36°F to 46°F (2°C to 8°C), although it will be effective at
room temperature (56°F to 89°F [13°C to 32°C]) for up to 28 days.32,33 Someone in a very hot or
cold environment may not be able to temperature regulate their medication appropriately;
therefore, planning ahead is essential for those with diabetes. Some diabetic patients currently
wear insulin pumps that both check glucose levels and administer the appropriate amount of
insulin. These may fail, however, so alternative means of insulin delivery and blood glucose
monitoring should be carried as a backup. Our recommendation for patients with insulin pumps
that are apparently failing is to keep them in place while supplemental insulin is administered.

Treatment and Disposition

Treating a patient with diabetes depends on whether the patient is hypoglycemic or
hyperglycemic. As a medical provider, if you are unsure of a patient’s glucose status, it is better
to err on the side of giving extra sugar. If the patient is hypoglycemic, this can be a lifesaving
maneuver. If the patient is hyperglycemic, the small amount of extra sugar will not be
detrimental in the setting of profound hyperglycemia.
FIRST AID
For the first aid provider, encourage the hypoglycemic patient to orally take 15 g of rapidly
absorbed carbohydrate such as glucose tablets, juice, or hard candies if it is clear the patient can
safely swallow.34 If the patient knows he or she is hyperglycemic, encourage aggressive
hydration and diabetic medication use.
BASIC LIFE SUPPORT
BLS providers should monitor blood glucose levels on these patients as often as possible. If a
patient has altered mental status from presumed hypoglycemia, administer oral glucose. If there
is concern about the patient’s ability to swallow appropriately, apply sugar or a sugary substance
onto the gums or under the tongue. Recheck until glucose levels and mental status have
normalized.
ADVANCED LIFE SUPPORT
ALS providers can provide IV glucose in the form of 25 g of 50% dextrose in water for adults
(0.5 to 1 g/kg of 25% dextrose in water for children less than 8 years old) and 1 mg of IM or
subcutaneous (SC) glucagon in the setting of hypoglycemia.34 For patients with hyperglycemia,
IV or SC insulin can be administered along with aggressive IV hydration if medications and
equipment are available. Providers should frequently recheck blood glucose (approximately
every 30 to 60 minutes) to monitor treatment efficacy. If there is not a known precipitant for the
patient’s hyperglycemic or hypoglycemic state, that patient should be evacuated to a hospital
setting for further evaluation.
CLINICIANS
Clinicians should treat hypoglycemic patients with dextrose and hyperglycemic patients with IV
fluids and insulin as described previously (see ALS section). Additionally, clinicians should
attempt to determine the etiology of the problem such as infection, medication noncompliance,
or increased exercise level, and remedy the problem when possible. This includes treating
presumed infections, decreasing doses of insulin for patients with increased energy expenditure,
and closely monitoring patient medication compliance. Any patient who cannot safely maintain
control of his or her blood glucose levels needs to be evacuated.
Equipment Summary
Equipment required for the management of diabetes includes a glucometer, oral glucose (often in
the form of glucose tablets), IV dextrose if available, IV fluids, and insulin. A personal
glucometer, oral glucose, and prescribed diabetes medications, such as oral glycemic agents and
insulin, are mandatory for anyone with diabetes traveling in a wilderness environment. For a
medical provider, extra supplies such as IV setups and advanced resuscitation equipment will be
dependent upon location and situation; however, simple oral glucose solutions such as gels and
exercise electrolyte chew candies are easily available, usually present on backpacking trips, and
can be utilized in an emergency for hypoglycemia.

Allergic Reaction/Anaphylaxis
Allergic reactions occur when a person’s immune system overreacts to a specific substance
(allergen) and causes a systemic response. The systemic response is due to an IgE-mediated
degranulation of mast cells and subsequent release of histamine in the body.

Identification
Typically, an allergic reaction manifests with some combination of rash, watery or pruritic eyes,
rhinorrhea, urticaria (hives), nausea, vomiting, diarrhea, difficulty breathing, or wheezing.
Allergic reactions can range from mild to life-threatening. Mild allergic reactions present as an
immediate localized skin reaction of erythema and swelling, often to a sting or bite, or as
congestion, rhinorrhea, watery eyes, and wheezing if from an environmental allergen such as
pollen. Mild food allergies can cause gastrointestinal (GI) upset, as well as the symptoms of
environmental allergens. Mild allergic reactions differ from severe allergic reactions in that they
usually only involve one organ system, do not cause significant vital sign abnormalities, and do
not cause end-organ hypoperfusion. Severe allergic reactions, however, are potentially fatal if not
recognized and treated appropriately and quickly.
Anaphylaxis is a life-threatening type of allergic reaction involving a systemic
hypersensitivity reaction. It is important that wilderness providers are familiar with the clinical
presentations of anaphylaxis and its mimics. Systemic manifestations in anaphylaxis include
some combination of skin (urticaria, pruritus, flushing, angioedema), respiratory (dyspnea,
wheezing, stridor, hypoxemia, retractions), cardiovascular (tachycardia, hypotension), and GI
(abdominal pain, vomiting, diarrhea) symptoms. In order to differentiate this from other disease
processes, the WEMS provider should look for multi-organ involvement. Proposed diagnostic
criteria for anaphylaxis include the following: acute onset of illness with skin involvement and
either respiratory compromise or hypotension; some combination of skin involvement,
respiratory compromise, hypotension, or persistent GI symptoms in the setting of allergen
exposure; or hypotension after exposure to a known allergen for that patient.35 Anaphylaxis can
occur within a matter of minutes from exposure and progresses rapidly. Therefore, rapid
identification and management are imperative.

Prevention
Since allergic reactions and anaphylaxis are potentially life-threatening, prevention of allergen
exposure when possible is paramount. Many patients will have had a previous exposure to an
allergen and be aware of their potential risk. While some may experience anaphylaxis after a
first-time allergen exposure, many will have had a previous exposure (and likely a mild reaction)
to the given allergen. Therefore, it is important for anyone with a personal history of an allergic
reaction, and certainly a history of anaphylaxis, to carry injectable epinephrine with them at all
times. For a wilderness medicine provider, epinephrine is one of the few medications that should
be carried at all times, given its lifesaving potential. If a person has a known food allergy, it is
imperative that they ensure any food consumed in a wilderness setting does not contain and has
not been contaminated by the known allergen. Seasonal or environmental allergies can be
prevented with over-the-counter antihistamine medications such as loratadine or cetirizine.

Treatment and Disposition

The first step in treating an allergic reaction is recognizing the symptoms (see Identification
section under Allergic reaction/anaphylaxis). As soon as a patient has an exposure to a known
allergen, he or she should be monitored very closely for signs of a worsening reaction or
development of systemic as opposed to localized symptoms. Any patient with signs or symptoms
of anaphylaxis requires immediate evacuation.
FIRST AID
First aid providers can treat minor allergic reactions with oral antihistamines (such as
diphenhydramine [Benadryl]), nasal decongestants, topical itch relief and steroid creams, and
local wound care (such as ice to an area of swelling from a bite or sting). If there is concern for
anaphylaxis, more aggressive management is indicated. Auto-injectors of epinephrine, such as
EpiPen, AdrenaClick, and Auvi-Q, are easy-to-use injectable forms of epinephrine for use in
anaphylaxis. These auto-injectors are IM injections of a set amount of epinephrine (0.3 mg of
1:1,000 epinephrine for adults, and 0.15 mg of 1:1,000 epinephrine for children, for example, in
the EpiPen Jr). All first aid providers should ask anaphylaxis patients if they have an epinephrine
auto-injector and help the person administer it as necessary (Figure 22.6). While antihistamines
will not reverse the effects of anaphylaxis, they can be given to help mitigate some of the minor
symptoms. Administration of antihistamines should never delay or discourage the administration
of epinephrine in the setting of anaphylaxis.
BASIC LIFE SUPPORT
BLS providers can treat minor allergic reactions with oral antihistamines, nasal decongestants,
topical itch relief and steroid creams, and local wound care for stings and bites. For patients with
evidence of anaphylaxis, providers should administer or assist the patient in administering the
patient’s epinephrine auto-injector. Local law and protocol will dictate whether BLS providers
can assist a patient or administer the medication themselves. This treatment can be followed by
an oral antihistamine.
FIGURE 22.6. Use of epinephrine auto-injectors: note removal of blue safety cap (different brands may have different colors),
followed by application to the anterolateral thigh (exposed from clothing if possible) with steady downward force for a few
seconds. See instructions of your specific auto-injector for further details.

ADVANCED LIFE SUPPORT

For mild to moderate allergic reactions, ALS providers can administer oral, IV, or IM steroids,
an inhaled beta-agonist (albuterol), and histamine blockers (eg, diphenhydramine, ranitidine,
cetirizine, or loratadine) to decrease symptoms by blunting the inflammatory response to the
allergen. Providers may also need to administer epinephrine if an epinephrine auto-injector is not
available. The dosing is the same for all adults: 0.3 mg of 1:1,000 concentration of epinephrine
IM, and is weight based for children: 0.01 mg/kg 1:1,000 solution. It is important to note this is a
different concentration of epinephrine than that used in cardiac arrest (which is epinephrine
1:10,000 solution), but the medication used is the same. Therefore, if calculations are made,
either concentration can be used for anaphylaxis, provided the dose is correct. IM epinephrine
injections can be repeated at 15-minute intervals until signs of anaphylaxis and shock abate. If
advanced airway supplies, IV supplies, and IV fluids are available, these should be initiated as
needed, depending on airway and circulatory function.
CLINICIANS
Clinicians should treat allergic reactions similar to all other medical providers, administering oral
medications for minor reactions and IV/IM medications if available for severe reactions. For life-
threatening reactions not responding to IM epinephrine, clinicians can consider giving
epinephrine IV at a dose of 10 mL of 1:100,000 solution over 10 minutes (this can be made by
mixing 0.1 mL [0.1 mg] of the 1:1,000 solution in 10 mL of normal saline). If hypotension
persists, epinephrine can be administered as a continuous infusion at a rate of 1 to 4 µg/min
(which can be made by mixing 1 mL [1 mg] of 1:1,000 solution in 250 mL of normal saline) to
create a concentration of 4 µg/mL.36 All patients with severe allergic reactions or anaphylaxis
need to be evacuated to a hospital as rapidly as possible.

Equipment Summary
As with all other medical conditions in the wilderness, the readily available equipment will
depend on the location and activity. A wilderness medical provider should consider carrying an
oral antihistamine, an albuterol inhaler, and an injectable form of epinephrine at all times.
Injectable epinephrine may come in the form of a vial or glass ampule, which needs to be
manually drawn up with a needle and syringe, or in a prefilled auto-injector. If a wilderness
provider carries epinephrine in a vial or ampule, he or she should ensure they know the correct
concentration and volume to achieve the desired dose. Auto-injectors are often carried by
patients with a history of anaphylaxis, but are quite a bit costlier than vials or ampules. These
medications can be lifesaving for a patient with a severe allergic reaction or anaphylaxis.
Cardiopulmonary monitoring, supplemental oxygen, nebulizer equipment, IV supplies, and
advanced airway equipment may be indicated, but are likely not available, and depend on the
medical training of the provider and the location of the patient. It cannot be stressed enough that
patients with a history of severe allergic reaction or anaphylaxis should be equipped with their
own epinephrine auto-injectors.

Abdominal Pain/Illnesses
Abdominal complaints are relatively common in the wilderness setting. With changes in diet,
exercise, and bowel habits, many people will develop abdominal pain at some point during their
wilderness activity. A wilderness medicine provider should be able to recognize warning signs
for certain abdominal complaints that will require further treatment and evacuation.

Identification
The abdomen is divided into four quadrants, each of which contain certain abdominal organs,
thus location of the pain can be the first clue to its cause (Figure 22.7). If a patient is having pain
in the right upper quadrant, liver and gallbladder pathology would be high on the differential. In
the right lower quadrant, appendicitis and genitourinary (GU) pathology would be more likely.
The spleen and stomach may cause pain in the left upper quadrant, and large bowel or GU
problems are most often experienced in the left lower quadrant.
Many common abdominal complaints will present differently between different individuals.
Table 22.1 lists classic presentations for some of the major causes of abdominal pain.
Prevention
Some abdominal illnesses in the wilderness can be prevented with simple measures. One of the
most common abdominal complaints is diarrhea.37 This can often be avoided by ensuring good
hand hygiene before food handling, appropriate water purification techniques, and adequate food
storage. Certain dietary choices can help prevent loose stools and abdominal pain. Constipation,
another common cause of abdominal pain in the backcountry, can be avoided by maintaining a
diet high in fiber and ensuring adequate hydration. Decreasing the amount of high fat and spicy
foods can decrease the risk of developing symptomatic cholelithiasis and gastritis or
gastroesophageal reflux disease. Minimizing alcohol consumption can also decrease the risk of
gastritis and pancreatitis. Infections such as appendicitis, cholecystitis, and diverticulitis, as well
as acute abdominal emergencies such as bowel obstruction or perforation, are hard to prevent but
are relatively rare causes of abdominal pain in a wilderness environment.

Treatment and Disposition

The treatment of abdominal complaints begins with evaluating the symptoms a patient is
experiencing. All providers should perform a complete abdominal exam, paying close attention
to the appearance of the abdomen, the feel of the abdomen (soft versus rigid), areas of
tenderness, and any associated rebound pain or guarding. A thorough history including onset of
pain, location, exacerbating or alleviating factors, recent bowel movements, urinary complaints,
prior surgical history, and possibility of pregnancy should be obtained.
FIRST AID
First aid providers should evaluate the patient for abnormal vital signs such as hypotension, and
significant abdominal exam findings such as peritonitis. These indicate severe pathology and
require evacuation. If less severe causes are suspected, first aid providers should ensure the
patient is adequately hydrated, particularly in the case of vomiting and diarrhea. Commercially
packaged oral rehydration therapy (ORT) can be given to patients with significant vomiting
and/or diarrhea. ORT can also be made by combining six teaspoons of sugar, 0.5 teaspoons of
salt, and 1 L of potable water.38 Antacids such as Tums, Maalox, or Pepto Bismol can be given
for suspected gastritis or in cases of peptic ulcer disease.
BASIC LIFE SUPPORT
BLS providers can also provide ORT when indicated, or symptomatic treatment of gastritis
peptic ulcer disease (PUD). Additionally, providers should perform a detailed history and
physical exam to determine etiology of symptoms, to evaluate for peritonitis or worsening pain,
as well as take and monitor vital signs to ensure no changes such as tachycardia or hypotension
that would suggest clinical worsening.
FIGURE 22.7. Anatomy of abdominal quadrants. From Olinger AB. Human Gross Anatomy. Philadelphia, PA: Wolters Kluwer;
2015.

Table 22.1 Common Locations and Causes of Abdominal Pain

Location of Symptoms Diagnosis Description
Right upper quadrant Cholelithiasis (gallstones) Pain that is usually worse with eating, colicky, can be
associated with nausea and vomiting
Cholecystitis Pain usually worse with eating, associated with fever, nausea,
vomiting, point tenderness in RUQ (Murphy’s sign)
Right lower quadrant Appendicitis Pain starts in the periumbilical region and moves to the RLQ,
associated with nausea, vomiting, diarrhea, fever, point
tenderness in RLQ (McBurney’s point)
Epigastric Gastritis/gastroesophageal Burning pain, radiating up chest, worse after spicy or fatty
reflux disease meals
Peptic ulcer disease Burning or gnawing pain, worse with an empty stomach,
possible history of heavy NSAID use
Pancreatitis Presents with epigastric abdominal pain radiating to the back,
often with associated nausea and vomiting
Left lower quadrant Diverticulitis LLQ abdominal pain with associated bloody diarrhea; may
have associated fever, chills, nausea, and vomiting
Diffuse Diarrhea Diffuse cramping abdominal pain, associated with multiple
loose stools
Constipation Cramping, diffuse pain, associated with decreased bowel
movements, hard stools, straining with bowel movements, can
 cause abdominal distention and nausea
Gastroenteritis Diffuse cramping abdominal pain with associated nausea,
vomiting, and diarrhea. Fever may be present
Bowel obstruction Diffuse abdominal pain with distention, nausea, vomiting, and
obstipation (inability to pass gas or stool)
Bowel perforation Severe abdominal pain, initially may be localized but quickly
will be diffuse with associated rigidity and guarding of the
abdomen
Flank Nephrolithiasis (kidney stone Colicky and severe flank pain, sometimes radiating to inguinal
or ureteral stone) region, associated with inability to obtain a comfortable
position and hematuria

NSAID, nonsteroidal antiinflammatory drug.

ADVANCED LIFE SUPPORT

ALS providers should continuously monitor a patient with vital signs and serial abdominal
exams to evaluate for clinical deterioration. Providers who have access to IV supplies may
administer IV fluids and antiemetics for symptom control and hydration.
CLINICIANS
Clinicians may feel comfortable administering antibiotics, especially for certain diarrheal
illnesses. However, many abdominal pain complaints beyond simple constipation or diarrhea
will require evaluation, advanced imaging, and potentially surgical management. Therefore, if a
patient’s abdominal complaints are severe or worsening, the patient’s vital signs are
deteriorating, or hydration cannot be maintained, he or she needs to be evacuated.

Equipment Summary
All medical providers should ensure they have a hand sanitation method (either an alcohol-based
sanitizer or soap and water) as well as a water purification method while in a wilderness
environment. ORT and oral antiemetics are reasonable additions to any medical provider’s first
aid kit. Medical equipment such as IV supplies, IV fluids, and antacids, stool softeners, and
antibiotics may be warranted for treatment of more severe abdominal complaints. Ultrasound is
becoming increasingly smaller and more portable. If an ultrasound is present with a provider
trained to perform and interpret ultrasound images, this may help facilitate a diagnosis and target
therapy. However, any patient with severe abdominal pain, peritonitis, or unstable vital signs
with abdominal pain needs emergent evacuation for further evaluation.

Female Genitourinary Complaints

Female-specific complaints in the wilderness can present unique problems for a medical
provider. Women may be reluctant to discuss gynecologic symptoms with an unknown
practitioner, and potentially life-threatening conditions can develop before a provider is aware.

Identification
Urinary tract infections (UTIs) are often caused by bacteria traveling from the outside surface
of the vagina, through the urethra to the bladder. This is more common in females than in males
due to an anatomically shorter urethra. UTIs classically present with painful urination (dysuria),
frequent urination, hesitancy, and suprapubic abdominal pain. When bacteria travel from the
bladder to the kidneys, a kidney infection, pyelonephritis, can occur. This will often present
with flank pain, fever, and chills in addition to UTI symptoms.
Kidney stones (nephrolithiasis) are solid mineral deposits that form inside the renal system.
The most common makeup of these stones are calcium oxalate or calcium phosphate, although
they can be composed of other substances such as uric acid, struvite, cystine, or ammonium acid
urate. As the stone passes from the kidney through the ureter into the bladder, it can cause
significant pain. The pain is often described as sharp, stabbing pain in the flank, lower abdomen,
or inguinal region, radiating from back to front. Often patients appear distressed and cannot find
a comfortable position. Patients may endorse pain with urination or blood in their urine
(hematuria).
Inflammation and irritation of the external vagina can occur in the wilderness due to
constrictive clothing, increased sweating and moisture to the area, and decreased access to
bathing. This is termed vulvovaginitis and can be caused by yeast, such as candida, or other
external irritants. This often presents as itching and burning in the vaginal area with the
appearance of beefy red labia on external exam.
Internal vaginal infections such as sexually transmitted infections (STIs) can cause
symptoms of foul-smelling discharge and vaginal discomfort. Untreated infections can lead to
pelvic inflammatory disease (PID), an infection of the reproductive organs that has the
potential to cause infertility (Figure 22.8). PID often presents as lower abdominal pain, fevers,
and foul-smelling vaginal discharge. If an infection causes an abscess in one of the fallopian
tubes known as tuboovarian abscess (TOA), a patient may present with significant unilateral
lower abdominal pain and signs of systemic infection.
Note that there is a further discussion of infectious diseases such as these, including their
systemic manifestation as septic shock or severe sepsis, in Chapter 20.2.
Ovarian cysts and TOAs both put a woman at risk of ovarian torsion, a condition where the
twisting of the ovary can lead to decreased blood flow to the ovary and ultimately to ovarian
necrosis. Ovarian torsion will present with severe, sharp, colicky, unilateral lower abdominal
pain. This can be mistaken for kidney stones, as patients present with similar symptoms and
similar inability to obtain a comfortable position. This is a medical emergency and must be
evacuated immediately.
Pregnancy in the wilderness has the potential to become a medical emergency. Most normal
(intrauterine) pregnancies will not cause significant complications. However, some women may
develop severe nausea and vomiting during the first trimester of pregnancy (hyperemesis
gravidarum) that can lead to dehydration and electrolyte abnormalities. Pregnancy can put
women at risk of thromboembolic disease such as deep venous thrombosis or PE. Additional
pregnancy complications including spontaneous abortion (miscarriage) and placental abruption
have the potential to cause life-threatening vaginal bleeding.
Ectopic pregnancy is another cause of lower abdominal pain, usually unilateral, that can be
life threatening and needs immediate evacuation. This occurs when a developing embryo
implants in a location other than the uterus, most commonly in the fallopian tube, and is often
known as a “tubal pregnancy.” Common presenting symptoms are lower abdominal pain, vaginal
bleeding, and history of a missed or late menstrual period. This is also a true medical emergency
and requires immediate and rapid evacuation.
FIGURE 22.8. Pathway of bacteria causing pelvic inflammatory disease. From Soper DE. Upper genital tract infections. In:
Copeland LJ, ed. Textbook of Gynecology. Philadelphia, PA: Saunders; 1993:521, with permission.

Prevention
Most prevention for female-related complaints is centered on education prior to wilderness
travel. All females, regardless of their involvement in wilderness activities, should be counseled
regarding safe sexual practices to help mitigate the risk of STI, PID, and TOA. Females who are
planning to be out in a wilderness environment for long periods of time should ensure they have
proper undergarments (breathable and dry), and should know their pregnancy status if they are
currently sexually active. Leaving on a multi-week wilderness trip may not be the time to try new
soaps, detergents, or clothing, as this can lead to vulvovaginitis. Education for the prevention of
UTIs relates to good bathroom hygiene, staying well hydrated, urinating frequently, and
urinating after sexual intercourse.39

Treatment and Disposition

Treatment of any gynecologic issue should start with taking a good history. Knowing the
complaint, duration of symptoms, last menstrual period, previous gynecologic history, any
infection exposure, and any recent changes in medications or use of feminine products can help a
provider begin to determine the cause of symptoms.
FIRST AID
First aid providers should focus on determining the likely etiology of symptoms and whether the
patient will need to be evacuated. As discussed below in the equipment section, providers of all
levels can test for pregnancy with relatively inexpensive, lightweight, and over-the-counter home
pregnancy tests.
BASIC LIFE SUPPORT
BLS providers should monitor vital signs and ensure the patient is not developing a systemic
infection or acute blood loss anemia (in the event of a ruptured ectopic pregnancy or heavy
vaginal bleeding).
ADVANCED LIFE SUPPORT
ALS providers should focus on determining etiology, monitoring for clinical deterioration, and
can begin resuscitation with IV fluids if necessary. If kidney stones are suspected, the mainstay
of treatment is hydration and pain management. For vomiting in pregnancy, IV hydration with a
glucose-containing solution (eg, normal saline with 5% dextrose) is preferable when available.
CLINICIANS
Clinicians should attempt to determine the etiology of the complaint when possible. Often a
thorough history and examination may be enough to determine the cause. IV fluids and
antibiotics can be given as necessary. If there is concern for PID, the antibiotic regimen consists
of 250 mg IM ceftriaxone once and 100 mg oral doxycycline twice daily for 14 days. There is a
more comprehensive discussion of GU infectious diseases in Chapter 20 (Management of
Infectious Diseases).

Equipment Summary
In the wilderness setting, recommended equipment for female gynecologic complaints includes
extra tampons (which can double as nasal packing for epistaxis management) and a urine
pregnancy test (UPT), which is cheap, portable, easily available, and can be the diagnostic
difference between staying in the backcountry and initiating an emergent evacuation. All
providers should consider carrying a UPT in their first aid kit, especially when female patients of
childbearing age would reasonably be expected in their operational environment. In determining
this, remember that women can become pregnant as soon as they begin ovulating, which usually
occurs about a year after menstruation begins (between the ages of 11 and 12 in North America).
This may be earlier than some providers realize. Medications such as antifungals to treat yeast
infections and antibiotics to treat simple UTIs may be beneficial to carry for extended trips.
Other equipment such as IV supplies, IV fluids, IV antibiotics, and pain medicine should be used
based on provider training, situation, and clinical presentation. Any serious gynecologic
complaints, new diagnosis of pregnancy, peritonitis, abnormal vital signs, or evidence of
systemic infection will require immediate evacuation.

Male Genitourinary Complaints

Male-specific GU complaints, similar to female-specific complaints, carry a unique challenge for
medical providers in the wilderness. Men are also often reluctant to discuss GU complaints, and
some can have serious consequences if not properly managed.

Identification
Men, similar to women, can develop kidney stones (see above section regarding identification
and treatment).
Inguinal hernias are defects in the abdominal fascia that cause abdominal contents to
protrude into the inguinal canal. This can occur in females, but is much more common in males.
Typically, hernias present due to repetitive activity that causes straining of the abdominal
musculature. Clinically, a patient will notice a bulge in the inguinal region or scrotum that
worsens with standing and is usually reducible. Any hernia that is not easily reducible is
potentially a surgical emergency.
Two of the main anatomic structures in the scrotum are the testis and epididymis. Testicular
torsion occurs when the ductus deferens and blood vessels supplying the testicles twist, causing
decreased blood flow to the testicle (Figure 22.9). This can occur from very minor movements.
Classically, it will present as extreme testicular pain, abnormal lie of the affected testicle, and
loss of the cremasteric reflex (light touch to the inner part of the thigh causing cremasteric
muscle contraction and testis elevation).

FIGURE 22.9. Testicular torsion illustrating twisting of the spermatic cord and spermatic vessels. From Porth C. Essentials of
Pathophysiology. 4th ed. Philadelphia, PA: Wolters Kluwer; 2014.

Epididymitis is inflammation and infection of the epididymis, often caused by a sexually

transmitted disease. This presents as pain and swelling to the scrotum with tenderness to
palpation directly over the epididymis.
Other less common GU emergencies are phimosis and paraphimosis. These conditions
affect uncircumcised males. A phimosis occurs when the foreskin is unable to be retracted over
the glans of the penis. A paraphimosis occurs when the retracted foreskin cannot be reduced back
over the glans of the penis. Both conditions can cause significant pain, swelling, and urinary
obstruction. A paraphimosis can act as a tourniquet and cut off circulation to the distal portion of
the penis. Recognition and early intervention can potentially avoid significant morbidity.

Prevention
The majority of male GU complaints present acutely. As with females, all males should be
educated regarding safe sexual practices to minimize exposure to STIs and decrease the
incidence of epididymitis. Patients with known hernias should avoid heavy lifting if possible,
and can utilize devices such as hernia belts to decrease the chances of an incarcerated (non-
reducible) hernia. Testicular torsion presents acutely and not usually associated with specific
preventable risk factors. A male with a history of torsion in the past should have surgical fixation
to prevent further torsion episodes. Phimosis and paraphimosis often occur with infections to the
glans of the penis (balanitis). Males should ensure they keep good hygiene practices while in the
wilderness setting and alert medical professionals immediately if there are any problems with
foreskin retraction.

Treatment and Disposition

All levels of wilderness providers should attempt to diagnose male GU complaints with a
thorough history and examination, including genital examination. Most GU complaints will
require evacuation from a wilderness environment for specialist management.40
FIRST AID
First aid providers should focus on keeping a patient as comfortable as possible and attempting
to remedy the problem to the best of his or her ability.
Manual reduction of hernias may be attempted if the patient is not able to easily reduce it on
his own. This is achieved by providing slow steady pressure to the hernia. If possible, place the
patient in a Trendelenburg position and place ice on the hernia to assist with reduction.
If testicular torsion is suspected, manual detorsion can be attempted while plans are being
made for evacuation. Manual detorsion should be attempted by external rotation of the affected
testicle, similar to opening a book. More than one rotation may be required to fully detorse the
testicle. Successful detorsion will be evident by an immediate resolution of pain and return of the
testicle to a normal position.
A phimosis or paraphimosis can and should be reduced with gentle manual traction. To
reduce swelling, salt or sugar can be placed on the edematous foreskin, which will help to draw
out fluid, assisting with reduction.
BASIC LIFE SUPPORT
BLS providers should focus on monitoring vital signs and treating the patient if possible (see
First Aid section).
ADVANCED LIFE SUPPORT
In addition to treating the patient’s underlying complaint (see First Aid section), ALS providers
can provide IV pain relief and IV fluids when available.
CLINICIANS
Clinicians should obtain a thorough history and physical and attempt to remedy the problem if
possible (see First Aid section). Additionally, clinicians can give antibiotics if available and
indicated based on the patient’s presentation. Even if a patient is successfully treated in a
wilderness setting, he should still be evacuated for specialist evaluation and follow-up.

Equipment Summary
The evaluation and treatment of male complaints does not require much in the way of equipment.
For a patient in a significant degree of pain, any available pain medications will be helpful. If the
patient presents with evidence of systemic infection or illness, equipments such as IV supplies,
IV fluids, and cardiopulmonary monitoring are indicated while transport to definitive care is
being established. The treatment of systemic infections is discussed more completely in Chapter
20.

SUMMARY
Medical conditions can occur in a wilderness environment and may be worsened due to
increased activity and environmental exposures. All patients with chronic medical conditions
should be cleared by a physician prior to participation in wilderness activities, and should ensure
an adequate supply of all daily medications. Preexisting conditions can worsen acutely if
preventive measures are not employed appropriately. It is important that all wilderness providers
are aware of medical conditions among their group members, and are able to recognize and treat
basic medical conditions. The amount of equipment at a provider’s disposal will be dependent on
the location and activity. Before heading into remote locations, medical providers should
consider bringing basic first aid supplies and certain medications that could be potentially
lifesaving. Recommended medications for a wilderness medical kit include aspirin, albuterol, an
antihistamine (such as diphenhydramine [Benadryl]), injectable epinephrine, pain medication
(acetaminophen or ibuprofen), and oral glucose. Wilderness medical kits, and their constituent
medications, are discussed further in Chapter 7 (WEMS Equipment). Recommended diagnostic
equipment includes a working glucometer for all patients with diabetes and a UPT. All
wilderness medical providers should be prepared to encounter a wide variety of medical
complaints, attempt to stabilize patients to the best of the provider’s ability, and know how and
when to transport patients to a higher level of care when indicated.

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INTRODUCTION
Few areas of emergency response are as challenging and rewarding as managing an emotional or
behavior crisis in the remote setting: the climber in the grip of a panic attack clinging to a cliff
face 45 m (150 ft) above the ground; the isolated Antarctic researcher, plagued by suicidal
thoughts; or the relief worker, in the throes of psychosis, screaming that snakes are crawling on
her skin. Environmental stressors, prolonged evacuation times, and lack of available psychiatric
resources add a layer of complexity to already difficult presentations, calling on providers to
demonstrate innovation and resourcefulness.
No two behavioral health emergencies are alike, and rarely can providers rely on clear-cut
treatment protocols. Compounding this, training often focuses on a few extreme mental health
presentations, such as psychosis or violence. This often results in reluctance on the part of the
provider to engage in mental health issues that feel complicated, or “out of their scope.”
Avoiding mental health presentations is not an option in the remote setting, when the patient with
acute mental health concerns may be far from meaningful treatment. This situation creates a real
threat to not only the patient, but the expedition and the rescue operation as well.
The aim of this chapter is to increase the comfort and confidence of the remote provider by
providing examples of potential presentations and interventions with mental illness in the remote
setting. While this chapter cannot provide comprehensive skills for complete psychiatric care in
the remote setting, it will offer tangible tools for evaluating and caring for individuals in this
unique setting. This chapter will review the most common and most extreme mental health
concerns. For each mental health problem, information on the assessment of the patient’s
presentation, practical tools for management, and information regarding evacuation in mental
health emergencies will be described. As in other areas of mental health treatment, the mainstays
of interventions are basic, but important skills of communication, validation, calm presence and
often, the use of firm boundaries.
 Providers should keep in mind that feeling comfortable with treatment of behavioral crisis in
remote settings, ideally starts in the urban context. Providers should challenge themselves to
engage with difficult patients in their everyday practice settings. This challenge includes
engaging with individuals they ordinarily would avoid. Gaining experience and confidence
treating a range of mental health concerns in the urban context is important preparation for
treating such concerns in the more challenging context of a remote setting. Avoiding these
experiences not only adds to the responder’s anxiety, but prevents the responder from developing
the assessment and interventions skills needed to safely resolve individuals in crisis in the
wilderness.

Definitions
Although diagnosis of the patient with mental health issues is outside of the scope of most
wilderness providers, it is helpful to have a framework to understand the constellation of
symptoms that may accompany certain behaviors. A mental disorder is a syndrome that affects
thinking, behavior, or mood in ways that cause significant functional impairment in daily life.
Mental health practitioners rely on The Diagnostic and Statistical Manual of Mental Disorders,
now in its Fifth Edition (DSM-5),1 an important text that classifies and defines mental disorders.
It provides diagnostic criteria, definitions, and explanation of symptoms for mental illness, and
creates a common and consistent language to characterize and treat mental health presentations.
Table 23.1 lists the most common conditions in DSM-5.1
The cause of mental illness is complex, takes many forms, and is thought to derive from
multiple factors. Biologic factors, such as genetics (inherited conditions), medical illness, and
abnormalities in brain function may contribute to mental illness. Socioeconomic ecology, current
environment stressors, and exposure to stressors early in life can all play an equally important
role in the potential development of mental illness. For example, an individual may develop
symptoms such as severe depression, anxiety, or psychosis as a result of genetic predisposition,
alterations in neurotransmitter function in the brain, life circumstances (eg, child abuse or
neglect), or stressful life events. Medical conditions and exposure to drugs (both illicit and
prescribed) may also increase susceptibility to detrimental changes in emotional and behavioral
functioning.
Symptoms of mental illness are best viewed as part of a spectrum or range of symptoms.
Severity, persistence, and impairment to daily function are critical criteria for the clinical
diagnosis of a mental illness. For instance, depression and anxiety are among the most common
mental health concerns. An individual may experience depressive symptoms after the death of a
loved one, but may not meet the criteria for a major depressive disorder—a clinical diagnosis of
mental illness. Similarly, an individual in a wilderness setting may experience fear and anxiety
when engaging in high-risk activities (such as rock climbing), seeing a bear, or being far from
home. These symptoms may resolve completely upon arrival at home and would be considered
part of the adaptive, normal response to anxiety-producing situations.
Individuals with preexisting mental illness may be more at risk when they find themselves in
a stressful environment, like a remote setting. Stressors such as extremes in temperature, physical
exertion, unexpected obstacles (getting lost, bad weather), interpersonal dynamics in group
settings (a fellow participant may be irritating), interrupted sleep patterns due to altitude or
temperature, and lack of normally available coping skills, may worsen symptoms. For example,
someone who has a diagnosis of bipolar disorder may be more vulnerable to developing
hypomania or manic symptoms when sleep patterns change, a common occurrence at altitude. A
person suffering from a generalized anxiety disorder or panic disorder may find himself/herself
overwhelmed with debilitating anxiety, when separated from important loved ones in remote
settings. An individual with obsessive-compulsive disorder, with a fear of germs, may find
themselves affected by extreme anxiety from the lack of frequent opportunities for handwashing.
The understanding of neurobiology and function of the brain related to mental illness directs
medication treatment choices. For example, psychotropic medications (medications capable of
affecting the mind, body, and behaviors) generally target neurotransmitters (chemicals that
transfer information to other nerves, muscles, etc.) such as serotonin, norepinephrine, and
dopamine in the brain. These chemical “messengers” drive changes in mood and cognition
(thoughts, understanding, reasoning, etc.). Medications increase messenger availability, block
their reuptake or increase the amount of individual receptor sites. For example, one theory of the
development of major depressive disorder describes how deficits in the neurotransmitter
serotonin result in depressed mood, poor sleep patterns, and changes in appetite. Psychotic
disorders are thought to be the result of excess dopamine in particular areas of the brain.
Medications used to manage the symptoms of these disorders target serotonin and dopamine
respectively.

Table 23.1 Common Categories of Diagnostic and Statistical Manual of Mental Health
Disorders and Their Key Features
Disorder Key Signs and Symptoms
Depressive disorders Sadness, tearfulness, loss of interest, social withdrawal,
(major depressive disorder) suicidal ideation, disruptions in sleep and appetite, poor
concentration
Anxiety disorders Excessive worry, fear of impending doom, panic,
(generalized anxiety disorder, specific phobias) hyperventilation, shaking/trembling, restlessness, muscle
tension
Schizophrenia spectrum and other psychotic disorders Hallucinations, delusions, paranoia, disorganized/bizarre
(schizophrenia, schizoaffective disorder, delusional disorder) speech and thinking, bizarre behavior activities
Bipolar and related disorders Mood swings, abnormally elevated mood, grandiosity, racing
(bipolar disorder type I and II) thoughts, excessive energy, rapid speech, significant insomnia,
risk-taking, impulsiveness, poor judgment, major depressive
episodes
Obsessive-compulsive disorders Repetitive thoughts and behaviors, obsessions, ritualistic
behaviors
Trauma and stressor-related disorders Intrusive thoughts, nightmares, increased fear, increased startle
(posttraumatic stress disorder, acute stress disorder) response, avoidance, withdrawal, dissociation
Personality disorders Interpersonal difficulties, problematic or extreme emotional
(narcissistic personality disorder, obsessive-compulsive responses, difficulties with impulse control, distorted thinking
personality disorder, borderline personality disorder, antisocial patterns
personality disorder)
Substance-related and addictive disorders Excessive substance use, intoxication, drug/alcohol-seeking
(alcohol use disorder, opioid use disorder) behaviors

Adapted from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA:
American Psychiatric Publishing; 2013.

In addition, the wilderness provider must consider the impact of psychotropic medications on
the patient, as hydration levels, maintenance of core body temperatures, appropriate sweating and
cooling, and the body’s propensity to develop a fever may all be impacted by psychotropic drugs
a person may be taking. For instance, sun exposure and dehydration may impact levels of drugs
such as lithium and antipsychotics, and excess exposure and dehydration may lead to toxicity.
Some drugs, such as antidepressants, may cause hyperthermia when overdosed or taken in
excess. The wilderness provider must consider environmental conditions that may precipitate
adverse drug reactions.

CLINICAL MANAGEMENT
Behavioral and emotional emergencies in remote settings pose unique challenges to the safety
and continuation of an expedition or activity. Anxiety, depression, or agitation requires
enormous amounts of time and resources to manage. The provider will often be in a position to
determine whether the expedition can continue, or how an individual can safely be evacuated
when they present as dangerous to themselves or others. As in medical rescue scenarios, safety
of the provider, fellow rescuers, and other expedition members must be prioritized over
diagnosis or treatment.
Once safety has been established, the second priority in the remote setting is stabilization and
treatment of the presenting symptoms. Finding the underlying cause of the symptom can be key
to stabilizing and treating it, when the symptom is caused or exacerbated by an environmental
stressor that is reversible (eg, dehydration, heat stroke, altitude illness, medication side effect,
etc.). However, the cause of a symptom may not be clear in the moment. Psychosis in a
humanitarian aid worker, for example, might be related to underlying bipolar disorder, infection,
or a side effect of taking the antimalarial medication called mefloquine (Lariam). Indeed, even in
an acute care setting, it could take hours or days for a skilled clinician to determine the cause of
such a symptom. Thus, priority should remain with stabilization of the symptom and exploration
of the underlying cause with a thorough evaluation.

Anxiety
Epidemiology and Causes
Anxiety disorders tend to develop early in life, and wax and wane throughout the life span.
Anxiety disorders are often related to developmental transitions, such as starting kindergarten or
leaving for college, or life stressors such as moving, losing a job, financial stressors, or divorce.
One in four persons in the United States meets diagnostic criteria for at least one anxiety
disorder.2 Statistically, women tend to be more vulnerable to anxiety than men, with a 30%
lifetime prevalence rate for women compared to a 19% lifetime prevalence rate for men.2
The causes of anxiety presentation are often multifaceted. Abnormalities in
neurotransmitters, such as gamma-aminobutyric acid, norepinephrine, and serotonin, as well as
increases in stress hormones and heightened activity of the autonomic nervous system, all may
underlie the development of anxiety disorders. Genetic vulnerability is believed to play a role in
one-third of those experiencing anxiety disorders.1 Additionally, there are many medical
conditions known to cause symptoms of anxiety (Table 23.2).
In the remote setting, the stress of unknown environments, sleep disturbance, separation from
loved ones, as well as engaging in perceived risky activities such as climbing, can all induce
anxious responses in those already at risk. Ongoing studies into anxiety may show a relationship
between the onset of acute anxiety and ascending to high altitude.3,4 Recent studies also suggest
that withdrawal from technology may be a significant contributor to anxiety states in adolescent
populations. These study results may be possible to extrapolate to adult populations.5,6 It should
be noted that medications used to treat anxiety, when stopped abruptly, may cause distressing
withdrawal symptoms that include rebound anxiety. Immediate withdrawal of benzodiazepines
can be life-threatening.

Clinical Features
Everyone experiences anxiety. It is considered a highly adaptive process that initiates action in
times of danger, and is the cornerstone of our survival mechanism. Like depression, anxiety
becomes problematic only when it interferes with the capacity to complete necessary daily
activities and enjoy life. Presentations of anxiety vary widely. For those with more generalized
anxiety, symptoms include constant worry about a myriad of issues, restlessness or irritability,
difficulty concentrating, and sleep disturbance. Anxiety can also be very specific, focused on
isolated fears such as separation from family, social situations, phobias or obsessive-compulsive
thoughts and behaviors. These symptoms may be worsened or emerge unexpectedly in remote
settings, when patients are separated from loved ones, feel far from help, or are overwhelmed by
their environment. Encounter-specific phobia triggers in the wilderness, such as heights or
enclosed spaces, can also initiate anxiety or panic attacks.

Table 23.2 Medical Causes of Anxiety

System Diseases
Cardiovascular disease Hypertension, congestive heart failure, anemia, angina, mitral valve prolapse,
myocardial infarction
Drug intoxication Cocaine, amphetamines, nicotine anticholinergics, hallucinogens, marijuana
Drug withdrawal Alcohol, opioids, sedative-hypnotics, antihypertensives
Endocrine Hypoglycemia, diabetes
Pulmonary Asthma, pulmonary embolus, hyperventilation, dyspnea
Other conditions Electrolyte disturbances, systemic infections, anaphylaxis

Anxiety can be experienced as highly physical, and in fact can be mistaken for other medical
diagnoses such as cardiac or neurologic events. Physical symptoms of anxiety can include
fatigue, increased heart rate (HR), dizziness, trembling, chest pain, muscle tension, and upset
stomach. Panic attacks are characterized by these symptoms to the extreme and can be associated
with fear of dying or losing control. They generally last between 20 and 30 minutes and rarely
more than an hour.
In the remote setting, those paralyzed by anxiety may present a risk to the rescuers, because
their reactions may be erratic or unpredictable. Individuals may demonstrate compromised
problem-solving and decision-making skills, resulting in the inability to respond to directions, or
participate in self-rescue. Anxiety that is well controlled in familiar environments may produce
out-of-proportion or incapacitating symptoms in remote settings. Overwhelming environmental
stimuli or lack of available coping mechanisms, such as social supports and electronic devices,
may contribute to this.

Assessment
The remote provider should be prepared to address the physical symptoms first and use the
assessment to both calm the patient and build rapport. Patients who are experiencing high levels
of anxiety feel with certainty that something is physically wrong with them. Because of this,
even if the provider suspects the presentation is solely due to anxiety, addressing and validating
physical complaints serves to calm the patient and decrease anxiety. For instance, providers may
choose to listen to lung sounds, intentionally asking the patient to take deep breaths, as a means
to slow the patient’s breathing. This serves to demonstrate concern, while at the same time,
evaluating the patient for any underlying medical conditions, and physiologically calming the
patient. It should be noted that providers sometimes err by assuming that a presentation is related
to anxiety, when the patient is actually experiencing a medical emergency, such as
supraventricular tachycardia, myocardial infarction, or pulmonary emboli (Table 23.3). These
techniques form a key component of “psychological first aid”, a technique discussed more fully
in Chapter 10.
The most common medications used to address underlying anxiety states include selective
serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), serotonin norepinephrine
inhibitors (SNRIs) such as venlafaxine (Effexor), and short- and long-acting benzodiazepines
such as alprazolam (Xanax) and clonazepam (Klonopin) (see Table 23.4). These medications are
often relevant in wilderness settings, as 10% of Americans over the age of 12 take an SSRI.7
Abrupt discontinuation of SSRIs and SNRIs can cause symptoms of anxiety, flu-like illness,
insomnia, sensory disturbances, and hyperarousal. Benzodiazepines are also commonly
prescribed for anxiety disorders. When used on a daily basis and then stopped abruptly, they can
have serious and life-threatening withdrawal symptoms, such as seizures. Taking a robust
medical history is protective against missing less obvious causes of anxiety such as medication
withdrawal.

Table 23.3 Common Medications in Wilderness Medical Kits That Can Cause Anxiety
Dexamethasone
Pseudoephedrine
Epinephrine
Albuterol inhaler
Methylquin

Treatment
ALL LEVELS—CRISIS MANAGEMENT, NON-PHARMACOLOGIC TREATMENT
Responding to the anxious, panicking, or terrified individual in the remote setting can
paradoxically result in anxiety for the rescuer as well. The remote provider may feel that the lack
of their usual selection of tools and medications renders them powerless to treat the patient and
assist them in resolving troubling symptoms. Crucial to the provider’s response is understanding
that the emotional state of the rescuer will greatly impact the response of the individual patient.
Providers who understand this, and take necessary steps to calm themselves and enter the scene
in an emotionally regulated state, have already engaged the primary and most powerful remote
treatment tool: calming themselves in order to help calm their patient. The transmission of calm
from the provider to patient is transformational, but is often overlooked because of its simplicity.
Although other tangible tools for remote management will be discussed, the calm state of the
rescuer remains the primary treatment approach, and will be the treatment modality most likely
to have the greatest impact on the patient’s response and well-being. It should be considered the
foundation of management for the patient with anxiety. For more in-depth discussion and
additional tools for supporting patients in distress, see Chapter 10, Psychological First Aid and
Stress Injuries.
The principles of anxiety management include:

1. Calm oneself and build on-scene relationship with patient.

2. Complete patient assessment to rule out underlying medical causes for anxiety.

Table 23.4 Mental Health Medications and Withdrawal

Medication Withdrawal Symptoms Risk Related to Withdrawal Treatment
SSRI/SNRI Dizziness, weakness, nausea, Uncomfortable, not life- Resumption of
Examples: headache, rebound threatening medication if
Fluoxetine/Prozac depression/anxiety, insomnia, poor available
Sertraline/Zoloft concentration, flu-like symptoms,
Escitalopram/Lexapro paresthesias, headaches
Citalopram/Celexa
Paroxetine/Paxil
Venlafaxine/Effexor
Duloxetine/Cymbalta
Benzodiazepines Disturbances in mood/cognition, Can be life-threatening Resume
Examples: insomnia, tachycardia, increased Due to seizure risk benzodiazepines
Lorazepam/Ativan blood pressure, hyperreflexia, if available
Diazepam/Valium muscle tension, joint pain, motor, Monitor for
Alprazolam/Xanax agitation/restlessness, tremor, seizures
Clonazepam/Klonopin nausea, ataxia, diaphoresis, seizures, Evacuate
perceptual disturbances such as
illusions and hallucinations

3. Reflect to the patient tangible evidence of safety, when available.

4. Use appropriate calming techniques.

Calming Techniques
a. Reassurance- Normalize reactions of shaking, crying, anxiety, and fear, which are normal
responses to overwhelming situations. If possible, reflect to the patient true and encouraging
facts about the current situation. Stating the positive without unneeded details can achieve
this. This would include statements like “it has been confirmed that everyone survived,” or
“a helicopter has been deployed to our location.” Reflecting on evidence of safety is a
powerful tool to alleviate further stress response from the individual.
b. Validation- “This is a normal response to an abnormal situation” can be a very helpful
statement to normalize the reaction of the patient. Patients often feel ashamed of their
reactions and hearing that others might experience similar feelings can be very helpful.
c. Breathing- Deep breathing does not have to be complex. It may be as simple as asking the
patient to repeat slow, deep breaths, while the provider listens to lung sounds. Reflect back
on the evidence that breath sounds are present, saying “you’re doing good, keep taking a
few more deep breaths” can be comforting to the individual. Demonstrating slow, deep
breaths, often elicits the same breathing pattern from the anxious patient. Pausing to take a
deep breath, and perhaps exaggerating this for the patient will have the effect of
encouraging the patient to breathe deeply.
 Problem-solving and returning to the present moment- Those who experience severe
d.
anxiety often perseverate on things that could happen (this is often called catastrophizing).
Returning the patient’s thoughts to the present moment can be helpful. Assigning
individuals a task or engaging in problem-solving activities helps redirect and focus on
solutions, providing escape from disturbing thoughts.
e. Explore preexisting coping skills- Many individuals often have well-established coping
skills. Exploring with each person what they usually do when they feel anxious or what has
worked in the past to relax or calm down is useful. Patients may forget (until reminded) that
they already have many skills needed to care for themselves.
f. Grounding techniques- Examples of this include asking a patient to put their feet on the
floor and take in a deep, slow breath. The patient might then be asked to describe three
nonthreatening things they can hear around them (eg, birds chirping, rescuers talking, wind
in the trees). Taking a deep breath and counting to four before a slow exhale also connects
an individual to their body.
ADVANCED LIFE SUPPORT AND CLINICIAN PROVIDERS
Advanced life support (ALS) and clinician providers should implement all the interventions
discussed above for first aid and basic life support providers. At the advanced level, providers
with access to medication must weigh the risks and benefits of medication use for severe anxiety
(Table 23.4). SSRI and SNRI medications require 4 to 6 weeks to take effect, and are not used
acutely. Restarting an SSRI or SRNI if anxiety is due to abrupt discontinuation of the medication
is the simplest way of alleviating symptoms.
For the provider preparing for anxiety in the remote setting, hydroxyzine (Vistaril) is an
antihistamine indicated and frequently used for anxiety. It is also used off-label for insomnia.
This medication is well tolerated with minimal side effects. Hydroxyzine at doses of 50 mg may
be given up to four times a day for acute anxiety in adults. The onset of action for oral
formulation is 15 to 20 minutes. Side effects include dry mouth, sedation, and tremor. In
addition, the side effect (as noted above, sometimes used as a primary effect for insomnia) of
sleepiness may contraindicate this medication for wilderness operational activities requiring
alertness for safety.
Benzodiazepines may be considered for use in acute anxiety/panic symptoms that are
extreme and impairing. Lorazepam (Ativan) is a benzodiazepine of choice for acute symptoms,
given its relatively quick onset of action (15 to 30 minutes) and duration of action (4 to 6 hours).
Lorazepam 0.5 to 1.0 mg may be repeated every 2 to 4 hours. Side effects of lorazepam include
sedation, fatigue, dizziness, ataxia, slurred speech, weakness, forgetfulness, and confusion.
Respiratory depression, which can be life-threatening, can occur with an overdose or in
combination with other sedating agents such as alcohol. Avoid short-acting agents such as
alprazolam (Xanax) due to rebound anxiety symptoms. Benzodiazepines are not the medication
of choice for anxiety related to acute stress responses/posttraumatic stress disorder (PTSD)
unless there is the presence of agitation. Acute stress responses, PTSD, and the reasons why
benzodiazepines are less ideal for them are discussed more fully in Chapter 10. In addition,
benzodiazepines have their effect on cognitive function and an individual’s reaction time, which
could make wilderness travel and self-care hazardous in some settings. The Wilderness Medical
Society Practice Guidelines8 also recommend oral haloperidol (Haldol) 5 to 10 mg in cases of
anxiety with severe agitation. This would typically be reserved for the most severe cases, where
agitation may have dangerous consequences to the individual or rescuers and other means of
reducing anxiety have failed.
Evacuation
Many anxiety states can be managed in the remote setting. Some presentations of anxiety will be
outside the provider’s comfort level or ability to manage. In these instances, the patient must be
evacuated. The following situations related to anxiety can be used to indicate a probable need for
evacuation.

1. Severe or recurrent anxiety reactions or panic symptoms disruptive to the group.

2. Symptoms that interfere with the patient’s ability to care for themselves, or keep themselves
safe.
3. Anxiety presentations that are beyond the provider’s ability to manage.
4. Anxiety states that render the patient, rescuer, or group unsafe.

Depression
Epidemiology and Etiology
Like anxiety, depression is common, with depressive disorders in the United States affecting
approximately 7.6% of the population over the age of 12.7 Gender plays a role as well, with
females experiencing 1.5- to threefold higher rates of depression than males, beginning in early
adolescence.1 Like anxiety states, a variety of issues can contribute to depressive disorders,
including genetic vulnerability, early childhood trauma, current life stressors, and belief
structures. Deficits in neurotransmitters such as serotonin, norepinephrine, and dopamine are also
thought to contribute to the development of depression.

Clinical Presentation
Depression can manifest itself in a variety of ways, ranging from subtle changes in motivation
and energy, to complete disruption of one’s ability to perform daily tasks, to loss of desire to
live. Although there exist “classic” symptoms of depression, such as sadness, hopelessness, and
decreased energy, each individual will be unique in how they manifest their symptoms making
depression, at times, difficult to detect. This is in part due to the fact that many depressive states
are accompanied by shame, self-blame, social isolation, and a barrage of negative self-thoughts,
that result in the inability (or lack of desire) to share how truly painful the experience is. Many
individuals endure symptoms of depression without sharing them for weeks, months, or even
years. Often it is the objective physical findings (eg, weight loss, weight gain, decrease in
energy, or sleep disturbance) that draw the attention of medical personnel. Self-harm, suicidal
thoughts or attempts, and, rarely, psychosis account for the majority of emergency department
(ED) visits related to depression.
While the essential feature of depression is sadness or depressed mood, hopelessness, self-
blame, negative thoughts, and loss of interest or joy can all present in most who suffer from
depression. Sleeping too much or not enough, overeating or loss of appetite, isolation, fatigue,
and decreased ability to concentrate, complete tasks, or make decisions, can all be found in
depression. Rumination (repetitive and worrisome thoughts), worry, and anxiety can also
accompany depression.
Likely the most distressing and dangerous of symptoms of depression are repetitive thoughts
about death or dying, suicidal thoughts, or plans to commit suicide. Risk of suicide is ever
present among those experiencing depression. Especially concerning are patients with a history
of previous suicide attempts, history of family members who have completed suicide, and
individuals with highly lethal and available plans already formed. Prominent feelings of
hopelessness, substance abuse, and borderline personality disorder significantly increase the risk
of suicide attempts. Older males, single or living alone, are also particularly at risk.1

Assessment
Wilderness providers accustomed to assessing and treating physical symptoms often report
feeling reluctant to screen for suicidal thoughts or plans. The commonly expressed reasons for
this include feeling uncomfortable and concern for planting the idea of suicide in those who had
not previously thought of it. Inquiring about suicide does not increase suicide risk.2 Often, the
depressed patient has been contemplating suicide, planning and rehearsing for days or weeks,
before being queried by a provider. Patients who rehearse suicide, for instance holding a gun to
their head to “see what it feels like,” should be considered very high risk for suicide.
Those contemplating suicide may often express relief at being able to share the extent of how
bad they feel when asked directly about suicidal thoughts. They also may feel a connection with
the person asking. For those not accustomed to asking questions about self-harm, using
established questions to screen for suicide is highly recommended. When caring for a patient
with symptoms of depression, consider asking the following questions recommended by NOLS
Wilderness Medicine9:

1. “Are you thinking of harming or killing yourself?”

2. “Have you planned how you would do this?”
3. “Do you have the means with you now to carry out this plan?”
4. “When are you thinking of doing this?”
5. “Do you have a history of past suicide attempts?”

Of note, many people choose the wilderness setting to end their lives. The most easily
accessible means to complete suicide in remote settings include jumping from high places,
overdosing on medications, hanging, and gunshot. Determine if they have access to lethal means
and remove these items if possible. All individuals expressing suicidal ideation or thoughts
should be evacuated from the remote setting.

Treatment and Disposition

ALL LEVELS—CRISIS MANAGEMENT, NON-PHARMACOLOGIC TREATMENT
Treatment of depression is complex and long term in nature. Treatment requires resources not
often available in the remote setting, such as the presence of a psychotherapist and medication
management. Recognition and evaluation and safety planning are likely the greatest contribution
to the treatment of depression by the wilderness provider.
At all levels of care, priority treatments of depression include the following: recognition that
depression is the issue, provision of support and validation, connection with the patient, and
forthright questioning if there are suicidal thoughts and intent to self-harm. If the patient does
engage in self-harm behaviors such as cutting, evaluate and treat the wounds with general wound
care.
ADVANCED LIFE SUPPORT/CLINICIANS-MEDICATION ADMINISTRATION
There are no rapid acting medications for the treatment of depression. If the individual also has
symptoms like insomnia or agitation, see sections below on insomnia and agitation identification
and management.

Evacuation Recommendations
Individuals who present as a suicide or self-harm risk should be evacuated for evaluation, either
by a mental health professional or evaluation in an ED. Safety precautions for patients known to
have intent to self-harm include removing dangerous items or means for self-harm including, but
not limited to, ropes, cords, medications, and knives. Constant supervision and one-on-one
support is needed for those who have acknowledged suicidal thoughts.

Bipolar and Psychotic Disorders

Epidemiology and Etiology
Bipolar disorder is a mood disorder characterized by fluctuations in mood between abnormally
elevated to depressed while psychotic disorders, such as schizophrenia, are characterized by
symptoms such as hallucinations, bizarre thinking, delusions, and paranoia. Both bipolar disorder
and schizophrenia can present with extreme behaviors that may include agitation, confusion, and
detachment from reality. This may result in bizarre thoughts and behaviors that pose a risk to the
individual and others in a wilderness setting. The cause of both disorders is thought to be
primarily genetic, with alterations in neurobiology, specifically abnormal neurotransmission of
dopamine, glutamate, serotonin, and norepinephrine. The prevalence for bipolar illness is
estimated at 2.6%10 and about one in every 100 people will develop schizophrenia in their
lifetime.2 Environmental stressors can also trigger strange or paradoxical behaviors, such as an
individual disrobing despite the fact that it is cold outside. Exposure to decreased availability of
oxygen at high altitude may worsen or precipitate hallucinations.11 (Psychotic symptoms such as
delirium may also occur as a result of mushroom ingestion, illicit substance use, or overdose of
medications.)
While a bipolar disorder is considered a mood disorder rather than a psychotic illness, it is
included in this section because and management factors during an acute manic phase share
similarities with psychotic illnesses. Assessment and treatment considerations for depressive
phases of the illness were discussed in the preceding section on depression.

Clinical Features
Psychosis is a complex set of symptoms that are seen with schizophrenia, acute mania, and
sometimes in severe depression. Individuals may experience bizarre, fixed beliefs, such as a
backpacker who believes his tentmate is inserting thoughts into his head (delusion) or the
climber who hears voices telling her to let go of her climbing partner on belay (auditory
hallucination). They may have a bizarre or stilted way of engaging with others. They may be
very disorganized in how they speak and may not make sense to the first responder.
Bipolar affective disorder, historically referred to as manic-depressive disorder, is an illness
characterized by extremes. The individual may experience periods of significant depressive
symptoms alternating with periods of elevated mood or irritability, lack of need for sleep, risky
behaviors and, often, a loss of touch with reality and insight.
This illness can be difficult in a remote setting, particularly in managing symptoms of mania,
as the individual can be impulsive, have poor judgment, and demonstrate irrational thinking.
They may have difficulty following instructions, may be difficult to redirect, and require constant
supervision given their lack of judgment and risk-taking behaviors. This can be exceedingly
worrisome if the manic episode occurs while working in wildland firefighting, guiding, or in the
military context. During times of mania, an individual may not sleep at all for many days, and
still have energy and high levels of activity. The wilderness provider may note that the individual
is fidgeting and constantly moving, speech is rapid, and they are full of ideas that may be
grandiose in nature.
Patients experiencing mania rarely seek treatment unless they have insight gained from
previous episodes. Euphoria and elevated mood, accompanied by creativity and ability to “get
things done,” is often a welcome change for the patient from the depressive states that
accompany bipolar disorder during non-manic phases. Loss of insight into the manic episode
often complicates management and treatment, and can be especially frightening if associated
with psychotic symptoms such as delusions and paranoia. A patient with paranoia may have the
belief that the remote rescuer is working for the government and has an agenda to kidnap them or
poison their food. These delusions inhibit the rescuer’s ability to care for the patient and
transport them to advanced care, and may pose physical risk to the rescuer.
Those with a bipolar disorder can also carry a high risk of self-harm. The completed suicide
rate is about 8% in men and 5% in women.12 Self-injurious behavior (intentional self-harm
without suicidal intent) is also a risk, with rates as high as 30% to 40%,13 necessitating vigilance
and close monitoring, particularly in those experiencing the depressive phase of the illness. For
individuals suffering from schizophrenia and severely distorted thinking, the rates of suicide
attempts can be as high as 50%.2 Suicidal behavior may be the result of individuals responding to
command auditory hallucinations, voices telling an individual to harm him/herself or others.
Violence may also be related to untreated illness and delusions of a persecutory or paranoid
nature. A history of prior violence is highly related to the risk of future violence.

Assessment
Assessment of individuals in acute phases of illness can be challenging due to the unreliability
and bizarre nature of the individual’s thought content and conversation. It can be difficult to
engage an impulsive and manic individual long enough to complete an assessment. Assessing
individuals with psychosis or manic symptoms includes a thorough risk assessment and
evaluation of the content of the psychotic thought process. For instance, if the individual is
paranoid, explore whether paranoid thoughts are in regard to members of the group, and whether
it poses a risk to other group members? Assessing judgment and insight may be more difficult,
but can be observed in the individual’s engagement in risky behavior. In the remote setting, this
may include feats of climbing without a harness or protection, or setting out from camp without
means of navigating or supplies.
Medical- or substance-induced causes must be considered in the assessment. Psychotic
symptoms may be present in medical illnesses such as electrolyte imbalance, dementia, malaria,
brain tumors, and infectious diseases (eg, conditions as significant as AIDS or as minor as
urinary tract infections in the elderly). The individual with intoxication from substances such as
amphetamines or cocaine can present with both manic-like and psychotic-like symptoms.
Alcohol intoxication, barbiturate withdrawal, and phencyclidine (also known as “angel dust”)
can also result in psychosis or psychotic-like behavior.

Treatment and Disposition

CHRONIC TREATMENTS
Antipsychotic medications, such as risperidone (Risperdal), quetiapine (Seroquel), aripiprazole
(Abilify), and haloperidol (Haldol), are the primary treatment for psychotic illness and are often
also utilized in the treatment of bipolar disorder. Side effects from antipsychotic medications
include extrapyramidal symptoms (abnormal movements, restlessness, parkinsonism), sedation,
orthostatic hypotension, and dizziness.
Medication management of bipolar disorders includes the use of mood stabilizers whose
function is to moderate the highs and lows of the illness. Common mood stabilizers include
lithium, lamotrigine (Lamictal) and divalproex (Depakote). Lithium can cause side effects such
as ataxia (poor muscle control), delirium (at toxic levels), tremor, memory problems, polyuria
(excessive urination), polydipsia (excessive thirst), nausea, and diarrhea. A particular concern in
the wilderness setting with the use of lithium is the risk of toxicity that may occur with
dehydration or sodium depletion. Overdose of lithium can be lethal. Another notable
consideration in a wilderness setting is the abrupt discontinuation of lamotrigine—this may cause
the development of a life-threatening rash called Stevens-Johnson syndrome. Antidepressants for
bipolar disorder may precipitate manic episodes and are generally avoided.
ALL LEVELS
Building rapport is paramount. Psychosis associated with delusions of paranoia or grandeur may
fuel a patient’s bizarre behaviors. A patient may harbor paranoid thoughts about the rescuer,
including fear that the rescuer will harm him or her. These fixed beliefs inhibit the rescuer’s
ability to care for the patient and transport him/her to advanced care. Building rapport and
communicating in a calm, respectful, and nonthreatening manner remain the wilderness
provider’s primary tools for stabilization and care. Clear concise statements and direct
commands are most helpful, as are many of the tools listed in the section on de-escalation. Do
not directly challenge delusions as this will only escalate potential agitation.
ADVANCED LIFE SUPPORT/CLINICIAN
Patients may be agitated and may be moving quickly. If there is access to benzodiazepines, this
may temporarily serve to manage acute behavioral concerns, though it will not directly address
the cause of their symptoms. Side effects to benzodiazepines can include sedation, fatigue,
ataxia, dizziness, slurred speech, forgetfulness, confusion, and weakness. Respiratory depression
can occur in high doses and/or in combination with other central nervous system (CNS)
depressants. Use of lorazepam 1 mg as needed every 2 to 4 hours is recommended for acute
agitation that poses risks to safety. Intramuscular medications can be very helpful (and preferred)
in this context but are rarely stocked in the wilderness medical kit. Antipsychotic medications are
also unlikely to be found in the wilderness medical kit, but can be extremely helpful in the
treatment of acute agitation and can assist evacuation of individuals experiencing psychosis or
mania when non-pharmacological methods have failed. Serious side effects can occur with the
use of antipsychotics; therefore they should be used judiciously and only by advanced providers.
If antipsychotics are to be used, we recommend the use of haloperidol, which is inexpensive
and generic, or the oral dissolving tablet (ODT) olanzapine (Zyprexa Zydis). The latter has a
quick onset of action and dissolves in the mouth, although it is expensive. Both have evidence
for use in the acute management of psychotic or manic symptoms as well as agitation. Dosages
for use in these acute situations are haloperidol 2 to 5 mg orally or olanzapine ODT (Zyprexa
Zydis) 5 mg orally. Side effects can include extrapyramidal symptoms (abnormal movements,
restlessness, parkinsonism), sedation, orthostatic hypotension, and dizziness.
The side effects of sedation and altered cognitive status with use of both these classes of
medications need to be weighed when considering evacuation. Concomitant use of
benzodiazepines and antipsychotics can be used but will have more significant sedating side
effects, making walking on uneven terrain, rappelling, or participating in self-rescue a dangerous
option.

Evacuation Recommendations
While encountering an individual with acute psychotic or manic symptoms in the backcountry
may be rare, symptoms must be considered serious and warrant evacuation. Evacuate any patient
with acute changes in mental status or new onset of bizarre or paranoid thinking.

Sleep Disorders
Epidemiology and Etiology
Approximately 30% of adults suffer from at least one symptom of insomnia.14 Sleep is
restorative, conserves energy, helps maintain the body’s homeostatic functions, and even affects
thermoregulation. Disruptions in normal sleep patterns can be caused by a number of factors
including pain or physical discomfort (such as sore muscles or injury), nightmares, medical
issues like asthma or sleep apnea, consumption of substances such as caffeine (including coffee,
tea, energy drinks), nicotine (including e-cigarettes), alcohol, or from underlying psychiatric
issues like anxiety, depression, or bipolar disorder. Sleep disorders carry diagnostic categories
independent of mood symptoms such as insomnia disorder (not sleeping enough), narcolepsy
(falling asleep at inappropriate times or places), hypersomnolence disorder (sleeping too much),
or breathing-related sleep disorder (difficulties with sleep due to conditions such as sleep apnea).
Sleep apnea can worsen at higher altitudes and worsen sleep issues. Narcolepsy or sleep walking
(somnambulism) may prove dangerous in wilderness settings, when individuals may not be in
control of their wakefulness and may wander unintentionally.
There are multiple factors in the remote setting that will interfere with normal sleep patterns.
High altitude has long been associated with insomnia including sleep disturbance and
restlessness (see Chapter 15 for a further discussion of high altitude physiology).11 Exacerbating
this may be extremes of hot or cold temperatures, hypoxemia, the sounds of wind against tent
flaps, insects buzzing, animals rustling, and the stress of being in new places. A study on the
psychological impact of polar expeditions on patients indicates common sleep disruptions occur
related to the disruption of circadian rhythms. This is speculated to result from changes in
sun/dark exposure in summer and winter, cold exposure, and the general psychological stress of
such expeditions.15 Medications such as antimalarials or steroids can also interfere with the sleep
cycle. Changes in time zones from international travel and extended hours of sunlight consistent
with higher latitudes may precipitate sleep issues. Ultimately, sleep disorders can have complex
causes with a number of environmental factors that can worsen preexisting vulnerability to sleep
disturbances.
Mental health and sleep are inextricably linked. Depression, anxiety, and bipolar illnesses are
characterized by sleep disturbance, whether that be difficulty falling asleep, staying asleep, early
morning awakenings, decreased need for sleep, or sleeping too much. Unfortunately, those with
a predisposition to mental illness will likely experience worsening of their symptoms of mental
illness when sleep is disturbed.

Clinical Features
Sleep deprivation is likely the most clinically relevant sleep disturbance in a remote setting.
Common insomnia-related complaints include difficulty falling asleep, frequent awakenings, and
early awakenings. Sleep deprivation has been linked to a multitude of issues including decreased
alertness, impaired memory, increased health consequences, decreased ability to manage stress,
and poor decision-making. Prolonged episodes of sleep deprivation are associated with
significant symptoms such as confusion, hallucinations, and delusions.

Assessment
Assessment of sleep issues does not have to be complicated. Simply asking if there is a sleep
issue is the most important part of an assessment (Table 23.5). Asking specific questions
regarding sleep can help target the nature of the sleep disturbance. Patients often do not think to
share this information until the disturbance becomes extreme or has existed for some time.

Treatment and Disposition

FIRST AID AND BASIC LIFE SUPPORT
Identifying factors that are interfering with sleep is a priority. “Sleep hygiene” is a term used to
describe healthy sleep practices that can help manage support sleep initiation. These principles
include going to bed and awaking at the same time each day, removing excessive stimuli just
prior to sleep, ensuring the environment is suitable to sleep, and avoiding substances such as
nicotine, alcohol, or caffeine. In addition, avoiding electronics immediately prior to sleep and
engaging in relaxation techniques such as progressive muscle relaxation or meditation before
sleep can be helpful. Simple measures to improve sleep hygiene in the remote setting may
include ensuring the tent is battened down, ensuring the individual is warm enough on cold
nights, managing pain, and addressing mosquito bites or other skin irritants. We recommend that
patients avoid napping during the day and that they engage in regular exercise. More serious and
chronic sleep disorders may not respond to these simple techniques.
ADVANCED LIFE SUPPORT/CLINICIAN
Medications can be used to address sleep deprivation, but should be used conservatively and
only after other methods have been tried. Diphenhydramine is a commonly used over-the-
counter medication to induce sleepiness. This can be a low-risk medication to address moderate
sleep deficits. It may be tempting to reach for the benzodiazepines to manage sleep issues, but
there are increased risks of benzodiazepines associated with high altitude. Changes in oxygen in
the blood while sleeping will decrease and may be even more accentuated in those with sleep
disorders (eg, sleep apnea) or susceptibility to the effects of high altitude. Benzodiazepines,
which depress the respiratory drive, can worsen sleep problems.

Evacuation Recommendations
Sleep is the foundation for mental and physical health. Significant sleep disturbance can place an
individual at risk due to decreased alertness and poor decision-making. More severe sleep
disturbances may have even more deleterious effects on an individual’s functioning and, at
times, can be an indication of a worsening psychiatric illness. Rapidly evacuate any person with
sleep disturbance accompanied by hallucinations, agitation, psychosis, or marked changes in
mood.

Substance Use
Epidemiology and Epidemiology
Statistics for 2014 indicate high rates of substance use disorders (substance abuse) in the United
States. Seventeen million people live with an alcohol use disorder, 7.1 million with an illicit drug
use disorder, and 2.6 million have both an alcohol use and an illicit drug use disorder.16
Marijuana and nonmedical use of prescription pain medications (such as opioids) are the most
widely used illicit substances. Recent statistics cite that 4.2 million people met the criteria for
marijuana use disorder in the United States.16 50% of individuals with substance use disorders
will also have a comorbid psychiatric illness.16
Factors contributing to substance abuse include genetic vulnerability in combination with
environmental factors such as ease of access to substances, peer pressure to use, social norms,
and psychological coping. Poor self-esteem and family members who used substances often are
associated with substance use. Brain function also plays a role in making an individual with low
concentrations of baseline endorphins (hormones that activate the body’s opioid receptors)
vulnerable to developing substance abuse. The varying of substances on brain function,
particularly in response to pleasure and reward, can positively reinforce use such that addiction
and dependence develop.
Substance use disorders in a wilderness setting can be dangerous due to the resulting
impairment of cognitive functioning, lack of inhibition, erratic behavior, and life-threatening
risks of overdose or withdrawal. Presentations of acute intoxication can vary widely. Those
under the influence of hallucinogens may display features of paranoia and bizarre thinking,
whereas those under the influence of opioids may present as drowsy and confused. It may at
times be difficult to differentiate between mental illness, substance use, and medical
complications. Gathering a history of substance use is crucial, although at times difficult to
execute due to substance users not reporting accurately.

Table 23.5 Asking About Sleep

Typical Interview Questions Related to Sleep
How long is it taking you to fall asleep?
Do troubling thoughts interfere with falling asleep or getting back to sleep?
Do you wake up in the middle of the night unable to fall asleep?
Do you ever wake up early in the morning unable to return to sleep?
Do you ever have nightmares that interfere with sleep?
Do you normally take medications to get to sleep?
Have you ever suffered from insomnia in the past?
Are you using any substances such as alcohol, nicotine, or caffeine?

Clinical Features
Substance use disorders are characterized by the use of alcohol and/or drugs in a manner that
causes significant impairment in daily functioning in areas such as work, social contexts, or
interpersonal relationships. Substance abusers often find themselves using larger amounts over
time, with the user experiencing difficulty cutting back. The individual may develop symptoms
of tolerance (needing more of the substance to reach the desired effect), as well as withdrawal
symptoms if their normal “dose” of alcohol or drugs is reduced. A critical differentiation (for
legal substances) between use and abuse/addiction is that abuse and addiction continue even in
the context of negative consequences such as motor vehicle accidents, loss of job, or significant
relationships as a result of drug or alcohol use.
The primary features of all substance use disorders are (1) impaired control; (2) social
impairment; (3) risky use; and (4) pharmacological indicators (tolerance and withdrawal).1
Presentations and symptoms of intoxication in an individual differ based on the type of
substance, the dose, the state of intoxication, and the state of withdrawal. Signs and symptoms of
acute intoxication and withdrawal are outlined in Tables 23.6 and 23.7.
Route of use can determine the intensity of intoxication, with snorting, smoking, and
injecting causing the fastest onset of intoxication. Alcohol, marijuana, opioids, stimulants, and
hallucinogens are the most commonly abused classes of substances. Any substance use in a
wilderness setting can create dangerous scenarios since impairment of both cognitive function
and judgment accompanies most intoxication. Nor is abrupt cessation by a habitual user effective
when entering a wilderness environment. Withdrawal from substances like alcohol and
benzodiazepines for chronic users can cause a life-threatening medical emergency and require
immediate evacuation. Serious withdrawal symptoms may occur in addiction when use has been
heavy and prolonged (for instance with alcohol and benzodiazepines), but may still be significant
and impairing even with one-time use due to profound “crashing” (for instance with
methamphetamines).
Marijuana, opioids, and stimulants can be addictive, but do not cause life-threatening
withdrawal. Hallucinogens tend not to be addictive and have limited withdrawal symptoms. It
should be noted that moderate use of substances infrequently causes withdrawal symptoms, and
can often be managed by monitoring behavioral symptoms and waiting out the acute intoxication
phase.

Assessment
Thorough assessment of patterns of use, inquiring frequency of use, amounts used, route of
administration, time of last use and history of withdrawal symptoms, can help the wilderness
provider assess the level of risk for withdrawal. For instance, an individual who drinks once a
month, but is acutely intoxicated from consuming eight beers, does not present a risk for acute
withdrawal. However, the individual who consumes this amount of alcohol on a daily basis and
cannot miss a day of drinking may present a withdrawal risk. Identifying the early signs of
alcohol withdrawal—shaking, sweating, anxiety, and elevation in heart rate and blood pressure—
can help the provider initiate treatment and determine the need for evacuation. Alcohol
withdrawal can occur as little as 4 hours following the last drink in significant alcohol use
disorders. Typically, though not always, tremulousness, jitteriness, or “the shakes” develop
within 6 to 8 hours after the last drink. Perceptual disturbances such as hallucinations develop
after 8 to 12 hours, and seizures after 12 to 24 hours.3 Delirium tremens is a withdrawal
syndrome characterized by confusion, hallucinations (“delirium”), and tremors or shaking
(“tremens”).

Table 23.6 Signs and Symptoms of Acute Intoxication

Substance Signs and Symptoms of Acute Intoxication
Alcohol Slurred speech, dizziness, incoordination, unsteady gait,
impaired attention or memory, double vision, involuntary rapid
eye movements (nystagmus); impaired judgment, poor impulse
control, stupor, and coma
 Marijuana Euphoria, decreased anxiety or increased anxiety, paranoia,
lack of coordination, impaired memory, lack of coordination,
difficulty with social interactions, increased appetite, dry
mouth, blood shot eyes, reduced HR, persistent cough
Opioids (oxycodone, heroine) Decreased perception of pain, drowsiness, mental confusion,
slurred speech, impaired memory and attention, euphoria,
nausea, constipation, respiratory depression
Stimulants (methamphetamine, cocaine) Increased alertness, attention, decreased sleep, increased
energy, increased BP, HR and respirations, seating, cardiac
arrhythmias or chest pain, nausea, vomiting
Hallucinogens (Psilocybin mushrooms, Peyote, Distortions of perception of time, surreal experiences, visual,
MDMA/Ecstasy, LSD, Ayahuasca, Acid) tactile, and auditory hallucinations, euphoria, hallucinations,
impulsivity, belligerence, hallucinations, and impaired
functioning, nystagmus, decreased control over body
movements, increased blood pressure or lowered HR, speech
difficulties, dilated pupils, ataxia, increased HR, respirations

MDMA, 3,4-methylenedioxymethamphetamine; LSD, lysergic acid diethylamide; BP, blood pressure; HR, heart rate.

Table 23.7 Symptoms of Withdrawal

Substance Withdrawal Treatment
Alcohol Sweating, tremors, insomnia, nausea/vomiting, Immediate evacuation if addiction is
autonomic hyperactivity, present
hallucinations/perceptual disturbances, delusions,
agitation, anxiety, delirium seizures, death
Marijuana Irritability, anxiety, depressed mood, sleep Not life-threatening, uncomfortable
disturbance, and restlessness, fever, chills,
tremors, sweating, and abdominal pain
Opioids Severe muscle camps and bone aches, diarrhea, Not life-threatening, very
abdominal pain, runny nose, goosebumps, uncomfortable
yawning, fever, dilated pupils, increased BP and
HR, temperature dysregulation, restlessness,
depression, tremor, weakness, nausea and
vomiting
Stimulants and methamphetamines Fatigue, vivid, and unpleasant dreams, sleep Not life-threatening, very
problems, increased appetite, or irregular uncomfortable
problems in controlling movement, depression,
extreme irritability, fatigue

BP, blood pressure; HR, heart rate.

Given the prevalence of mental health disorders accompanying substance use disorders, it is
also crucial to assess for worsening mood symptoms. Acute intoxication increases the risk of
suicide in depressed individuals and can increase the risk of violence and agitation toward others.
Consider also, the acute risk of aspiration and respiratory depression in the individual who
cannot manage their own airway secondary to use of substances.

Treatment and Disposition

ALL LEVELS
Anticipate potentially life-threatening withdrawal from alcohol. If an individual is demonstrating
active withdrawal symptoms, alcohol, if available, can intercede with withdrawal symptoms.
Withdrawal from opioids, stimulants, marijuana, and hallucinogens is not life-threatening, but
can be very uncomfortable.
 Manage behavioral issues that may emerge with either intoxication or withdrawal from all
substances using verbal de-escalation strategies. Assess for suicide and violence. Wait for acute
intoxication to resolve, with continuous monitoring of airway when appropriate. A patient having
a negative experience on a substance may require reassurance and support. Provide safety and
monitoring as decision-making may be poor and impulsivity may be high.
ADVANCED LIFE SUPPORT/CLINICIAN
In alcohol withdrawal, administration of benzodiazepines can be lifesaving. Monitor for seizures.
Typical dosing for oral lorazepam is 2 mg every 6 hours, but this may need to be adjusted based
on levels of sedation or agitation. Monitor vital signs closely. Be cautious not to oversedate and
be aware of the potential for respiratory depression with high dosing. In hospital settings,
benzodiazepines will often be given intramuscularly (IM) or intravenously (IV), and this would
also be an option in a wilderness setting, depending on resources.
Similarly, benzodiazepine withdrawal also carries the risk of seizures, and is treated by the
administration of benzodiazepines. Again, monitoring for oversedation and respiratory
depression is necessary.
Naloxone (Narcan) can be considered as part of the medication tool kit for opioid overdose.
Naloxone can be given IV, IM, or subcutaneously. Doses are repeated until the patient awakes.
The typical dose range is 0.4 to 2 mg IM repeated every 2 to 3 minutes until awake. Auto-
injection and intranasal formulations are available. A new innovation in many EMS systems is
the use of naloxone by law enforcement. In a wilderness setting, this may similarly become a
potential or actual practice for rangers.

Evacuation Recommendations
Evacuation of any individual with acute withdrawal symptoms and known addiction is
warranted, as some withdrawals can be life-threatening. Overdose of illicit substances requires
immediate evacuation. Acute intoxication can often be managed in the wilderness setting, given
its self-limiting nature, but the discomfort and impairment in functioning that accompanies many
withdrawals may warrant evacuation.

Agitation, Aggression, and Violence

Epidemiology and Etiology
Agitation is a general symptom that can occur as a result of a number of conditions and can be
extremely problematic. It may be a response to a disturbed emotional state from an underlying
illness, a response to environmental stressors, a reaction to medications/illicit substances, or a
symptom of an acute medical condition. Attention to de-escalation and understanding the risks of
poorly managed agitation are critical to avoiding danger for the individual and health care
provider.
It is important to remember that mental illness is not the major cause of violent behavior, and
most people with mental illness will never demonstrate violence toward others. The most
consistent predictors of violence are excessive alcohol use, history of violence with arrests or
criminal activity, and a history of childhood abuse.2

Clinical Features
Recognizing initial signs/symptoms of increasing agitation, the underlying causes of out-of-
control behaviors, and the precipitating factors involved are crucial. Conditions that may increase
confusion also impair decision-making/judgment, cause cognitive impairment, or precipitate
delirium. These factors may all contribute to out-of-control behaviors (Table 23.8). Some
psychiatric disorders carry increased risk of agitation and violence such as substance
abuse/dependence, untreated psychotic illnesses, paranoid or persecutory delusions, acute mania,
antisocial personality disorder, and some severe PTSD reactions.

Assessment
Early identification of increasing agitation can offer avenues for early intervention. Signs of
increasing agitation (Table 23.9) can include repetitive/non–goal-directed movements (tapping
one’s foot, pacing, wringing hands), repetitive vocalizations (making statements such as “I need
to get out of here, I need to get out of here”), increasing volume of speech, and appearing “on
edge”.

Treatment and Disposition

ALL LEVELS
The primary goals of de-escalation are to support the patient in calming him/herself down and
maintaining his or her own locus of control. Providers do well to understand that, even in the
face of extreme agitation and escalating violence, the goal is to “help the patient help
him/herself” rather than doing something to the patient or maintaining the traditional dominant–
submissive tone often used in de-escalation.17 The goals of de-escalation involve first and
foremost safety, helping the patient regulate their emotions and behavior, avoiding use of hand-
on means of de-escalation (restraints), and avoiding coercive interventions.17 Formal training and
preparation in verbal de-escalation as well as methods of physical restraints if necessary is useful
and often outside the scope of the wilderness provider; however, the following principals can
serve to protect both the individual and the rescuer.17,18

1. Prioritize personal and group safety at all times. Establish a body position for easy exit;
remove objects that may be used as weapons. Give the patient personal space; maintain at
least two arms-lengths between yourself and the patient.
2. Pause for self-calming and maintain a regulated state. Maintain neutral body posture
(stand at angle with calm facial expression and arms at side) and use a calm, slow voice at
normal volume. Do not give in to the temptation to speak louder than the patient. Utilize
silence to create the opportunity to de-escalate the situation. It may be necessary to repeat
this process multiple times throughout the de-escalation process.
3. Engage with the patient. Having multiple individuals attempting to interact and de-
escalate may in fact feel aggressive and overwhelming or convey confusing messages to the
patient. Clearly identify the provider who will take the lead in verbal de-escalation.
Introduce yourself, explain your role, and identify that you are there to help and keep them
safe. Provide reassurance. Ask how they prefer to be addressed.
4. Maintain a position of respect, honesty, and active listening. Demonstrating respect and
empathy for the individual’s situation and needs is essential to the de-escalation process. A
patient who does not feel respected or heard will likely continue to escalate. Demonstrate
that you are listening and paying attention with your body language and verbal responses.
Often a patient presents with one central need that is not being met and will continue to
escalate until the individual perceives that the need has been heard. Reflecting that you have
 heard (“it sounds like you are trying to find your daughter”) and validating the difficulty of
the situation (“it sounds like she is lost and I can see why that would be so frustrating)
facilitates de-escalation.
5. Avoid engaging with negative questioning and irrational statements. Although
tempting, it is not helpful to challenge irrational thought with facts. Respond to legitimate
information-seeking questions and ignore all questions with an abusive tone. By assuming
truthfulness of the patient experience, whether this be a delusion that someone is going to
harm them or a hallucination that someone is talking to them, the provider is able to better
empathize and understand the behavior of the individual, and more importantly build trust
and rapport with the patient. Refuting delusional beliefs may only escalate agitation.

Table 23.8 Underlying Causes of Out-of-Control Behaviors

Underlying Causes of Out-of-Control Behaviors Examples
Substance intoxication/overdose Alcohol, amphetamines, hallucinogens, mushrooms
Substance withdrawal Benzodiazepine withdrawal, alcohol withdrawal
Medical illness Delirium, hypoxia, altitude illness, cerebral edema, electrolyte
imbalance, heat illness, hyponatremia, hypothermia,
hypoglycemia
Conditions that may increase confusion, precipitate delirium, Head injury, bleeding, brain tumor, stroke, seizures
and impair judgment may all contribute to aggression/may
precede
Commonly used medications in wilderness settings Mefloquine (Lariam), corticosteroids (eg, prednisone)

Table 23.9 Signs of Escalation and Emerging Violence

Signs of escalating agitation and emerging violence
Repetitive/non–goal-directed movements: wringing hands, foot tapping, hair pulling
Repetitive vocalizations
Raised voice, high-pitched tone
Heightened arousal to stimuli
Clenched fists
Rapid speech
Fidgeting
Sweating
Aggressive posture
Shaking

6. Agree or Agree to Disagree. Finding a way to agree with an agitated patient may build
rapport and help to de-escalate. Richmond et al.17 describe three means of finding ways to
agree: agree with an element of truth in the situation (“Yes, the sleet is miserable”), agree
with a principle (“I agree, everyone should be treated respectfully”), and agree with the
odds (“There are other climbers who would feel the same way in this situation”). The
provider can acknowledge that they themselves have never experienced this but could
imagine the strong emotion or fear that it would produce if the provider was in such a
situation. Finally, agree to disagree if there is no way to honestly agree. Using this
 agreement principle can help the provider become an ally with the patient.
7. Set limits on what is acceptable or tolerable. Avoid challenging. Rather, reflect what you
as a rescuer are willing to do. For example, “I’m willing to help you as long as you are not
yelling,” or “We can continue to help you find your daughter as long as you maintain safe
behaviors.”
8. Give choices, where possible, in which both alternatives are safe ones. This increases the
perception of control and collaboration. “Would you like to keep talking about this or start
walking back to camp?”
9. Empathize with feelings, but not with behavior. For example, “I understand that you are
angry that you cannot use the satellite phone, but it is not acceptable to yell and threaten
me.” Suggesting alternatives to behavior can be helpful: “Would you like to take a break
and get some water?” Remember that it is not considered helpful to discuss or analyze
feelings or guess what the patient is feeling—use the patient’s own words when possible.
For instance, if the patient uses the terms “furious” or “pissed,” use these words rather than
“angry.”
10. Discuss consequences of out-of-control behavior without threats or anger. Firm, calm,
limit-setting informs the patient what is acceptable and expected without creating a
confrontational dynamic. Be specific and concise about behaviors.
11. Keep the goal of the interaction to calm and promote emotional regulation. Very little
can be accomplished with a patient who is in a dysregulated state. Avoid the temptation to
reason or persuade. Many patients in an agitated state are not accessing their decision-
making and problem-solving capacities and are driven by the limbic fight-or-flight
response. In fact, the majority of the communication will be based on nonverbal cues, tone
and inflection, and not on the content of the conversation. Use simple and concise
statements and be aware of the nonverbal cues you are giving.
12. Trust instincts. If the scene begins to feel unsafe, it probably is. Remember that physical
containment is risky for both rescuer and patient, especially in the remote setting where law
enforcement backup is not available. Prioritize the safety of the group and fellow rescuers
over the safety of the patient. If the choice must be made to allow the patient to run or try to
restrain him or her, the rescuer may need to make the difficult decision to allow the patient
to run. If there is a choice between getting attacked and fleeing, the rescuer may need to
flee, or in extreme cases defend himself or herself against aggression.
ADVANCED LIFE SUPPORT/CLINICIAN
The use of benzodiazepines can be considered in an agitated patient who may be withdrawing
from alcohol or other substances in inpatient or acute emergency situations. When agitation is
present and there is concern of imminent danger, antipsychotic medications have often been used
to facilitate de-escalation.
If the provider has access to benzodiazepines, this may serve temporarily to manage acute
behavioral concerns, though won’t directly address the cause of symptoms. Lorazepam 0.5 to 2
mg is often utilized for acute agitation that poses risks to safety. While ideal administration
would be intramuscular injection for the quickest onset of action, this may not be feasible and
oral tablets may be used. Side effects to benzodiazepine use can be sedation, fatigue, ataxia,
dizziness, slurred speech, forgetfulness, confusion, and weakness. Respiratory depression can
occur in high doses and/or in combination with other CNS depressants. Utilizing a
benzodiazepine is preferred if agitation is likely related to substance withdrawal such as alcohol
or benzodiazepine withdrawal.
 Antipsychotic medications are traditionally used in emergency medical settings to manage
these scenarios, and the sedation produced by their use can be advantageous in acute situations in
wilderness settings.9 Serious side effects can accompany the use of these medications, so they
should be used judiciously. If antipsychotics are used, we recommend use of haloperidol.
Second-generation antipsychotics may also be used given their more favorable side effect profile
and we recommend disintegrating olanzapine (Zyprexa Zydis) given the ability to use the rapidly
ODT and the higher levels of sedation this medication can produce.
Dosages for use in these acute situations would be haloperidol 2 to 5 mg or olanzapine ODT
(Zyprexa Zydis) 5 to 10 mg. Haloperidol also can be delivered in IM formulation. Olanzapine
comes in oral, disintegrating tablets or IM formulations. Side effects can include extrapyramidal
symptoms (abnormal movements, restlessness, parkinsonism), sedation, orthostatic hypotension,
and dizziness. IM olanzapine and IM benzodiazapines should not be used together given
compounding sedative effects.
Ketamine, a medication typically used to achieve sedation and analgesia (pain management),
is now being used to treat out-of-control behaviors in both the urban and the remote context. Its
relative safety, versatility and use as an agent for sedation, pain management, and acute agitation
has gained favor with the Department of Defense, National Parks System, and many urban EMS
systems. Ketamine shows promise in having fewer adverse effects than both benzodiazepines
and antipsychotics and has significantly less risk for respiratory depression than
benzodiazepines.19-21 It has a rapid onset of action (faster than IM haloperidol), short duration of
action, and produces anesthetic effect.19 It shows efficacy in sedating individuals where
antipsychotics and benzodiazepines have failed.21 Side effects to the medication can include
hypersalivation, nightmares, hallucinations, changes in HR, hypotension, and nausea and
vomiting. Hypersalivation may be managed with suction or by placing the patient in a dependent
position to facilitate clearing of secretions and prevent blocking the airway. In very rare cases,
ketamine can produce recovery agitation when the drug wears off. The benzodiazepine
midazolam has been given to manage this rare adverse effect. Typical IM dosing of ketamine is 2
to 4 mg IM, with onset of action between 3 and 5 minutes and lasting approximately 20 to 30
minutes.
Physical restraints are used when an individual is so dangerous that they pose a significant
threat to themselves or others and means of de-escalation have failed—many means of
improvised restraints have been used, including duct tape and climbing rope to physically stop or
subdue a patient. Improvised methods should be used with extreme caution, and only when there
is imminent risk of harm to the patient, rescuer, or bystander. Physical restraints carry risk of
injury to the patient and rescuer, impedes upon patient rights, and can place the rescuer in peril
of lawsuit. There exists immense legal and ethical complexity in the use of chemical and
physical restraints associated with advanced management of aggressive and out-of-control
behaviors. Civil rights of any individual include the right for a capacitated patient to refuse
treatment and the right to the least restrictive form of treatment. In wilderness scenarios, these
legal and ethical issues may arise if a rescuer considers administering medications without the
consent of an individual (eg, crushing and hiding medication in food) or restraining an individual
when verbal de-escalation has not been tried or when a significant threat of danger does not
exist. A provider must implement the least restrictive method of treatment, while balancing the
safety of all individuals involved. See Chapter 5 for a more complete discussion of the legal
circumstances surrounding patient capacitation and restraint. Physical restraint as a means of
intervention is not recommended without adequate training in hands-on interventions.
Evacuation Recommendations
The underlying cause of increasing agitation, aggression, and violence likely warrants immediate
evacuation, as will the consequences of aggression and violence. It is prudent to consider
whether law enforcement or any additional support may be needed at the completion of
evacuation. It is important to remember that in the United States law enforcement support can be
initiated from the remote setting whenever communication allows.

Prevention of Behavioral Emergencies

Prevention of mental health emergencies in the remote setting can be elusive. Preparation,
however, for mental health emergencies may profoundly improve the outcome of difficult
situations. Most encounters in the remote setting will not afford the opportunity to elicit a
thorough mental health history. Identifying potential concerns and obtaining health history
includes medical conditions, substance use and responses to environment and/or previously
administered treatments are foundational in anticipating concerns and managing emotional and
behavioral issues in the wilderness. Often neglected is the screening of rescuers participating on
search and rescue operations, medical providers on international groups, wildland firefighters, or
expedition medics. Consider including mental health screening in addition to physical health
screenings and obtaining of emergency contacts. Note that providers may be reluctant to disclose
previous mental health issues or medication use out of fear of stigma or exclusion.
Rather than firm exclusion criteria for psychiatric diagnosis and medication history, many
outdoor programs favor case by case assessment of stability, severity of symptoms, and often
pursue communication with therapists or psychiatric prescribers for the patient in order to make
more nuanced decisions about allowing participation in programming. As in the management of
all complex medical conditions, severity of the illness, time since last hospitalization or acute
flair, and complexity of medication management will all be part of the decision-making matrix
for inclusion in programming of those with a mental health history.

Table 23.10 Medication Toolkit

Medication Class Typical Dose Range Indications
Hydroxyzine (Atarax) Antihistamine 25–50 mg oral Anxietya, Insomniaa
Diphenhydramine (Benadryl) Antihistamine 25–50 mg oral Insomniaa, treatment of
movement side effects from
antipsychotic medications
(parkinsonisma)
Lorazepam (Ativan) Benzodiazepine 0.5–2 mg oral, IM, IV Anxietya, agitation insomnia
related to mania,
benzodiazepine and alcohol
withdrawal
Haloperidol (Haldol) Antipsychotic 2–5 mg oral, IM, IV Agitation, psychotic
symptomsa, mania
Olanzapine disintegrating tablets Antipsychotic 5–10 mg oral, disintegrating Agitation, psychotic
(Zyprexa Zydis) tablet, IM symptomsa, maniaa
Naloxone (Narcan) Opioid Antagonist 0.4–2 mg IV, IM, SC Opioid overdose

aIndicates
FDA-approved use.
IM, intramuscular; IV, intravenous; SC, subcutaneous.

Further training in how to manage behavioral emergencies is also foundational for

prevention. This may involve ongoing training such as trauma-informed care, psychological or
stress first aid, mental health first aid, or a practical course in de-escalation.

Equipment Summary
Preparation for the mental health emergency can be challenging, and can feel somewhat sparse,
given the few actual recommended medication to be used to treat in the field. The good news
about treatment behavioral health issues in the remote setting is that nearly all the tools needed
for effective interventions are those one carries with them at all times: Interventions of calming,
connection, listening, validating, and connecting with patients are the foundations of
intervention.
Few tools are need in the actual medical kit, but depending on one’s setting, preparation may
include packing medications specifically for the treatment of mental health. Table 23.10
describes medications to consider as part of your first aid kit.

SUMMARY
Management of the mental health emergency unquestionably calls on the innovation,
compassion, and fortitude of the remote rescuer. Few situations ask more of a provider in terms
of offering one’s own calm presence, courage, and previous experience to problem solve and aid
the distressed patient.
Given the growing need for engagement in mental health emergencies in the urban context,
the likelihood of encountering some aspect of behavioral presentations in the remote setting is
very high, and providers owe it to their patients to do all they can to prepare for these
challenging presentations.
Although the medications and medical supplies in one’s kit may be limited, the practical and
tangible interventions of engagement, calming, and connecting with the patient are available to
every provider. The key to successfully managing the behavioral health crisis is taking the
critical first step: consenting to try to help, even if feeling inadequate for the task or that someone
else might do it better. Pursuing opportunities to practice and engage with psychiatric
presentations in the urban setting, when it would be easier to avoid such action, will be the
hallmark of the provider who makes a difference in the lives of his or her patient in the remote
setting.

References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA:
American Psychiatric Publishing; 2013.
2. Sadock BJ, Sadock VA, Ruiz P. Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry.
11th ed. Philadelphia, PA: Wolters Kluwer; 2015.
3. Fagenholz PJ, Murray AF, Gutman, JA, et al. New onset anxiety disorders at high altitude. Wilderness Environ Med.
2007;18:312-316.
4. Sracic MK, Thomas D, Pate A, et al. Syndrome of acute anxiety among marines after recent arrival at high altitude. Mil
Med. 2014;179:559-564.
5. Block JJ. Pathological Computer use in the USA, in 2007 International Symposium on the Counseling and Treatment of
 Youth Internet Addiction. Seoul, Korea: National Youth Commission; 2007:433.
6. Chou C, Condron L, Belland JC. A review of the research on internet addiction. Educ Psychol Rev. 2005;17:363-388.
7. Pratt LA, Brody DJ. Depression in the U.S. Household Population, 2009-2012. NCHS Data Brief, No 172. Hyattsville, MD:
National Center for Health Statistics; 2014.
8. Forgey W. Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care. 5th ed. Guildord, CT:
Wilderness Medical Society; 2006.
9. Schimelpfenig T. Wilderness Medicine: National Outdoor Leadership School. 5th ed. Mechanicsburg, PA: Stackpole
Books; 2012:239.
10. Kessler RC, Chiu WT, Demler O, et al. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the
National Comorbidity Survey Replication (NCS-R). Arch Gen Psychiatry. 2005;62(6):617-627.
11. Virues-Ortega J, Buela-Casal G, Garrido E, et al. Neuropsychological functioning associated with high-altitude exposure.
Neuropsychol Rev. 2004;14:197-224.
12. Nordentoft M, Mortensen PB, Pedersen CB. Absolute risk of suicide after first hospital contact in mental disorder. Arch
Gen Psychiatry. 2011;68:1058-1064.
13. Novick DM, Swartz HA, Frank E. Suicide attempts in bipolar I and bipolar II disorder: a review and meta-analysis of the
evidence. Bipolar Disord. 2010;12(1):1-9.
14. Roth R. Insomnia: definition, prevalence, etiology, and consequences. J Clin Sleep Med. 2007;3(5):s7-s10.
15. Palinkas, LA, Suedfeld P. Psychological effects of polar expeditions. Lancet. 2008;371:153-163.
16. Center of Behavioral Health Statistics and Quality. Behavioral health trends in the United States: Results from the 2014
National Survey on Drug Use and Health. (HHS Publication NO. SMA 15-4927, NSDUH series H-50). Available at:
https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf. Accessed August 13, 2017.
17. Richmond JS, Berlin JS, Fishkind AB, et al. Verbal de-escalation of the agitated patient: Consensus statement of the
American Association of Emergency Psychiatry Project BETA De-escalation workgroup. West J Emerg Med.
2012;13(1):17-25.
18. Fishkind A. Calming agitation with words, not drugs: 10 commandments for safety. Curr Psych. 2002;1(4):32-39.
19. Scheppke K, Braghiroli J, Shalaby M, et al. Prehospital use of IM ketamine for sedation of violent and agitated patients.
West J Emerg Med. 2014;15(7):736-741.
20. Hopper A, Vilke G, Castillo E. Ketamine use for acute agitation in emergency department. J Emerg Med. 2015;48(6):712-
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In some cases, WEMS providers are responsible for technical rescue. In others, WEMS
providers interface with dedicated technical rescue specialists. These chapters will seek to
strike a balance between offering information for providers exclusively providing medical
care as well as more advanced principles for EMS providers who are responsible for
orchestrating complex rescue operations themselves.
INTRODUCTION
Section One of this text focused on the principles of wilderness EMS (WEMS) systems, and how
they are organized in overarching topics of medical oversight, equipment, and medicolegal
considerations. Section Two followed with the management of wilderness medical conditions
where specific injuries and illnesses common to WEMS settings were discussed in depth (ie,
management of heat and cold injuries, altitude, and other environmental conditions). The eight
chapters that compromise Section Three explore how WEMS actually interfaces with the
technical environments commonly associated with wilderness, austere, and resource-limited
settings. It will look at specific technical realms where patient care decisions must be balanced
with the risk of further injury or illness to both the patient(s) and rescuer(s). Each rescue and
patient encounter balances multiple variables that are generally not significant factors in most
traditional EMS settings.

Definition—Technical Rescue Interface

Defining the technical rescue interface for the WEMS provider can be a challenging concept if
looking for specific or exact fundamentals that must be applied across all technical settings. Each
technical rescue interface must be evaluated individually with a set of principles that balance the
specifics of the technical situation with the complex medical decision-making and patient care
priorities being managed by the WEMS provider. This confluence becomes the technical rescue
interface. While each situation is different, there emerge some common themes that persist
across each situation. Regardless of the WEMS provider’s medical skill level, each WEMS
individual must have a reasonable set of technical skills to keep themselves safe in the setting in
which they are performing patient care and ultimately extrication. This interface is a unique facet
of WEMS operations.1–4
Ideally, a WEMS provider is trained and able to enter the technical environment with the
appropriate technical skills, but also has the medical knowledge and equipment to begin
necessary medical care. This WEMS provider may be a search and rescue (SAR) team member
entering an avalanche path to begin resuscitation of a patient, or a ski patroller on the side of a
ski slope where a skier just collided with a tree, or a spelunker in the depths of a cave where a
patient has taken a serious fall and has an altered mental status. Each of these situations requires
medical decision-making to be balanced with the extrication problem and thus bridges the
WEMS technical rescue interface.

Search and Rescue Principles: Locate—Access—Treat—Extricate (LATE)

While some challenges in this technical rescue interface are common between different technical
realms, unique challenges also exist. Some simplified principles spanning the majority of SAR
and other WEMS operations can be summarized by the acronym LATE: Locate—Access—
Treat—Extricate. All WEMS operations typically have some degree of each LATE principle in
the technical rescue interface; some incidents will require a greater amount of focus and energy
based on a specific component (see Box 24.1).

Locate
The Locate portion may prove easy if there is a known location reported, but this may entail a
significant part of the SAR event when the location is unknown or not exact. In a traditional
EMS system, a 911 call generally gives the location to respond. In the WEMS setting, a SAR
team may be called for an overdue party and a search operation will entail. Whole fields of
science exist to help frame this type of response with lost person behavior statistics, terrain
considerations and rate of travel, techniques for managing search function, etc.5–8

Access
A common theme that also separates WEMS from traditional EMS is patient Access. Once the
patient has been located, the WEMS provider must be able to access that location. They may be
located across a raging river, on the side of a cliff, in a cave, or buried in avalanche debris.
Figure 24.1A–D give some examples of different access problems that exist. These challenges
highlight another paramount difference between traditional EMS, where the ambulance can just
“drive up,” have immediate access to the patient, begin patient care, and rapidly initiate transport
to a hospital. While some areas of frontier EMS settings have long transport times, the
ambulance still has control of the patient compartment temperature and carries all the typical
EMS tools.9 WEMS takes providers one step further to a remote setting where patient access
becomes a significant challenge. Sometimes specialized tools such as helicopters can be utilized,
but other times a prolonged terrestrial approach is necessary. These ground-based approaches
often require another set of very specialized technical skills and tools (see Chapter 7 for a more
complete discussion of WEMS equipment and Chapter 28 for a more complete discussion of
WEMS vehicles). Figure 24.2 demonstrates how helicopters provide a useful tool in WEMS
settings when a short haul rescue is utilized.
 Locate—Access—Treat—Extricate (LATE) Represent Simplified
Box 24.1
Principles in SAR and Other WEMS Operations
• Locate: the first step in any event. The patient must be located before the next steps of a rescue can be taken.
• Access: once a patient is located, the WEMS provider must be able to access the location in order to begin patient care.
• Treat: this is the main function of the WEMS provider, but in some settings, Extricate may become a higher priority
delaying care until the patient arrives at a safe location.
• Extricate: the last step of a SAR or other WEMS operation. Removing the patient from the technical environment toward
definitive care.

Previous definitions of wilderness medicine have used a 2-hour transport or extrication time
to separate WEMS from traditional EMS. But, as previously presented in this text, this definition
has several limitations and may not foster best patient care practices. As an example, an urban
setting may quickly turn into and WEMS setting in a disaster (ie, Hurricane Katrina in New
Orleans, LA); or alternatively when a helicopter extrication mitigates a prolonged ground rescue
from hours to a matter of minutes over very complicated terrain. This chapter uses the definition
of wilderness medicine and WEMS as outlined in the Introduction and presented in Chapter 1.
There are many resources and courses available to increase the proficiency of a WEMS provider
in safely gaining access to their patients.1,10

Treat
Initial patient assessment occurs once the provider accesses the patient and can begin to Treat
the patient. There are circumstances when the initial assessment can be completed from a
distance, over the phone, or possibly in surveillance photographs or videos. Is the patient
moving? Are they calling out for help? Or are they motionless or appear to have an unsurvivable
injury? This is another facet of remote medical care that presents additional challenges over
traditional EMS care. Out-of-hospital providers are taught at virtually all EMS skill levels that
the patient should be exposed, or at a minimum just the injured area to perform a focused
assessment. In some WEMS settings, this is impractical and can lead to increased problems with
hypothermia or other risks with removing personal protective equipment (PPE) such as a
climbing harness or helmet. Typically, if there isn’t an immediate life threat, the focused or in-
depth assessment may be deferred until the patient is extricated. In such cases, whole-body
immobilization in a vacuum mattress (Figure 24.3) will essentially splint everything until the
exact injured body area can be determined. This allows for rapid extrication in a dangerous
environment and reduces the time the patient and rescuers are exposed to hazards.
Medical decision-making in these technical rescue interface settings is possibly one of the
biggest challenges a WEMS provider encounters. This decision-making is undoubtedly the
toughest skill to learn and master, as each setting differs and the traditional linear EMS protocols
must now be applied or modified while weighing both the benefit and risk of each decision in
technical settings. This complexity and added challenge, however, is also why many WEMS
providers truly enjoy providing patient care in these types of environments.
FIGURE 24.1. A–D, These images depict a small representation of some access problems, and packaging and movement
solutions, that WEMS providers can experience: avalanche, swiftwater, cave/confined space, and cliff/high angle. Note that the
backboard in image (B) is being used as a brief patient movement tool and not a longer-term medical immobilization tool.
Courtesy of William R. Smith, with permission.

WEMS protocols2–4,11,12 must be flexible to allow for this dynamic medical decision-making,
and give the WEMS provider the ability to deviate when necessary (see Chapter 4 for additional
discussion on protocols and implementation in the WEMS setting). The Wilderness Medical
Society has published practice guidelines on many topics that WEMS providers will find useful
in patient care in wilderness and austere environments (see Box 24.2). In these technical rescue
settings, some of the variables that influence medical decision-making are summarized in Box
24.3.
Direct handover of the patient to a care facility (eg, hospital or clinic), or to another EMS
transport service (air or ground) is the last step in the continuum of care in the WEMS setting.
The essential details that must be conveyed during this critical step of treatment are covered in
more detail in Chapter 6.

Extricate
The last segment of the LATE acronym that helps simplify SAR rescue principles is Extricate.
Treatment may continue during this segment but should be concurrent with patient extrication
from the technical terrain toward definitive care. In some cases, extrication is simple, but in other
situations, it may prove the most difficult part of the operation. As previously mentioned, the
circumstances of some environments (Box 24.5 on page [434]) may necessitate the rapid
extrication and allow patient care only after the patient has been extricated (eg, avalanche,
swiftwater, high angle). This decision is generally made by the lead patient care WEMS
provider, and sometimes occurs even before airway, breathing, circulation life threats can be
identified.

FIGURE 24.2. Helicopters provide a useful tool in WEMS, although their risk must be balanced to the benefit in the overall
operation. Short haul is a rescue technique with the use of a helicopter and one or more persons suspended beneath the helicopter.
This can be used for inserting rescuers as well as extricating injured patients from very technical terrain. Courtesy of William R.
Smith, with permission.
FIGURE 24.3. The vacuum mattress has become the standard of care for most patient packaging situations in WEMS. Courtesy
of William R. Smith and David Bowers Photography, www.davidbowersphotography.com, with permission.

Box 24.2 Wilderness Medicine Society Practice Guidelines

• Prevention and Treatment of Acute Altitude Illness13
 • Use of Epinephrine in Outdoor Education and Wilderness settings14
• Treatment of Eye Injuries and Illness in the Wilderness15
• Treatment of Exercise-Associated Hyponatremia16
• Prevention and Treatment of Frostbite17
• Prevention and Treatment of Heat-Related Illness18
• Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia19
• Prevention and Treatment of Lightning Injuries20
• Treatment of Acute Pain in Remote Environments21
• Spine Immobilization in the Austere Environment22,23
• Basic Wound Management in the Austere Environment24
• Prevention and Treatment of Drowning in the Austere Environment25
• Prevention and Treatment of Envenomation from North American Venomous Snakes26
• Prevention and Management of Avalanche and Nonavalanche Snow Burial Accidents27
• Wilderness Fluid Resuscitation Guidelines (in development)
• Prevention and Management of Cardiovascular Emergencies in Remote Environments (in development)

From www.wms.org/research/practiceguidelines.
Varying care priorities in this manner during different phases of an operation parallels the
military’s phases of care as outlined in the Tactical Combat Casualty Care (TCCC) guidelines:
Care Under Fire (CUF), Tactical Field Care (TFC), and Tactical Evacuation Care
(TACEVAC).28,29 The TCCC concepts have been applied to more civilian EMS settings in
adapted protocols in Tactical Emergency Casualty Care.30 The terminology for these specific
care settings is summarized in Table 24.1. In general, many of the patient care principles used in
different dangerous situations from TCCC and TECC can be applied to WEMS settings. The
specific danger can be swapped from bullets flying in combat settings, to hazmat or active
shooter situations in traditional EMS settings, to the side of a cliff in WEMS operations.31

Documentation and Quality Improvement

Like traditional EMS, thorough documentation is also essential in WEMS and should be
completed immediately after the call if possible or ideally within 24 hours. Patient care details
become difficult to recall after this time frame as other day-to-day priorities will often delay the
WEMS provider from submitting the most complete patient care report. Documentation is
essential in both supporting the quality improvement (QI) process for patient care improvement
and capturing data which can help make future decisions for the WEMS program.
Documentation is discussed in more detail in Chapters 30 and 31.

Box 24.3 Variables That Influence Medical Decision-Making

These variables are only a partial set of thoughts that must be considered when a WEMS provider is incorporating medical
decision-making into the technical rescue interface.
• Changing patient status (improving or deteriorating)—very important to have one dedicated provider [if possible] to
monitor and reassess the patient frequently. Also passing this information forward through the succession of care is
important. SOAP (Subjective, Objective, Assessment, Plan) notes are often a good format to document and pass onto the
next caregiver.
• Anticipated medical problems (ie, hypothermia, continued blood loss)—a patient with a head injury and concern for
increasing intracranial pressure will require a more rapid and higher risk acceptance for helicopter versus a prolonged
ground rescue.
• Technical realm accessed (ie, cave, high angle, avalanche, swiftwater).
• Specific or specialized medical equipment, medication, and supplies available for WEMS operations.
 • Number of patients—a wilderness MCI adds multiple levels of complexity over a similar traditional EMS MCI.
• Extrication time and anticipated time to definitive medical care.
• Weather—precluding helicopter options or complicating care plans.
• Time of day—nighttime operations generally increase risk, and can have additive effects with hypothermia and other
mental/psychological challenges.
• Elevation/altitude—Elevation of the scene and altitudes attained during the rescue can affect patient physiology, as well
as rescuer health, as well as limit aircraft capabilities.
• Acceptable risk/benefit ratio to the team and patient—a definitive discussion point that should be made by the incident
commander with input from the safety officer and others, especially the rescuers who will be entering the technical
terrain. Some algorithms exist to help flush this out as well as identify mitigation strategies that may be helpful.

Adapted from Leo Lloyds Chapter 14 (p. 237): Patient Care Challenges in Technical Rescue in Mountain Medicine and
Technical Rescue.12
Other forms of QI are sometimes used in WEMS operations. Immediate debriefing often
occurs after an event and is sometimes called a “hotwash.” This generally occurs in the field
before members of SAR teams or other organizations demobilize from the event. It can be
performed in different formats and can cover different topics that may have been specific for that
event. Generally, the “hotwash” covers how the mission went, were there any safety issues
identified and how were they mitigated, what could be done better next time, and what needs to
be done to make the team operational for the next event (ie, resupply, stocking, fuel). For larger
or more complex WEMS events, often a more formal after action review is held. This is
generally facilitated and involves multiple agencies and looks at larger system integration
between jurisdictions. Other small intra-team debriefings should occur in order to share lessons
learned from each event. This allows the whole team, not just those members who may have only
seen a single isolated part of the event or members who may not have even been on scene, to
benefit from the experience. This sharing of information from each event can help disseminate
best practices to WEMS providers that often have a limited number of calls.
Emotional debriefing may also be needed and this should be considered as a separate event
from a tactical or operational debriefing. More discussion is included on critical incident stress
debriefing and how WEMS providers and teams should be aware of mental health in Chapter 10.

PRINCIPLES OF BASIC TECHNICAL RESCUE

Technical rescue is a necessary component of many WEMS operations. Each environment offers
technical challenges and the Access and Extricate problems often require a technical
component. Focused individual and team training is a must when dealing with each of these
environments or realms. Proficiency must be maintained by initial and ongoing training. If a
WEMS provider is not currently proficient, they should not be entering any location where they
will be faced with the technical problem. In this situation, it may be necessary that a non-WEMS
provider does the extrication to a safe location where the WEMS provider can then begin patient
care.

Table 24.1 Recognized Phases of Care As Compared by TCCC and TECC Guidelines,
with Common Care Principles Which Can Be Applied to Different WEMS
Situations28–31
Phases of Care
TCCC TECC Priorities
Care Under Fire (CUF) Direct threat care (Hot zone) Return fire
Self aid/buddy aid
Tourniquet
Tactical Field Care (TFC) Indirect threat care (Warm zone) Additional limited patient care as
situation allows
Tactical Evacuation (TACEVAC) Evacuation care (Cold zone) En route care
Traditional trauma care

Rescue Group Structure

Rescue groups vary in size and composition depending on multiple variables and requirements.
Box 24.4 gives some examples of rescue group structures. The most basic of these possible
structures is self-rescue or rescue from companions who are traveling with the patient. In some
cases, bystanders can help initiate a rescue, before an organized team can even be dispatched or
arrive on scene. These solutions generally allow for the quickest resolution of the event. Groups
traveling in very remote areas should consider self- or companion-rescue as their first option as
organized rescue may not be available or only be possible with significant delays.
There have also been increases in dedicated groups that are providing rescue services in
WEMS realms (eg, SAR teams, ski patrols, cave rescue associations). These can be small
focused teams that are trained for extreme technical environments such as a high angle terrain or
swiftwater. When an organized rescue occurs, personnel rely on the Incident Command System
(ICS) to efficiently manage the incident (ICS implementation in WEMS operations is discussed
in more detail in Chapter 3). The Mountain Rescue Association (MRA)* also has many teams
that are certified in ICS and other areas so that they can near-seamlessly integrate with other
teams in a coordinated response. Other more diverse SAR teams may train in multiple skill areas
and can accomplish a rescue in several different types of terrain independently with only organic
resources. In some locations, a municipal or rural fire department may have teams that interface
with WEMS to augment the overall rescue capability. In complex rescue settings, there may be
an overlap between several technical realms and multiple teams must coordinate together,
especially in a larger disaster type setting (eg, hurricane, earthquake). Note that natural disaster
WEMS care is discussed in more detail in Chapter 18.

Rescue Group Structures Can Be Quite Variable Depending on

Box 24.4
Location, Resources, and Other Factors
Some examples are:
• Self-rescue
• Companion rescue
• Bystander rescue
• Organized small group/strike team rescue (ie, specialized SAR team)
• Ski Patrol
• Organized large group rescue
• Fire department technical rescue teams
• Industrial site rescue teams
• Military systems (eg, airforce pararescue—PJs)
• Multigroup/interagency rescue response

Many organized SAR teams in the United States fall under the jurisdiction of the local
county Sheriff and have a duty to respond.32 In some locations such as ski areas, private
organizations are tasked with coordinating the technical rescue and WEMS care. Some ski
patrols only provide basic life support (BLS) level care, often with Outdoor Emergency Care
(OEC) training and certification.33–35
There are also for-profit companies that offer memberships that, when activated, will send
technical experts with paired medical assets to help a client in need. This service, in some
situations, will literally rescue a patient anywhere around the globe. The military also has a
robust WEMS care capability worldwide as well. As stated multiple times, the variation and
complexity of different technical realms require specialized teams to bridge the technical rescue
interface. Many excellent references and courses exist to teach a WEMS provider how to be
proficient in each technical rescue setting.See Chapter 2 for more information about WEMS
educational opportunities, and in particular Box 2.1.

Rescue System Fundamentals

Technical rescue requires significant training and skill acquisition for the WEMS provider.
Proficiency well outside the scope of this text is required to be able to employ these skill sets
safely in a real-world situation.
Static system safety factor (SSSF) is a term that defines a baseline knowledge required
whenever a team is utilizing a rope or other rescue system.1,10,12 A rescue system can be any set
of components from ropes, carabiners, pulleys, webbing, etc. The SSSF considers the breaking
strength of individual components within the rescue system and then allows for a margin of
safety. A 10:1 SSSF is considered standard in most technical rescue situations. This value
corresponds to a 10-fold increase in system strength of each component over the anticipated
static load to be applied. This allows for ample strength to accommodate a dynamic loading
event before reaching the breaking strength of the weakest component. In most rescue systems
there is also a belay or backup system in case of a main rescue line failure. This principle is
strictly followed when there is a high consequence of injury or death to the patient and/or rescuer
if a system failure occurs (eg, side of cliff or over a rapidly moving river).

Technical Rescue Systems

There are common gear options that form the basic components of most technical rescue
systems. These same items can be used in various SAR or WEMS realms, such as cave/confined
space, high/low angle, and swiftwater. Basic rigging principles can then be used across a
multitude of environments.1,10,12
Rescue ropes, cordage, and webbings all come in varying diameters, breaking strengths, and
other distinct properties (Figure 24.4). There are a multitude of other components that can make
up a rescue system from carabiners to pulleys to a host of other commercial devices. The
characteristics of each component are important and determine how a specific rescue system is
rigged. Knowing the properties of all the components available will facilitate a safe, timely, and
successful rescue. For example, it is important for a rescuer to know the differences between a
recreational climbing rope (high-stretch) and rescue ropes (low-stretch). Equipment inventory
and use logs should be meticulously maintained, as there are varying recommendations for life
span and the number of times a product should be used. Storage of all rescue gear, both personal
and the team, should adhere to the manufacturer’s recommendations. Other care considerations
should also be taken, such as making sure to avoid any contact with caustic and other substances
that may affect the manufacturer’s rated breaking strength, so when equipment is deployed on a
life safety mission it does not fail.

FIGURE 24.4. Various ropes, webbing, and cords are used in technical rescue with varying breaking strengths and other
properties. Courtesy of William R. Smith and David Bowers Photography, www.davidbowersphotography.com, with permission.

Although this chapter covers some common rescue system components, it is far from
comprehensive for all the options currently available for technical rescue. The International
Technical Rescue Symposium (ITRS)* is held annually by many stakeholders in the technical
rescue realm and can be a great venue to keep up to date with current and developing rescue
systems, as well as many other pertinent WEMS topics.

Webbing
Although there is no international or national standard, one common convention, following
recommendations of the International Fire Service Training Association (IFTSA) and multiple
mountain and technical rescue textbooks, uses the following color and length associations.12,36–38
(Note that some rescue texts suggest the 7.5 m length should be white).

Green webbing: 1.5 m (5 ft)

Yellow webbing: 3.5 m (12 ft)
Blue webbing: 4.5 m (15 ft)
Red webbing: 6 m (20 ft)
Black webbing: 7.5 m (25 ft)
 Note that these are widely accepted conventions but are not standards set by any consensus
or accrediting body. Regardless of the color/length scheme utilized, it is important that a team
has a unified internal standard to increase the efficiency of the rescue with standardized
equipment and training.
One of the most common knots used with webbing is the water knot (aka ring bend) to join
one or more strands together. This begins with a simple overhand knot and then is traced back
through with another strand to form the water knot. Often webbing is used to tie around solid
object such as trees, large boulders, or other natural features to create an anchor for a rescue
system (eg, Wrap 3 Pull 2).
FIGURE 24.5. A–D, Overhand knot in webbing as the start of the overhand bend. This same knot can be a simple backup or
safety knot in rope or cord as well as seen in Figure 24.8E. Courtesy of William R. Smith and David Bowers Photography,
www.davidbowersphotography.com, with permission.
FIGURE 24.6. A–E, The overhand bend (aka water knot or ring bend) is the most commonly used on two lengths of webbing, or
making a connecting loop for an anchor such as a wrap 2 pull 1 or a wrap 3 pull 2. Courtesy of William R. Smith and David
Bowers Photography, www.davidbowersphotography.com, with permission.

Overhand knot (Figure 24.5A–D)

Water knot (Figure 24.6A–E)

Knots
Technical rescue systems can vary from very simple systems using only basic components to
very complex systems that incorporate specialized equipment.1,10,12 Often the location of the
rescue will determine what equipment will be used. For example, a low angle rescue on the side
of a mountain pass road, can utilize heavier and more specialized equipment versus a remote
rescue where the only access is by foot and only the lightest and simplest of equipment is able to
be transported to the scene. Each rescue environment will determine the exact type of rescue
equipment chosen. In most rescue situations, there are some basic knots that are standard across
many rescue realms from swiftwater to cave to high angle. The most common are listed below
with accompanying figures, descriptions of how to tie, and possible uses in a rescue system.

FIGURE 24.7. A and B, Square knot is a secure knot that is easy to recognize and untie after being loaded. It must be backed up
with safety knots if used in a rescue system. Courtesy of William R. Smith and David Bowers Photography,
www.davidbowersphotography.com, with permission.

Square knot (Figure 24.7A, B)

Simple bowline (Figure 24.8A–E)
Long tailed interlocking bowlines (Figure 24.9A, B)
Figure 8 variations (single [Figure 24.10A, B], on a bite [Figure 24.11], follow through
[Figure 24.12A–C])
Münter hitch (Figure 24.13A–C)
 Clove hitch (Figure 24.14A–C)
Simple prusik hitch (Figure 24.15A–G)
Purcell prusik system (Figure 24.16A, B)
Radium release hitch (Figure 24.17A–D)
Double fisherman’s knot (Figure 24.18A–F)

Commercial Devices
There are various ways to solve each technical rescue problem encountered. Many rescues can be
performed with simple solutions and basic gear. Some situations can be executed with
specialized commercial devices that can be purchased. The frequency of rescues, typical terrain,
and local budgets all help determine which specialized equipment is most appropriate in a given
region.

Rescue Gear Organization

SAR teams need to be efficient and organized not only with training, but also with how gear is
stored in a rescue-ready configuration. Figure 24.19A and B show an example of a SAR rescue
vehicle, equipped to manage a rescue. Rescue systems are generally broken down into different
systems and stored accordingly for easy deployment. These general systems include:

Main line package (Figure 24.20)

Belay package (Figure 24.21)
Haul system package (Figure 24.22A, B)
FIGURE 24.8. A–E, The simple bowline is another commonly used knot in technical rescue. It allows for adjustment without
completely untying, but the tail must be tied off with a safety knot. Courtesy of William R. Smith and David Bowers
Photography, www.davidbowersphotography.com, with permission.
FIGURE 24.9. A and B, Long tail interlocking bowlines are a common technical rescue tie that can be used to attach a load
(patient, attendant(s), and litter) into a double rope rescue system. Backup knots are not needed as the long tails are terminated at
either the patient’s or attendant(s)’s harnesses. Courtesy of William R. Smith and David Bowers Photography,
www.davidbowersphotography.com, with permission.
FIGURE 24.10. A and B, Figure 8 variations have several uses as anchors and other attachments in technical rescue. A single
figure 8 is the basic platform on which the other knots in the figure 8 series build as shown below. Courtesy of William R. Smith
and David Bowers Photography, www.davidbowersphotography.com, with permission.
FIGURE 24.11. Figure 8 on a bite is one of the basic essential knots for technical rescue and is often used in recreational
climbing and other sports as well. This allows for an easy clip in point for a carabiner or attaching to another component in the
rescue system (ie, ascender, anchor). Courtesy of William R. Smith and David Bowers Photography,
www.davidbowersphotography.com, with permission.
FIGURE 24.12. A–C, Figure 8 follow through, another figure 8 variation that can be used to tie into an anchor or harness. No
safety knot or backup is required on a figure 8 knot. Courtesy of William R. Smith and David Bowers Photography,
www.davidbowersphotography.com, with permission.
FIGURE 24.13. A–C, The Münter hitch can be used for individual rappelling, lowering, or belaying. This should not be used for
a rescue load and can cause significant rope twisting. Courtesy of William R. Smith and David Bowers Photography,
www.davidbowersphotography.com, with permission.
FIGURE 24.14. A–C, The clove hitch is a secure and easily adjustable way to securely fix a length of rope (eg, edge attendant’s
tether). Courtesy of William R. Smith and David Bowers Photography, www.davidbowersphotography.com, with permission.

FIGURE 24.15. A–G, Simple prusik hitch can be applied to a rescue rope. A 2 mm difference in diameter is ideal to optimize
grip. Two raps can be used for a personal load and three wraps should be used for a rescue load. Courtesy of William R. Smith
and David Bowers Photography, www.davidbowersphotography.com, with permission.

Specialized anchors and gear (Figure 24.23)

Patient packaging and edge protection (Figure 24.24)

OVERALL MEDICAL INTEGRATION IN TECHNICAL

RESCUE
There are universal problems in many WEMS settings that must be considered, while some
realms have their individual problem sets. For example, in virtually all SAR callouts, whether it
is water-based, alpine, or most other WEMS environments, consideration should be given to
prevent/treat hypothermia. Patient rehabilitation to allow self-powered evacuation should be
another goal of every encounter. While this is not always feasible, if the patient can be warmed,
hydrated, and provided food/calories, they may be able to self-evacuate, which decreases the risk
of a litter carry evacuation for all involved (patient and rescuers).
FIGURE 24.16. A and B, Purcell prusik system can be used for multiple tasks in technical rescue. They can be used as an
adjustable anchor attachment. They can be used to tie a patient into a litter with the long and short purcells threaded through a
patient’s harness. In combination, they can be used in ascending a rope when placed in series and attached to a climbing harness
and the long purcell used as a foot loop. Courtesy of William R. Smith and David Bowers Photography,
www.davidbowersphotography.com, with permission.
FIGURE 24.17. A–D, Radium release hitch (RRH) is a load-releasing hitch that incorporates a Münter hitch and a 3:1
mechanical advantage that can be released under tension. It is most commonly used with a tandem prusik belay. The tail must be
anchored to prevent a total release if pulled all the way out. Courtesy of William R. Smith and David Bowers Photography,
www.davidbowersphotography.com, with permission.

FIGURE 24.18. A–F, The double fisherman’s knot is commonly used to tie two ropes together, and can even be used for ropes
of different diameters. Once fully loaded, they can be difficult to untie. Courtesy of William R. Smith and David Bowers
Photography, www.davidbowersphotography.com, with permission.
FIGURE 24.19. A and B, SAR response vehicle. This vehicle can organize virtually all gear needed to conduct a rescue. All
equipment is organized and labeled with slide out trays allowing easy access. Courtesy of William R. Smith and David Bowers
Photography, www.davidbowersphotography.com, with permission.
FIGURE 24.20. Main line package includes: two sets of 8 mm tandem prusik belays (red-short 46 inches and green-long 58
inches), Scarab rescue tool, micro brake bar rack, anchor plate, prusik minding pulley, nine carabiners, 10 m of 8 mm cord (to tie
radium release hitch), and 15 and 25 ft lengths of webbing. Utilizing the equipment in this bag you can build a main line system.
Courtesy of William R. Smith and David Bowers Photography, www.davidbowersphotography.com, with permission.
FIGURE 24.21. Belay line package includes: two sets of 8 mm tandem prusik belays (red-short 46 inches and green-long 58
inches), 540 Rescue Belay device, anchor plate, prusik minding pulley, 11 carabiners, 10 m of 8 mm cord (to tie radium release
hitch), and 15 and 25 ft lengths of webbing. Utilizing the equipment in this bag you can build a belay system. Courtesy of
William R. Smith and David Bowers Photography, www.davidbowersphotography.com, with permission.
FIGURE 24.22. A and B, Haul system package includes: three micro pulleys, two sets of 8 mm tandem prusik belays (red-short
46 inches and green-long 58 inches), 540 belay device, 10 carabiners, 10 m of 8 mm cord (to tie radium release hitch), and 15 and
25 ft lengths of webbing. Utilizing the equipment in this bag you can build a mechanical advantage raising system, with the
addition of appropriate length 11 mm rescue rope of varying lengths; 600 ft, 300 ft, 80 ft, as shown. Courtesy of William R.
Smith and David Bowers Photography, www.davidbowersphotography.com, with permission.
FIGURE 24.23. Specialized anchors and gear allow for hard tie off points from the rescue vehicle, bolt kit for placing bolts in
rock, ice screws for anchors in ice, and other specialized equipment for specific settings. Courtesy of William R. Smith and
David Bowers Photography, www.davidbowersphotography.com, with permission.
FIGURE 24.24. Patient packaging and edge protection package allows for protecting rescue ropes over rocks and sharp edges, as
well as a patient harness, helmet, and litter lashing equipment. Courtesy of William R. Smith and David Bowers Photography,
www.davidbowersphotography.com, with permission.

Principles of Basic Patient Packaging

Patient packaging becomes a paramount issue in WEMS care as ultimately the patient needs to
be extricated from the remote environment to definitive care. Sometimes this can be an easy task
when managing an isolated injury. For example, an upper extremity injury can be splinted and
the patient can walk or be assisted out of the technical environment. However, other injuries that
can still be minor, such as a lower extremity sprain or fracture, may also require the patient to be
carried out. More critical or life-threatening injuries generally always require some degree of
patient packaging and more intensive extrication. Different tools can be used to evacuate a non-
ambulatory patient such as a wheeled litter or other litter system in a technical raise or lower
situation. Figure 24.25 shows a litter that is a common rescue tool to move a patient in technical
terrain when they are unable to walk. This can be rigged into a technical raising or lowering
system (Figure 24.26) or placed on a wheeled litter to move over relatively flat trails (Figure
24.27). In overwater operations, care must be made to ensure proper flotation for the patient (eg,
personal flotation device), in addition to the extrication capability (Figure 24.1B). More
information on overwater operations is detailed in Chapters 26 (Swiftwater Rescue) and 27
(Open Water Rescue).

Physiologic Splinting
Physiologic splinting uses the premise of bringing the injured part of a patient to normal
physiologic alignment and then immobilize or support it in that position.12 This concept can be
applied to virtually any injury in technical rescue settings. Physiologic splinting generally
requires generous padding, much more than is typically used in traditional EMS. Additional time
taken to ensure the patient is packaged appropriately at the onset of Extrication, not only
decreases overall discomfort, but also promotes normal neurovascular function and allows for
expedited rescue operations. A hurried patient packaging without appropriate physiologic
splinting and ample padding may lead to delays in the rescue if a patient must be repackaged.
Other standard treatment protocols are incorporated in physiologic splinting, such as
immobilizing the joint above and below a long bone injury, and the bone above and below a joint
injury. Distal circulation, sensory, and motor assessments should be performed before any
splinting and then continuously reassessed.
The vacuum mattress (Figure 24.3) has become the standard of care for WEMS patients
requiring whole-body packaging (including spinal cord protection). As with any specialized tool,
it must be brought to the rescue scene but it is often more portable than the urban alternatives.
FIGURE 24.25. Stokes litter. Such a litter is used for extricating patients from many technical rescue settings. This model can be
separated into two parts in order to be carried to remote settings. Stokes litters are often made of titanium or other lightweight
materials. Courtesy of William R. Smith and David Bowers Photography, www.davidbowersphotography.com, with permission.

Airway Considerations
During extrication of an immobilized patient, especially if they are supine, the WEMS provider
must be able to monitor and access the patient. Airway considerations with the potential for
vomiting and airway compromise are a concern. Elements of technical rescue and evacuation
must be balanced with patient packaging and physiologic splinting. Sometimes lateral packaging
is an option with the vacuum mattress to allow fluids and vomit to more likely drain from the
airway based on gravity (Figure 24.28). Other considerations for prolonged patient care with a
concern for vomiting may be to pre-treat the patient with an antiemetic. One easily administered
option is ondansetron (Zofran) as an orally dissolving tablet. Other antiemetic options such as
diphenhydramine (Benadryl) and promethazine (Phenergan) can be considered and can have an
additive effect. A more complex discussion of WEMS pharmacology is presented in Chapter 11.
FIGURE 24.26. A Stokes litter secured into a low angle rescue system with long-tailed interlocking bowlines. Rescuers are tied
into the system and give enough upward deflection of the litter to carry and hold the patient off the ground, while the main haul
system at the top with additional rescuers (usually using mechanical advantage with a pulley system) provide most of the upward
force to bring the rescue package up the hill. Courtesy of William R. Smith, with permission.
FIGURE 24.27. A wheeled litter usually incorporates a litter or basket and attaches it over a single wheel and two rescuers can
guide it along a trail. A braking system similar to what is used on a mountain bike is usually also in place to control speed on
steeper terrain. In some cases, a belay rope can also be used. Courtesy of William R. Smith, with permission.

FIGURE 24.28. Lateral patient packaging in a vacuum mattress. Courtesy of William R. Smith, with permission.
Ideal to Real Care
While traditional EMS care may be clearly delineated, there may be situations in technical rescue
where deviation from that standard is required. This ability to improvise is almost the standard in
technical rescue situations. A concept of Ideal to Real Care must be appreciated with the risk
and benefit of each procedure, medication, or decision being balanced.4 Without deviation from
some traditional EMS standards, in some WEMS circumstances can: (1) prohibit a timely rescue;
(2) potentially not allow a rescue to occur at all (ie, backboarding a patient with a potential spinal
injury in a cave, where there is no physical way a traditional rigid backboard would fit through
some of the narrow openings); (3) dramatically increase the risk to the patient and/or WEMS
providers. The ideal to real care concept drives this point home to make sure WEMS providers
are doing what patient care is appropriate and balanced for that situation. It is important to
remember that traditional EMS protocols should not be blindly applied to the WEMS setting
without solid consideration of the consequences.
The ideal to real care concept can also help guide the WEMS provider in improvisation if a
particular tool is not available. The provider can adapt another device, medication, or procedure
to perform the same or similar function. In WEMS settings this may be packaging or splinting
with backpacks, skis, or other padding and improvised options. It may be knowing that a certain
drug is normally indicated, but you only have access to another drug and could be substituted. In
the end, it is providing real care to the patient based on the situation and supplies at hand based
on the ideal care that represents the normal standard.

Pain Management
The goal of pain management in the technical rescue setting varies based on the injury, the
patient, and other factors specific to the rescue. Ideally, the purpose is to decrease pain to a
tolerable level while ensuring that the patient maintains normal or near-normal physiologic
function. Oligoanalgesia, the undertreatment of acute pain, can have short-term complications
that do not allow an optimized rescue to potentially longer term complications such as increasing
the risk of posttraumatic stress disorder. Alternate pain control strategies are emerging with
ketamine and other shorter acting narcotics such as fentanyl.21 Novel delivery strategies are
becoming useful and more adapted in the WEMS environment as well. Transmucosal delivery of
fentanyl has had great success in such settings (eg, military, ski patrol, SAR). Intranasal (IN)
administration of ketamine, fentanyl, and versed has become a much more frequent
administration route for pain medications during a rescue. Nonsteroidal antiinflammatory drugs
(NSAIDs), such as ibuprofen and other NSAID varieties, as well as acetaminophen are great
nonnarcotic options that can provide adequate pain management with very few side effects.
Some injuries require an expanded pain control regiment, and in those cases narcotics and other
pain medications (eg, ketamine, methoxyflurane [Penthrane], nitrous oxide) can be administered.
A hybrid pain control strategy may decrease the total amount of narcotic medication required, as
well as decrease dose-related side effects. For example, administering 50 mg of ketamine and 50
mcg of fentanyl IN may provide better analgesia than higher doses of either medication alone. As
with any medication, the WEMS provider must balance the risk versus benefit of the single agent
chosen with the polypharmacy approach. Figure 24.29 shows a WEMS medical kit being used to
treat a fractured femur on a backcountry rescue. Chapter 11 discusses some of these
pharmacologic agents further.
Pain management, however, needs to be approached in a much broader sense and not just
about any specific medication a WEMS provider can give. It encompasses much more, including
psychological reassurance, physiologic splinting, as well as medication support. Psychological
first aid is explained more in Chapters 10 and 23, and can be a very useful tactic in any pain
control strategy. A WEMS provider balances all of these tools to provide optimal patient care in
technical environments. The Wilderness Medical Society Practice Guidelines for the Treatment
of Acute Pain in Remote Environments give a good summary of treatment options and Figure
24.30 shows a pain treatment pyramid that begins with comfort care and PRICE therapy and
builds with more advanced treatments up to intravenous (IV)/intraosseous medications.21

FIGURE 24.29. WEMS medical kit being deployed on a rescue. Courtesy of William R. Smith, with permission.

Other Medical Considerations in WEMS Realms

Different care environments entail complexities that either enhance the universal medical
considerations or provide additional challenges to patient care and/or access or extrication. Some
of these realms are included in Box 24.5.
In some technical settings, it may actually be safer for all personnel, including the patient, to
walk out or be assisted through technical terrain if they are able. Rehabilitation of the patient for
a short period of time, or maybe resting overnight, may allow the patient to resume function and
be able to self-extricate with little assistance. This delay in extrication for some cases may be the
best rescue option. Ultimately, each case must be evaluated and a decision made by the WEMS
provider that offers the best solution for patient care and efficient extrication.
Cave rescues and other confined space environments present additional challenges including
prolonged extrication, hypothermia, atmospheric safety (eg, toxic gases), etc. These specific
challenges are covered in more detail in Chapter 29.
FIGURE 24.30. Pain management pyramid. IV, intravenous; IO, intraosseous; IM, intramuscular; IN, intranasal; PRICE
(protection, rest, ice, compression, elevation). From Russell KW, Scaife CL, Weber DC, et al. Wilderness Medical Society
Practice Guidelines for the treatment of acute pain in remote environments: 2014 update. Wilderness Environ Med. 2014;25:S97,
with permission from the Wilderness Medical Society.

Box 24.5 Specific WEMS Environments

Each of these environments has certain variations that can sometimes impact the WEMS care given and the decision-making
that must ensue. Each environment is discussed in greater detail in various chapters in this book.
• High angle: Chapter 25
• Low angle/steep angle: Chapter 25
• Stillwater/swiftwater/open water: Chapters 26 and 27
• ATV/off-road vehicles/snowmobile/mountain bike: Chapter 28
• Helicopter rescue/fixed wing rescue: Chapter 28
• Snow/glaciated and crevasse rescue: Chapter 31
• Ski patrol and mountaineering: Chapter 31
• Avalanche: Chapter 31
• High altitude: Chapters 15, 28, 30, 31
• Diving: Chapter 17
• Cave/confined space rescue: Chapter 29

Spinal Injuries and Spinal Cord Protection

One of the biggest discussions over the past several decades in WEMS, as well as the broader
fields of EMS and emergency/trauma medicine, has been the question of best care for spine
injuries or suspected injuries when there is a concerning mechanism of injury. The patient with a
clear spinal cord injury and neurologic deficit at the point of injury has a well-defined treatment
pathway. They are unable to walk and/or move extremities based on the level of their spinal cord
injury and must be packaged to prevent further spinal cord injury, ideally with a vacuum
mattress. Next, they are extricated out of the backcountry to definitive medical care. In contrast,
the more challenging cases are with patients who have a mechanism of injury for spine trauma
(eg, climbing fall, snowmobile crash), but do not have any associated neurologic deficit. What is
their best treatment pathway? Should they be immobilized in the traditional sense, with spinal
cord protection which has been a backboard for rigid immobilization, cervical collar, and head
blocks? Should they be allowed to maneuver under their own power to walk out or extricate
themselves from their current situation? The indications and risks associated with the traditional
procedure of spinal immobilization were introduced in Chapter 21.
The greatest concern in these patients is the potentially unstable bony or ligamentous spinal
injury that could lead to a spinal cord insult and possibly lifelong paralysis or even death.
However, the traditional treatment is not without its own risks, especially in the WEMS
environment. Complications include airway compromise, aspiration risk, pressure sores,
increased pain and discomfort, and additional specific risks from cervical collars of increased
intracranial pressure, decreased cerebral outflow, and cervical distraction.39–41 Every intervention
in medicine has some balance of risk to benefit. Health care providers must integrate all the
variables and make an appropriate patient care decision. In relation to spinal column injury, it is
paramount that WEMS providers “do no harm,” but harm can be done by immobilizing or
inflicting treatment on a patient that is not warranted.
Spine injuries can be further separated by the clinical terms “stable and unstable.” Unstable
injuries generally require surgical repair or stabilization, while stable injuries are generally
allowed to heal with less invasive methods such as a thoraco-lumbo-sacral orthotic brace or other
specialized cervical collars (much different from the traditional rigid cervical collar used in the
out-of-hospital EMS realm).
The other distinct factor in WEMS is when the patient must be extricated from the technical
environment. If the patient can walk out, there is a significant risk reduction when compared to a
patient completely immobilized in a cervical collar and bound to a long spine board, who must
be carried or transported requiring additional resources now exposed to the technical
environment. Again, the overall risk of the extrication must be balanced to the possible risk of a
spine injury, and careful consideration and decision must be made. An example of this occurred
in Cornish, New Hampshire, in 2006, when a patient tripped and injured her ankle. She was also
backboarded for the concern of a possible head/spine injury and then transported on a rescue
boat that sank. The patient died from the rescue and not her minor injuries.42 Cases like this must
remind WEMS providers that the real risk of the rescue decisions and the potential risk from
possible spine injury and blindly following rigid protocols must be balanced.
To discuss this topic further, terminology used when WEMS providers have concern for a
spinal column injury (whether that be a bony or ligamentous) versus spinal cord injury represents
an important distinction. Spinal cord protection is now the preferred term over spinal
immobilization as there is difficulty splinting the spine’s curved structure with a flat backboard,
and there is no clear evidence that further injury is related to physiological movement. With the
introduction and widespread acceptance of vacuum mattresses, it has become a more ideal device
to actually achieve spinal cord protection. Attempts to completely immobilize a back or neck are
virtually impossible to achieve in the out-of-hospital environment without causing harm.
Physiologic range of motion is unlikely to cause any additional harm, as the forces required to
injure the spine are generally orders of magnitude greater and occur during the initial injury.41,43,44
Owing to the evidence that immobilization may be harmful, and that there is no evidence that
spinal motion restriction reduces injury—it appears that physiological motion is not related to
further injury—“spinal cord protection” is the best term for preventing further neurological
injury. This term expresses the universal goal (protecting the spinal cord) rather than specific
maneuvers that are rapidly changing to achieve that goal (immobilization, motion restriction,
etc.) and may be quickly outdated.”
Traditional EMS has also begun to move away from routine use of long spine boards as an
immobilization tool. This development has occurred with the renewed understanding that the
backboard was primarily introduced to EMS in the 1970s as an extrication tool and not an
immobilization device. Since that time, the backboard and c-collar became the standard of care
without evidence that these devices were actually providing benefit. The goals then and now
remain the same—spinal cord protection, or reducing the possibility of further spinal cord injury.
Currently, reducing painful or non-physiological movement appears the best maneuver to
achieve that goal. Validated studies have been performed to limit the use of radiographic
evaluation in emergency departments,45,46 and extrapolated from those studies has been a
decreased need for spinal cord protection or spinal immobilization. Spinal cord protection, either
by spinal motion restriction or by some other non-immobilizing maneuver, may still be required
in some patients, but protocols and medical decision-making strategies continue to be aimed at
decreasing unnecessary immobilization.47,48
In looking further, multiple studies have shown that an actual spinal cord injury is
exceedingly rare, especially in non-vehicular accidents, and the realization that progression of a
potentially unstable injury to become an actual spinal cord injury is even more rare.49 The fact
remains that there are real complications to patients from applying rigid cervical collars and
immobilizing. The paramount question that should be asked during the WEMS medical decision-
making process is: Will the benefit of a certain procedure outweigh the possible harm? Since
limited movement is the intended outcome for any patient packaging, and hard cervical collars
can cause harm, especially in prolonged application settings, the use of a hard cervical collar in
most WEMS settings is not recommended. With the use of modern vacuum mattress, the head
section can also be molded to limit movement without the use of any collar type device, thus
achieving the goal of spinal cord protection when required.
The concept of physiologic splinting can also be applied to spinal cord protection. Again,
this principle should be the basis of care of all injured body parts in the wilderness. Whether this
is a concern for a spine injury or a femur fracture, the ideal treatment is to return to the injury
anatomic alignment (if possible) and then reduce further motion until definitive care can be
reached. As mentioned before, the vacuum mattress remains one of the ideal splinting tools in a
WEMS cache, but often improvised treatments are still necessary to take us from the ideal to real
care in some given situations.

Suspension Syndrome
Suspension syndrome is best defined as a state of shock caused by blood pooling in dependent
lower extremities while the body is held upright without any movement for a period of
time.46,48–50 Climbers, cavers, and other recreationalists who wear a harness and can have their
legs become immobile in a dependent position are susceptible to this syndrome. Other industrial
workers, circus performers, stunt actors, and military service members (parachutists) who wear a
harness or are suspended vertically as part of their occupation may also be exposed to similar
pathophysiology.
Suspension syndrome has been called by many names over the years including suspension
trauma, orthostatic intolerance, harness-induced death, suspension trauma cascade, and harness
hang syndrome. These terms are imprecise and less descriptive, as there is little to no direct
trauma. A harness does not even need to be involved to cause the condition, and the real
pathophysiology is actually a cascade of events that better fits with the preferred term suspension
syndrome.48
Cardiovascular collapse from blood pooling in the dependent lower extremities is a real and
potentially fatal condition that leads to suspension syndrome. This type of orthostatic intolerance
is possible anytime a person is required to stand still or is held in a vertical position for a
prolonged period of time. The condition may be worsened by any other factor that leads to
hypovolemia (eg, hemorrhage, dehydration), vasodilation (eg, heat, infection), or other factors
that alter the body’s ability to maintain homeostasis (eg, illicit or prescribed drugs, alcohol).
Soldiers standing at attention are trained to make small flexing movements of their calf muscles
as lower extremity venous return to the heart is primarily a result of muscle contraction. By
contracting these muscles and the one-way valves in the lower extremity veins, a venous pump is
essentially created that returns blood to the central circulation. Failure of this venous pump
mechanism can quickly lead to suspension syndrome in a matter of minutes and potentially death
in as little as 10 minutes if the patient remains suspended upright.48 Mortimer’s landmark 2011
publication in Wilderness & Environmental Medicine51 provides one of the best case report
summaries of suspension trauma, as well as an excellent summary of the pathophysiology that
helped change the modern approach to treat this condition.48
When a patient experiences a passive hanging situation, blood pools in the lower extremities.
Although no blood is lost, a relative hypovolemic state in induced. Some estimate that as much
as 60% of the body’s blood volume can collect in the lower extremities. This dramatically
reduces the preload for the heart, and in essence cannot fill adequately to pump any blood
forward with subsequent contractions. Due to this decreased blood flow, the brain quickly
becomes affected and the patient will lose consciousness. Often this is called postural syncope
and in most normal and unencumbered settings, the patient will fall to the ground and restore
blood supply to the brain. However, in the technical rescue environment, the patient is often
suspended upright and the body’s protective mechanisms are thwarted, often leading to death if
not quickly reversed.48
In addition to venous pooling and decreased cardiac preload, it is thought that additional
maladaptive responses also contribute to the hemodynamic collapse in suspension syndrome.
Hyperkalemia and acidotic blood are thought to also contribute to the morbidity and mortality as
patients are resuscitated. Pooled blood may have become relatively hypothermic and cause a
systemic shock when reintroduced to the central circulation. There is some speculation that
overlapping problems of asphyxia from certain harnesses causing chest constriction or patient
positioning and airway compromise may also accelerate the mental status changes and death
curve in these patients. While some of these additional factors may play a role, some
pathophysiologic parameters still remain unclear.51
Treatment recommendations for suspension syndrome include extricating the patient as soon
as possible to a supine position. After this most critical step, WEMS providers can begin
traditional BLS and advanced life support (ALS) care and rapidly transport the patient to a
definitive care facility. Concern has arisen about case studies of “rescue death,”48,51 where
patients experienced cardiac arrest immediately after being extricated from their prolonged
suspension. Prior recommendations suggested that a delayed extrication and slow removal of the
harness would result in less morbidity and mortality. Mortimer and others have shown that this is
no longer recommended, and immediate extrication to a supine position provides the best chance
for the patient to restore circulation to the heart and brain.48–51,53 Standard treatments for crush
syndrome and other rhabdomyolysis conditions suggest IV hydration and possibly even
alkalization of the urine with sodium bicarbonate added to IV fluids may be beneficial. These
advanced discussions are beyond the scope of this text.
Patients with possible suspension syndrome, even if no clear outward symptoms are present,
should be evaluated by a medical professional. Signs and symptoms of delayed rhabdomyolysis
(muscle breakdown), compartment syndrome, and renal failure could develop during rescue or at
a later time.
If a patient or rescuer becomes trapped in a suspended vertical position for any period of
time, they should immediately call for help, attempt to self-rescue, and extricate themselves from
the situation. If self-rescue is not possible or they become exhausted, an attempt should be made
to support, raise, or move the legs to decrease the dependent pooling of blood. Another
preemptive measure would be to engage the body’s normal venous pump mechanism by
contracting the calf and leg muscles to help return blood to the central circulation. Pushing up
against a rock wall or using a set of Purcell prusiks to provide something to push against may
delay the progression of suspension syndrome.
Technical rescue teams should practice patient pickoffs and other techniques that can be
efficiently executed in a technical rescue setting. In small group training, prevention and
preplanning can decrease, if not prevent, situations where suspension syndrome can occur. This
may be teaching less experienced members how to ascend or rig themselves out of a situation.
Specialized equipment may be strategically placed in a small group to be able to quickly
extricate a patient if a person becomes suspended and unable to self-rescue. Specific group order
can place more experienced rescuers with less experienced providers, and if a situation develops
they can intervene quickly.
While this life-threatening condition has been reported in the literature, only recently has
there been a better understanding of the pathophysiology and updated treatment
recommendations. In summary, the best WEMS care for suspension syndrome is to extricate the
patient as soon as possible to a supine position and restore blood flow to the vital organs and then
continue standard resuscitation protocols.

Prolonged Field Care

WEMS care provided in a wide variety of technical rescue settings often has several similarities
to other military and austere settings. TCCC has led to the lowest conflict mortality rate to date.29
With military theaters changing from Iraq and Afghanistan to other more remote areas of the
world (eg, Africa, Pacific), the Prolonged Field Care (PFC) working group has been established
to help focus on medical and trauma care in extended patient care settings ranging from hours to
days. The group has identified 10 essential PFC capabilities to help focus training for these
prolonged care settings (see Figure 24.31). Virtually all the lessons learned can be bridged
between the WEMS provider and the military PFC settings.54

Training for the WEMS Technical Rescue Interface

Training provided to WEMS providers in the technical rescue interface should be as realistic as
possible. Training in traditional EMS settings simply does not provide the challenges that need to
be managed for more remote or technical environments.55 Improvised tools must be thought
through as not all equipment is able to be carried to some rescue settings. Often veterinary or
hospice-type procedures can provide an alternative perspective on care options outside of
traditional EMS paradigms. For example, using adult diapers to allow a patient to urinate and/or
defecate on a prolonged extrication can avoid completely repackaging the patient. Other
hydration routes such as oral, rectal, and dermal can be used when IV access is not possible or
practical.

IMPLICATIONS FOR PRACTICE LEVELS

In most technical settings, the medical skill level becomes much less important than the technical
skills of the individual rescuer and the team. For example, proficiency in cave navigation or
glacier travel is of paramount importance to keep the rescuers safe. This is necessary before even
considering the patient access and the additional challenges that come with treatment in these
settings. In many remote and/or technical settings, it is of greater importance to perform the
extrication before performing definitive medical interventions. Of course, there are a few
exceptions when dealing with immediate life threats, but there are even cases where extrication is
the ultimate mission priority over any medical care. In any case, the technical rescue interface is
a balance of experience in both the terrain as well as the dynamic medical decision-making
required during rescues. Flexible medical protocols with realistic but assured medical
oversight,54,55 built around familiarity with the challenges inherent in these settings, is of great
importance to allow for the best patient care possible without unduly putting rescuers or patients
at increased risk.
FIGURE 24.31. Prolonged Field Care (PFC) 10 Core Capabilities identified as key to providing care in austere locations. From
Keenan S, Riesberg JC. Prolonged field care: beyond the “Golden Hour.” Wilderness Environ Med. 2017;28(2S):S135-S139,
with permission from the Wilderness Medical Society.

Minimum Level of Training for WEMS Provider on a SAR or Other Technical

Rescue Team
The minimum level of medical training for a WEMS provider can be debated.2,3,12,58–60 As with
many systems of care, it depends on a variety of factors. In any case it should interface with the
National EMS Scope of Practice Model61 to allow for optimal EMS system integration between
all agencies. The final decision should rest with the leadership of the specific organization, time
available to maintain the desired certification, surrounding medical resources, discussions with
the medical director of the organization, likely patient types, as well as many other factors. The
Wilderness Emergency Medical Responder (WEMR), also known as Wilderness First Responder
(WFR) for non-EMS providers, appears to be an ideal level for many BLS agencies as it teaches
the practical skills and medical decision-making needed for most basic technical rescue
situations.36,59 If a WEMS team encounters more critical situations without close ALS resources,
it may be necessary to bring the program up to ALS level care with paramedics, physicians, or
other advanced providers. Maintaining an ALS level of care requires a considerable time
commitment, not only initially with wilderness-specific protocols and training to ensure
appropriate medical decision-making, but also maintaining advanced medical equipment and
supplies. However, this investment can be lifesaving in many cases. More details about various
training credentials can be found in Chapter 2.
Other specific settings such as ski areas have specific needs, and the level of WEMS
provider will be determined in those locations. For example, as discussed in Chapters 2 and 31,
Outdoor Emergency Care (OEC) is commonly found as the WEMS training level for many ski
patrols.33–35

EQUIPMENT SUMMARY
Specialized equipment for each setting is an ongoing decision each WEMS group will need to
constantly evaluate and balance the cost with the benefit or desired outcome. Items that have
multiple uses or cross over between different rescue settings should take priority over very
expensive or equipment with limited use options. Some examples might be how to secure a
patient in a litter. Is the all-purpose tape (duct tape) best or should specific Velcro straps (Spider
Straps) be purchased? Other questions must be asked and decided on, such as tourniquets and
other items with a focused purpose. Manufactured tourniquets are widely acknowledged to be
quicker and easier to apply with more reproducible results to stop bleeding quickly, over
improvised tourniquets. Many other rescue tools are available for specific technical settings (eg,
rigid litters and ski toboggans) as well as being able to improvise equipment with the gear
already at hand (eg, skis, bulky clothing, improvised litters).
FIGURE 24.32. Personal protective equipment (PPE) gear for high angle. Courtesy of William R. Smith, with permission.

PPE for each technical setting (Figure 24.32) is also mandatory in virtually all technical
rescue interface settings. Chapters 7, 20, and 21 cover WEMS equipment in greater detail.

SUMMARY
The technical rescue interface is a patient care setting that distinctly becomes the unique
specialty of a WEMS provider. The different medical decision-making paradigms that must be
applied in these environments clearly shows the separation from traditional EMS. In addition, the
specific technical skills that must be mastered to provide care safely in these settings provides an
additional challenge. When all of these skills are mastered, WEMS providers become an
invaluable resource in decreasing morbidity and mortality for patients in technical settings.

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lightning injuries: 2014 update. Wilderness Environ Med. 2014;25:S86-S95.
21. Russell KW, Scaife CL, Weber DC, et al. Wilderness Medical Society practice guidelines for the treatment of acute pain in
remote environments:2014 update. Wilderness Environ Med. 2014;25:S96-S104.
22. Quinn R, Williams J, Bennett B, et al. Wilderness Medical Society practice guidelines for spine immobilization in the
austere environment: 2014 update. Wilderness Environ Med. 2014;25:S105-S117.
23. Zafren K, Smith WR, Johnson DE, Kovacs T. Spine protection in the austere environment. Wilderness Environ Med.
2014;25:364-366.
24. Quinn R, Williams J, Bennett B, et al. Wilderness Medical Society practice guidelines for basic wound management in the
austere environment: 2014 update. Wilderness Environ Med. 2014;25:S105-S117.
25. Schmidt AC, Sempsrott JR, Hawkins S, et al. Wilderness Medical Society practice guidelines for the prevention and
treatment of drowning. Wilderness Environ Med. 2016;27:236-251.
26. Kanaan NC, Ray J, Stewart M, et al. Wilderness Medical Society practice guidelines for the treatment of pitviper
envenomations in the United States and Canada. Wilderness Environ Med. 2015;26:472-487.
27. Van Tilburg C, Grissom CK, Zafren K, et al. Wilderness Medical Society practice guidelines for prevention and
management of avalanche and nonavalanche snow burial accidents. Wilderness Environ Med. 2017;25(28):23-42.
28. National Association of EMTs. Prehospital Trauma Life Support, Military Edition. 8th ed. Burlington, MA: Jones & Bartlet
Learning; 2016.
29. Tactical Combat Casualty Care Guidelines. Available at: http://www.cotccc.com/. Accessed February 18, 2017.
30. Tactical Emergency Casualty Care (TECC) Guidelines. Available at: http://www.c-tecc.org. Accessed February 18, 2017.
31. Smith W. Integration of Tactical EMS in the National Park Service. Wilderness Environ Med. 2017;28(2S):S146-S153.
32. Russell K, Weber D, Scheele B, et al. Search and rescue in the Intermountain West states. Wilderness Environ Med.
2013:24;429-433.
33. McNamara EC, Johe DH, Endly DA, eds. Outdoor Emergency Care. 5th ed. Upper Saddle River: Prentice Hall; 2012.
34. Hawkins SC. The relationship between ski patrols and emergency medical services systems. Wilderness Environ Med.
2012;23:106-111.
35. Constance BB, Auerbach PS, Johe DH. Prehospital medical care and the national ski patrol: how does Outdoor Emergency
Care compare to traditional EMS training? Wilderness Environ Med. 2012;23:177-189.
36. International Fire Service Training Association. Essentials of Fire Fighting. 6 ed. Stillwater, OK: Fire Protection
Publications; 2013:96.
37. Department of the Interior National Park Service Emergency Services. Technical Rescue Handbook. 11 ed. Washington,
DC: US Department of the Interior, National Park Service; 2014.
38. Lipke R. Technical Rescue Rigger’s Guide. 2 ed. Conterra Technical Systems; 2011.
39. Kwan I, Bunn F, Roberts IG. Spinal Immobilisation for trauma patients. Cochrane Database Syst Rev. 2001;(2):CD002803.
40. Ben-Galim P, Dreiangel N, Mattox KL, et al. Extrication collars can result in abnormal separation between vertebrae in the
presence of dissociative injury. J Trauma. 2010;69:447-450.
41. Hauswald M, Ong G, Tandeberg D, et al. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad
Emerg Med. 1998;5:214-219.
42. Senz K. New Hampshire Rescue Squad Denies Fault in Woman’s Drowning. Sept 10, 2007. Available at:
http://www.emsworld.com/news/10408685/new-hampshire-rescue-squad-denies-fault-in-womans-drowning. Accessed
February 18, 2017.
43. Hauswald M. Did you ever have to make up your mind? spine care and decision making when there is not adequate data.
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44. Hauswald M. A re-conceptualisation of acute spinal care. Emerg Med J. 2013;30:720-723.
45. Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in
patients with blunt trauma. N Engl J Med. 2000;343:94-99.
46. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients.
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prehospital spinal assessment and care. Prehospital Emerg Care. 2014;18:429-432.
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Mountaineers. New York, NY: The Countryman Press; 2017.
49. Oto B, Corey DJ II, Oswald J, Sifford D, Walsh B. Early secondary neurological deterioration after blunt spinal trauma: a
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http://www.jems.com/articles/print/volume-40/issue-6/features/redefining-the-diagnosis-and-treatment-of-suspension-
trauma.html. Accessed February 2017.
54. Keenan S, Riesberg JC. Prolonged field care: beyond the “Golden Hour.” Wilderness Environ Med. 2017; 28(2S):S135-
S139.
55. Rush S, Petersen C, Smith W, et al. Optimization of simulation and moulage in military-related medical training. J Spec
Ops Med. 2017 accepted for publication.
56. National Association of EMS Physicians and the National Association of State EMS Officials. Medical direction for
operational emergency medical services programs. Prehospital Emerg Care. 2010;14:544.
57. Millin MG, Johnson DE, Schimelpfenig T, et al. Medical oversight, educational core content, and proposed scopes of
practice of wilderness EMS providers: A joint project developed by wilderness EMS educators, medical directors, and
regulators using a Delphi approach. Prehosp Emerg Care. 2017. doi:10.1080/10903127.2017.1335815
58. Welch TR, Clement K, Berman D. Wilderness First Aid: is there an “industry standard.” Wilderness Environ Med.
2009;20:113-117.
59. Weil C, Schimelpfenig T. Wilderness First Responder (WFR) Scope of Practice (SOP). Wilderness Medicine Magazine.
March 29, 2016. Available at: http://www.wms.org/magazine/1176/WFR-Scope-Of-Practive. Accessed February 28, 2017.
60. Singletary EM, Charlton NP, Epstein JL, et al. Part 15: first aid: 2015 American Heart Association and American Red
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61. National Highway Traffic Safety Administration. The National EMS Scope of Practice Model. Washington, DC:
 Department of Transportation/National Highway Traffic Safety Administration; 2005.

*www.mra.org
*www.itrsonline.org
INTRODUCTION
High and low angle rescue in the wilderness is much the same as high and low angle rescue in
traditional EMS jurisdictions. The specific differences are the type of terrain negotiated,
associated environmental factors, and the distances involved in accessing this terrain and
eventual evacuation of the patient. The inherent difficulties associated with these factors add
greater complexity to the rescue environment. Members of high and low angle rescue teams must
be comfortable in exposed situations, have the technical and medical skill sets to work in
extreme conditions, and be focused on their own and their patient’s safety.

Definition
Interest in outdoor and wilderness sports continues to increase, with 48.4% of all Americans
participating in some form of outdoor activity in 2014.1 Millions of these participants identified
hiking, trail running, mountain biking, hunting, climbing, and canyoneering as their sport of
choice. All of these activities bring outdoor users into close proximity to high angle terrain and
none more so than climbing, caving, and canyoneering.
According to the Outdoor Foundation, a not-for-profit organization dedicated to the increase
in outdoor participation by Americans, sport climbing increased in popularity by 3.5% and
traditional climbing and mountaineering increased by 16.0% since 2011. Combined, this
accounts for over seven million participants in 2014 alone.1,2 Some of these climbers will have
unfortunate accidents while enjoying the outdoors. Realistic training with an emphasis on safety,
medical and technical skills, and the application of this knowledge in a resource-limited
wilderness environment is the key to successful rescue, care, and transport of these individuals.
Rescues in traditional EMS high angle terrain are generally associated with human-made
structures such as buildings, water towers, silos, power line structures, and radio/phone towers
above ground, and vertical tunnel complexes such as sewer, water, and power structures
underground. High angle wilderness terrain is defined as any environment where geographic
challenges reduce or alter the availability of medical resources and that require rescuers to utilize
a rope rescue system where the rescuer and patient are primarily supported by this system. Most
commonly this terrain includes cliff lines, canyons, mountains, and vertical caving.
Low angle wilderness terrain has the same medical limitations in care and transport as high
angle, and requires rescuers to utilize some aspects of the rope rescue system to assist in the
recovery of an injured person. This terrain is most often characterized as mildly sloping land,
hillsides, and steep trails leading to or surrounding high angle terrain.
Standards for training and equipment within a high and low angle rescue environment can be
found in the National Fire and Protection Association’s (NFPA) documents 1006, 1670, and
1983 (Figure 25.1). NFPA 1006, Standard for Technical Rescuer Professional Qualifications,
NFPA 1670, Standard on Operations and Training for Technical Search and Rescue, and NFPA
1983, Standard on Life Safety Rope and Equipment for Emergency Services define and regulate
the conduct of operations and types of equipment used in high and low angle terrain.3-5 The
Mountain Rescue Association (MRA), formed in 1959, is the oldest mountain search and rescue
(SAR) association within the United States. MRA teams are spread across the country and this
organization has been instrumental in promoting SAR techniques. The International Commission
for Alpine Rescue (IKAR) is a global association of mountain rescue specialists and has
developed recommendations across a broad range of high angle rescue topics. These three
organizations and the techniques they promote serve as the doctrinal foundation of technical high
angle rescue today.
FIGURE 25.1. Photo of NFPA Standards 1670 and 1983. Courtesy of R. Bryan Simon.

Scope of Discussion
The focus of this chapter will be the technical and medical aspects of care within high and low
angle wilderness terrain. This includes the specific characteristics and hazards of the operating
environment, the makeup and technical skill sets required of rescuers, and the common civilian
user groups and their skill levels.
Technical rescue discussions related to mountaineering rescue, including non-snow or
glaciated terrain, is discussed in depth within Chapters 30 and 31. Caving rescue is presented
within Chapter 29. The fundamentals of medical care within high angle rescue described within
the context of this chapter are much the same as the terrains discussed in those chapters as well.
Concentration on terrain associated with cliff lines and canyons is the focus of the following
discussion.
A particular emphasis will also be made to communication within this operating
environment. This aspect of rescue is important whether in traditional or wilderness EMS
(WEMS), but can be more difficult due to the vertical nature of a high angle environment, as
well as the difference in terminology between recreational rock climbers and canyoneers, and
professional rescuers. This chapter will examine the differences between each group to bridge
what can be the most difficult aspect of operating in high angle terrain.

PREVALENCE
Accidents in vertical terrain occur across the United States every year. High angle rescue teams
are often activated in order to locate, access, stabilize, and transport injured persons from the
wilderness environment to definite care. There are multiple environmental factors that must be
considered during rescue; teams train their members to identify and mitigate these elements in
order to safely conduct rescue operations.

Care Environment
Safety
As with other wilderness environments, high angle terrain presents substantial risks to rescuers.
Care must be maintained and an accurate scene assessment should be conducted and include risk
assessment and hazard identification. This assessment should be ever-evolving as the rescue
scenario develops. Particular attention should be placed on changing weather conditions. Safety
is the primary concern of all rescuers and not just the assigned safety officer, team leaders, or the
incident commander. Safety priorities for team members should be: person, team, patient. All
members of a WEMS technical rescue team must take precautions when working in this
environment.

Terrain
The chief environmental hazard in high and low angle terrain is the height and makeup of the
cliff or canyon where a rescue is taking place. The rock composition of these cliffs and rock
walls can vary from solid walls of granite to a crumbly mix of dirt and pebbles. Knowing and
understanding the geologic basics of an area forms a helpful foundation for high angle risk
assessment. Operations often include a combination of high and low angle terrain and rescuers
must be prepared to transition between both types (Figure 25.2). Rock and ice fall does occur
during rope rescues and is one of the most common dangers to patients and rescuers. The freeze-
thaw cycle at the end of winter and heavy precipitation are nature-related causes for rockfall.
Rescuers or other climbers can also inadvertently dislodge rocks from above. Data collected by
the American Alpine Club (AAC) since 1951 and included in their yearly book, Accidents in
North American Mountaineering (ANAM), showed that 13.4% of all reported accidents were due
to falling rock, ice, or objects. This danger is a very real one for outdoor adventurers as well as
rescuers and the use of helmets is recommended.6 An additional hazard with rockfall includes
damage to rescue gear, particularly ropes. Redundancy of systems assists to prevent catastrophic
system failure that may occur due to rockfall.

FIGURE 25.2. Transitioning from high to low angle terrain takes organization and practice. Courtesy of Karsten Delap.

An additional terrain concern for rescues in canyoneering is the proximity of water to the
operation. The added complexity of working on rock that is slick from water must be addressed
and additional caution should be maintained. In addition, the risk of hypothermia increases both
for patient and rescuer when in running water.

Weather
Weather complicates delivery of care in any wilderness environment and cliffs and canyons are
no exception. Intense heat or cold, rain or snow, and windchill can create adverse conditions for
patients and rescuers and teams must be prepared for these occurrences. Additionally, altitude,
lightning, and avalanches should be considered depending upon the season and geographic
location of the rescue. These concerns are discussed in detail within Chapters 15, 18, and 31,
respectively.

Temperature
The effects that air temperature can have on rescuers and patients necessitate careful planning
and preparation. Specifically, extremes in heat and cold must be addressed. It is easy for rescue
team members to overlook the effect of even modestly cool weather on a patient while working.
Members are hot from exertion and can forget that the patient is often immobile and perhaps not
dressed for the conditions. It is much easier to prevent hypothermia and hyperthermia than to
treat these conditions. Temperature considerations should be addressed along with other
environmental hazards soon after the patient is secured and stabilized within a high angle
environment.

Precipitation
Much like air temperature, precipitation can have immediate negative effects on normothermia of
a patient. In conjunction with temperature and windchill, precipitation can quickly drop a
patient’s body temperature to dangerous levels. Protection from the elements is a priority for care
within the wilderness environment.

Wind
Windchill and its effect on rescuers and patients are an important consideration. Protection
against hypothermia must be initiated as soon as possible when high winds are present during
rescue. There are special wind patterns that occur in the mountains that should be considered by
rescuers in high angle terrain.
Gap winds, or channeled winds, are caused by restrictive terrain that can increase wind
speeds substantially. This creates a number of difficulties related to rope rescue, specifically
communication between rescuers and patients, rescuers and other team members, challenges to
rope work, and the prevention of the use of helicopter rescue assets. Terrain blocking is defined
as the effect on wind by a land feature that disrupts wind direction and speed. Usually occurring
on the leeward side of mountains, it can disrupt communication and alter evacuation plans. Day
and night wind shifts should be considered by rescuers for the warming and cooling effect that
they respectively can induce on patients and rescuers. The final and most important factor in
winds for high angle rescue is an understanding of wind speed versus force of the wind. The
force of wind increases exponentially as wind speed increases. For example, a 40 mph wind is
four times as strong as a 20 mph wind rather than just double. As with all weather, an accurate
and ongoing assessment of current and future conditions must be included in risk assessments for
the safety of rescuers and patients.7-9
Environmental Teams
As with other technical teams, high and low angle rescue teams and team members are
categorized into three levels of expertise. These levels, as designated by the NFPA 1006, are
divided into the awareness, operations, and technician levels.3 The categories can also describe
levels of technical expertise of teams. The NFPA document does not make recommendations
regarding the medical training levels of team members.

Awareness Level
At this level, an individual can recognize high and low angle rescue situations, resources needed,
and related hazards. This is the minimum capability of organizations that respond to SAR
operations and individuals at this level act as support for these incidents. Members of a team at
the awareness level can competently conduct site control and scene management at the location
of a high angle rescue.

Operations Level
At the operational level, individuals can recognize technical rescue situations and its related
hazards, respond using appropriate equipment, and apply knowledge of the needed systems in
conjunction with the technician level responders. Examples of technical competencies at this
level of training include selecting anchor points and constructing anchor systems, selecting and
conducting belays, performing self-rescue if necessary, ascending and descending a fixed line,
and loading, securing, and negotiating a patient using a litter.

Technician Level
The technician is capable of identification of high angle rescue situations and its associated
hazards, has the knowledge of the equipment and systems to select, employ, and apply advanced
techniques to coordinate, perform, and can supervise high angle SAR incidents. Within the
technician level, there are two designations: Technical Rope Rescue Technician I and II. These
individuals can conduct all techniques associated with rope rescue and often develop policies and
procedures for the team, provide leadership, and serve as instructors for their organization.
Additional details related to the specific technical skills of high angle rescue teams and their
members at each level can be found in Chapter 5 of NFPA 1670.4 This chapter provides a
systematic framework from which high angle rescue teams can develop training, insure
competencies of members, and provide high and low angle rescue within their area of operations.
In addition to the technical competency levels, members of high angle rescue teams must
also have some level of medical training. While many teams are composed of “rescue first” and
“medical first” team members, the best teams are composed of members who are strong in both
technical rescue skills and medical skills. Requiring a certain level of medical training as each
level of technical training is acquired results in teams that can better respond to, and care for,
patients who need assistance in high angle terrain. Without this redundancy of training for all
members, care for injured persons could be delayed and critical assessments and interventions
missed until providers with additional medical training arrive at the scene or until the patient is
transferred from the high angle environment. In our opinion, a minimum medical standard for
official teams responding to high and low angle rescues is Emergency Medical Responder
(EMR), ideally with a wilderness modular addition.
EPIDEMIOLOGY OF INJURIES IN A HIGH ANGLE
ENVIRONMENT
Identification and knowledge of the most common injuries sustained in a high angle environment
is the foundation for all technical and medical rescue discussion. In the past three decades,
researchers have completed multiple studies examining the epidemiology of injuries for all types
of climbing. The majority of these studies identified chronic or overuse injuries of the upper
extremities to be the most common injuries sustained by rock climbers of all types, but these
injuries are rarely categorized as emergencies and generally do not require the response of SAR
assets. Acute injuries, most often from falls while climbing or from falling objects such as rock
and ice, are the primary reason for need of rescue. Other causes contributing to the activation of
high angle rescue teams include inability to successfully negotiate high angle terrain by the
climbing party and environmental exposure.
Climbing injury research began in the 1960s with a study conducted by Ferris of accident
data gathered from the AAC.10 Other early research, such as the studies by Addiss et al.,11 and by
Schussman et al.,12 drew data from National Park Service (NPS) reports and from SAR agencies
and detailed acute injuries related to falls (75% and 92%) being more common than overuse
injuries. Other studies, drawing data from emergency departments (EDs), found the same
trends.13-15 A large study with data collected between 1990 and 2007 found a 63% increase in the
number of climbing patients seen in EDs during this period.13 This study found that climbing
falls were the most common cause of injury (77.5%) and the most common injuries to be:
fractures (29.0%), sprains and strains (28.6%), lacerations (17.1%), and soft tissue injuries such
as contusions (16.9%).13 The most common anatomic location of these injuries was the lower
extremities, and this trend is exemplified within the greater body of literature related to acute
injury.13
Studies that gathered data from SAR agencies, the NPS, and EDs across the United States
routinely found that acute injuries were the most common type for rock climbers. Later studies,
utilizing data obtained by online, on-site, or postal questionnaires, showed the opposite. These
studies found overuse or chronic injuries to be the most common type suffered by climbers and
the underrepresentation within earlier studies is understandable due to the lack of acute injury
that required immediate care.16 Traumatic injuries from climbing falls often require the activation
of high angle rescue teams, transport to an ED, and along with environmental related effects, are
the primary concern of this chapter.17
Currently, there is an underreporting of climbing accidents within the United States. The
AAC attempts to gather as much data as possible for inclusion in their yearly book, Accidents in
North American Mountaineering (ANAM), renamed Accidents in North American Climbing
(ANAC) in 2016. ANAC is the most comprehensive source of climbing-related accident data and
relies on SAR teams, the NPS, state park officials, and individuals involved in accidents to
voluntarily submit details of climbing accidents and injuries (Figure 25.3). All high angle rescue
teams are encouraged to submit reports to the AAC for inclusion. Submissions to ANAC are
helpful to the climbing community to learn from and help prevent future accidents and are useful
to high angle rescue teams in the identification of past incidences in an operational region.
Accurate injury data are also extremely beneficial to current researchers as every case adds to the
growing body of knowledge regarding accidents and resulting injuries. Additionally, the
accounts produce outstanding and realistic vignettes that teams can use to develop training
scenarios.
Other high angle environments include vertical caving and canyoneering. In comparison to
current climbing literature, there are far fewer instances of research regarding injuries sustained
within these environments. Hazards in caves and canyons are similar to that of rock climbing and
research has shown that injuries are similar in type and location. A large study of caving
accidents from 1980 to 2008 found that caver falls was the most common cause of traumatic
injury (74%) and caver fatalities (30%) with the lower extremities being the most common
anatomic area of injury (29%), followed by the upper extremities (21%) and the head (15%).18
Many rescues in this environment are not related to injuries but instead are due to the inability of
participants to exit the cave they are exploring. The National Speleological Society publishes
American Caving Accidents on a yearly basis with a mission to pass on hard gained experience to
others. As with ANAC, this publication tracks all reported accidents within the caving
community and gives some insight into the type of accidents and resulting injuries that occur in
caves (Figure 25.4).19 These descriptions also make a great basis for realistic training scenarios.
Further information on caving rescue is contained in Chapter 29.
There is even less published information regarding injuries requiring rescue for
canyoneering. A study published in 2007 related the injury patterns and first aid training from a
small sample size utilizing a web-based survey.20 This study identified environmental exposure
(hyperthermia and hypothermia) as being the top reason for major injuries with orthopedic
injuries (generally to the lower extremity) as the next most common. Of all 38 respondents, only
two needed outside assistance and both were due to lower extremity fractures.20 Hypothermia is a
particular risk to canyoneers due to the close proximity of running water that has the ability to
cause rapid heat loss even when wearing a neoprene wetsuit.

FIGURE 25.3. Reported climbing accidents in the United States (1951-2014). Data from MacDonald D, ed. Accidents in North
American Mountaineering. Golden, CO: The American Alpine Club; 2015.
FIGURE 25.4. Reported caving accidents in the United States (1986-2015). Data from National Speleological Society. American
Caving Accidents. 2016. https://caves.org/pub/aca/. Accessed July 6, 2017.

As detailed in all three areas prominent for high angle rescues, the most common reasons
identified in the literature for activation of assistance include traumatic falls and environmental
exposure. The most common injury type and site includes fractures of the lower extremity. These
issues will be discussed in detail within this chapter.

PATIENTS IN THE VERTICAL ENVIRONMENT

Having gained an understanding of the common injuries, illnesses, and other causes that result in
the need for high angle rescue and medical care in the wilderness, it is also crucial to understand
the background, knowledge, and capabilities of the user groups who may find themselves as
patients in high and low angle terrain. Recreational climbers, cavers, and canyoneers use much
of the same equipment as rope rescue teams though there are some differences, and younger or
inexperienced climbers may be unaware of some of the equipment used by rescue personnel.
Climbers may have never heard or seen a figure 8 descender, brake bar racks, or an ascender. On
the opposite end of the spectrum, there are many very experienced climbers who can assist in
their own or others’ evacuation.
There are few recent studies that describe in detail the demographic data of climbers, though
some basic information can be gleaned from the data collected in climbing medicine and injury
studies over the last two decades. The mean age of climbers participating in these studies was 30
years with a range of means among the 10 studies being from 27 to 35.2 years of age.15,21-29 The
mean gender breakdown in these studies that reported this metric was 79.6% male and 20.4%
female.15,21-25,27,28,30 The data are similar in both categories to an Outdoor Foundation study
conducted in 2005 that found the mean age of climbers to be 28 years of age with the gender
breakdown of 73% male and 27% female. Additionally, this study found that 93% of climbers
fell within the age range of 16 to 44.31 While none of these studies delineated the mean age and
other demographic data of injured climbers, it is appropriate to generalize that the demographical
data of injured climbers would be similar.
Based upon the epidemiological data discussed earlier and the demographic data mentioned
above, the most likely patient encountered by a high angle rescue team would be a person within
the 16 to 44 age range with a roughly 75% probability of the patient being male. This climber
most likely was injured in a fall and has likely suffered trauma to the lower extremity. So what
about the experience level of this injured climber? According to data gathered in reports to the
AAC since 1951, accidents occur to climbers throughout the range of experience.6 Understanding
the patient population and the most common types of injuries that cause activation of a rescue
team is the first step in planning and preparation for rescue and care of these persons (Table
25.1).

Table 25.1 Accidents by Experience Level (1951-2014) AAC Accidents in North

American Mountaineering
Experience Level of Injured Climber Accident (%)
Experienced (>3 years) 28
Moderate Experience (1–3 years) 21
Little/No Experience (0–1 year) 22
Unknown Experience Level 29

Adapted from MacDonald D, ed. Accidents in North American Mountaineering. Golden, CO: The American Alpine Club; 2015.

PLANNING AND PREPARATION

Planning and preparation for high and low angle SAR accidents are key components to
successfully care for injured patients. Careful conduct of both results in safe, efficient rescues,
improved patient care, better contingency planning and reaction, and confident rescue personnel.
Planning involves team leadership along with the EMS medical director and others. Preparation
involves acting on the components agreed upon in the planning phase and includes working with
the local community, local outdoor groups, conduct of training, and maintenance of individual
and team skills.
The planning portion entails identification of areas with high angle accident risk within
operational zones and the training of personnel to meet the needs of a particular area.
Identification of regions that contain high angle terrain is the first step in building contingency
plans for potential accidents. Team members can survey areas and identify access points and
trails to the cliff tops and base, identify locations that are conducive to raises and lowers of
patients, and identify potential landing zones or evacuation points. Environmental hazards should
be assessed and plans developed to mitigate these hazards. Training can then be developed and
conducted at these sites creating realistic scenarios that may mimic actual future rescues (Figure
25.5). All training should replicate as true of conditions as possible without jeopardizing safety.
All personal protective equipment (PPE) should be worn during training exercises. Leadership
should always be mindful of training for the worst possible scenarios to insure team skills are
adequate to meet these criteria.
The planning phase is continuous in nature to maintain the technical and medical skills of the
team and its members. These skill sets must match the technical environment of the area.
Understanding the technical environment allows for training that is focused on skills that will be
employed regularly. Additionally, knowing the patient and common injuries of the region is
helpful to direct medical training toward treatment of common injuries. Identification of past
incidents and associated injuries (epidemiology of the region) can help focus medical training
refreshers toward likely injuries in future incidents. While it is important to stay proficient in all
skills, both technical and medical, it makes little sense to focus training on situations that you
rarely encounter such as multi-pitch rescues in a single pitch environment or litter raises where
there is no cliff top access.
FIGURE 25.5. Realistic training in the operational environment best prepares teams for emergency response. (Courtesy of Seth
C. Hawkins.)

Preparation for incidents involves three aspects of training: technical, medical, and physical.
All three are of equal importance and are required of each team member to assure a successful
rescue operation. Rescue personnel who are confident in their technical and medical skills are
more composed in emergency situations, work fluidly with each other during these incidents,
have a better focus on safety, and can respond to unexpected situations in a calm manner. This
results in better patient care and a safer environment for rescuer and patient.
The physical aspect of training is of equal importance. Physically fit team members can
respond to the physical stressors of a situation more adequately. As anyone who has worked a
litter on the side of a cliff or was part of a litter team during a multiple mile journey across
difficult terrain can attest, a focus on routine fitness pays huge dividends for the rescuer, and
most importantly, the patient in a rescue situation.
Another important aspect of planning and preparation is interaction with the local
community and user groups of the region. Most popular climbing areas have nonprofit climber
groups that have formed to help protect the resource. These groups volunteer time for trail and
crag cleanup, trail development and rehabilitation, and other services to the area. Many climber
organizations have built and maintain rescue caches located at centralized areas of a crag for use
in an emergency (Figure 25.6). These groups are very active and can be of great assistance to the
high angle rescue team. An example of this is an effort by the climber nonprofit group Carolina
Climbers Coalition (CCC) with a grant from the Access Fund and in coordination with local
EMS to map climbing routes, cliff bands, and top access areas using global positioning system
(GPS) in western North Carolina. The data will allow better response to climbing accidents in an
area with complex cliff systems and difficult access points. Many climbers are willing and
excited to help and join teams, and developing a relationship with these groups can be beneficial.
FIGURE 25.6. Climber organizations often create caches of rescue supplies. (Muir Valley, Red River Gorge, KY.) Courtesy of
R. Bryan Simon.

An example of this cooperation is the Appalachian Mountain Rescue Team (AMRT). This
team is made up of recreational climbers and EMS-based high angle rescue team members who
have come together to offer training and rescue assets in the southern Appalachian mountains.
They have integrated techniques and knowledge of the local climbing community to the tried and
tested application of high angle rescue principles in WEMS. This team is bridging the two
communities through inclusion of members of both and by working with established EMS
services.

RISK ASSESSMENT AND MITIGATION

Safety of rescuers is rule number one in technical SAR and is the result of detailed risk
assessment and mitigation. Everyone participating in a high or low angle rescue is a safety
officer and should speak up if they have any doubts about an aspect of the operation, whether it
be how a knot is tied or the setup of an evacuation point (Table 25.2). Using rope systems is
inherently dangerous and mitigation of risk through proper planning and preparation is as
important as attention to detail and an understanding and implementation of safety rules during
the operation.

Table 25.2 Safety Priorities during High and Low Angle Rescues
Safety Priority #1 You
Safety Priority #2 Fellow Rescuers
Safety Priority #3 The Patient

Risk assessment templates should be completed for known areas of potential operations.
Operational risk assessment should be completed at the beginning of all rescues and updated as
situations change. By identifying potential risks to rescuers, the assessment can prevent exposure
to dangers in the operational area.
Risk mitigation begins with a culture of safety. This is developed through a conscious effort
of team leaders and members. All teams should have an appointed safety officer who has the
overall responsibility of development of safety procedures and monitors safety practices during
training and rescues. If possible, this person should not perform duties outside of that of the
safety officer and should not participate in rigging or other aspects of rescue operations. The
safety officer for a team may not always be present during an operation and other team members
should be trained to work in this capacity to insure proper over watch and adherence to safety
measures. This person, whether the primary team safety officer or the appointed officer on-site,
will conduct a safety assessment of the accident area, identify factors posing risks to the team,
and work with the leader to assess and implement measures of risk mitigation.
A culture of safety within a high angle team results from an emphasis being placed on this
portion of training and operations by leadership. When developed properly, it is the foundation
from which well-trained and technically proficient teams operate with a sense of measured
urgency to complete rescue and evacuate patients to definitive care.

COMMUNICATION
Effective communication is one of the most important skills to know and use during any rescue
operation. The ability to communicate quickly, clearly, and in detail are traits needed of all rope
rescue team members. There are a variety of communication techniques utilized during rescue
operations and determining which method or methods are most appropriate is an important facet
of command and control. Some common methods include direct voice, radio use, hand signals,
whistle signals, and line tugs. In addition to these forms of communication, a system of
commands is critical to prevent misunderstandings. It is also important to understand the
terminology used by the patient. This element of communication is often overlooked in training,
but can make the difference in a critical situation. The final component of communication that is
important to WEMS, and particularly high angle rescue, is the knowledge and use of new
technologies by patients. These include personal locator beacons (PLBs), Satellite Emergency
Notification Devices (SENDs), and satellite telephones.
Types of Communication
The most common methods of communication in high angle rescue operations include direct
voice, radio use, whistle signals, hand signals, and line tugs. All forms of communication should
be standardized within the team and all members of a rope rescue team must be proficient in each
type. Environmental conditions such as terrain and weather will usually dictate the primary form
of communication during a rescue and often multiple types will be used at the same time. On the
macro level, radio communications are best used to coordinate various assets within the
operation to include communication with secondary evacuation elements such as ambulances
and helicopters. Use of multiple radio frequencies to coordinate the larger rescue is an integral
piece of the communications picture of high angle rescue. On the micro level at the actual site of
the rescue, a combination of direct voice and radio along with hand, whistle, and line tugs can be
used.
Direct verbal communication by rescuers at the site of the rescue operation is usually the best
method to use if conditions allow. Extreme distances, wind noise, and rock overhangs are just a
few of the environmental factors that can reduce a team’s ability to use direct voice. In these
circumstances, use of a radio attached to a chest harness will overcome these difficulties and
allow monitoring by a larger number of team members. Other forms of communication can and
should be implemented to allow communication even in difficult circumstances and most rescues
will require the use of multiple forms simultaneously.
Whistle blasts are a complementary form of communication that is standardized for rope
rescue by the American Society for Testing and Materials (ASTM). ASTM standard F1768,
Standard Guide for Using Whistles During Rope Operations, utilizes the mnemonic “SUDOT.”32
While there is no standardized system for hand signals, many are commonly recognized. The
“OATH” system is used in dive rescue situations and can also be utilized in rope rescue
operations. See Tables 25.3, 25.4, and 25.5 for examples of these types of communication
methods.

Table 25.3 Whistle Commands (SUDOT)

S STOP One blast
U UP Two blasts
D DOWN Three blasts
O OFF ROPE Four blasts
T TROUBLE! Continuous long blast

Table 25.4 Common Hand and Arm Commands

Command Hand
Stop Hand in fist, arm extended above the head
Up Hand rotating, arm extended above the head
Down Hand rotating, arm extended down
OK Thumbs-up or patting head with one hand
Help Hand waving, arm extended above the head

Table 25.5 Line Tug Commands (OATH)

O OK One tug
A ADVANCE Two tugs
T TAKE UP Three tugs
H HELP! Four or more constant tugs

Common Commands and Clarity

Standardization of voice commands, whistle blasts, and hand signals is a must in all rescue
situations. All team members should understand and practice each form of communication.
Using terminology that is clear and concise limits the chances of misunderstanding. One or two
syllable words are best used in command sequences. Each high angle rescue team will develop a
vocabulary that best suits the team and region but many verbal commands are common across
teams and across the country. Terms such as, “On belay,” “Belay on,” “Climbing,” “Climb on,”
and “Stop,” are commonly used and understood. When teams work in conjunction with other
neighboring teams during an operation, prior cross training between these teams and
standardization of commands helps to prevent miscommunication.
Discipline is a key factor to ensure clear and concise communication. Adherence to
standardized verbal commands, repeating of commands, and minimization of unnecessary chatter
prevent misunderstanding. All team members should be empowered and encouraged to speak up
if they identify any situation that seems unsafe. Additionally, the use of what the military
describes as a “command voice” is encouraged. Simply defined, the “command voice” is a
method to deliver instructions that insures proper enunciation and results in a loud, distinct, and
clear verbalization of a command.

User Group Terminology

The climbing and caving communities have a specific language that is common to each and is
used to describe gear, terrain, and situations that are often different than the terminology used in
the SAR community. While many members of high angle rescue teams are also avid climbers
and cavers, this is not always the case and gaining an understanding of the terminology used by
these groups will assist in communication and speed of rescue.
The main area of terminology difference between recreational climbers and cavers and
professional or volunteer high angle rescue teams is the method each will use to describe an area
of terrain. Often climbers travel great distances to reach a climbing destination and are not
familiar with the proper names of roads, neighborhoods, or other points of reference that are
commonly known by members of local SAR teams. An example of this is: “We have had an
accident at Beer Wall in Bubba City. My partner fell at the top of Delirium Tremens. We started
to hike out, but had to stop on the trail that breaks away from the cliff between that 11c called
Dubious Young Lizards and the sport route Hi-C. My friend has now lost consciousness and we
need help.”
While this passage may seem completely nonsensical to the uninitiated, it is actually a pretty
descriptive passage that a rescuer can use. The key to understanding this information is access to
the latest climbing guidebook for an area. These guides almost always have indices that list
climbs by name and location. A rescuer could use any of the route names mentioned to hone in
on the location of the injured climber and translate it into a common geographic position using
known landmarks. In this case, the rescuer could translate it to the following: “We received a call
of an accident off of Ames Heights Road. The best access trail is located at the Wild Rock
neighborhood between lots 12 and 13. The injured climber is located about 500 m to the south
(climber’s right) of access gully #1.”
It is recommended that all high angle rescue teams and emergency dispatch own, carry, and
use climbing guidebooks for their region to help prevent miscommunication between
recreational climbers and rescue assets. Many of these guidebooks list the GPS coordinates of
individual climbs. This “lost in translation” moment can also occur within the caving or
canyoneering communities. Areas of caves and canyons are known and navigated using
terminology for features that might be unknown to rescuers. Working with local climber, caver,
and canyoneer organizations can help reduce misunderstanding and lead to faster identification
of accident location and subsequent rescue in a high angle environment.

Technology in Wilderness Communication

In the high tech world of today, people are traveling into the outdoors with a variety of
communication devices. Calling, texting, private messages, and social media posts are all forms
that outdoor adventurers are using in the wilderness and can be used by rescue services to
communicate if necessary. Advanced devices such as PLBs, once used only to locate ships and
airplanes in distress, can now be carried into the backcountry with ease. SENDs are inexpensive
and becoming very common. The SPOT line of messengers and the Garmin inReach Explorer
models are two of the most common types of devices used today. Additionally, cellular
telephones are commonly carried by almost all outdoor enthusiasts and the lowering of costs
associated with satellite phones now make them available for the general public.
PLBs are a one-way communication device that allows users to send out a distress call that
usually includes GPS coordinates. This system utilizes the COSPAS-SARSAT satellite system
and was developed in the 1970s by Canada, France, the United States, and the USSR. PLBs have
no subscription fees but must be registered with government authorities. In the United States, the
National Oceanic and Atmospheric Administration (NOAA) is the governing agency.
Registration allows SAR teams to gather needed emergency information.33
SENDs are more common than PLBs. These devices operate using private satellite services
(SPOT using Globalstar, and Garmin using Iridium) and can allow two-way communication via
text messages. Each device has different capabilities and technology is changing rapidly. Most
importantly, these devices can allow patients to “converse” with rescuers and can send GPS
coordinates. This can give high angle teams a better understanding of the situation as they
mobilize to the scene of the rescue.
Cellular phones are the most common communication device now carried in the outdoors
and are useful in initiating rescue and communicating with rescue services. A recent study of
outdoor rock climbers within the United States found that 86.8% carried cell phones “Always” or
“Often” while climbing.34 The key drawback of cellular phones in the high angle environment is
reception difficulty. With few exceptions, popular climbing and caving areas within the United
States have limited cellular service and users who do not turn off phones to conserve battery life
often find the batteries drained when they are needed most. Satellite phones are becoming more
accessible to users but are still rarely carried in the wilderness within the United States. These
devices, serviced by the Globalstar and Iridium satellite networks, are more commonly used by
groups traveling overseas on mountain or river expeditions or during ocean voyages.
TECHNICAL DISCUSSION

Technical High Angle Rescue Skills

Members of high angle rope rescue teams must be competent in a variety of personal and team
rescue skills. This section will outline the gear, personal, and rescue competencies needed to
effectively operate within a high angle environment. For detailed descriptions of each of these
high angle skill competencies, please consult relevant manuals. All the skills introduced in this
section are complex in nature, require detailed descriptions of the varied techniques and usually
require chapters, if not entire texts, to capture the nuances of each. Learning and practicing with
trained instructors is the best method to become proficient in each skill. The four facets of SAR
are summarized with the mnemonic LAST (Table 25.6). When technical skills are properly
employed in conjunction with a focus on safety, effective communication with other team
members, and appropriate medical knowledge, a rope rescue technician can successfully
negotiate the hazardous environmental conditions to efficiently and safely rescue patients.

Table 25.6 Search and Rescue Principles

L Locate
A Access
S Stabilize
T Transport

Gear Competencies
Before becoming a deploying member of a rope rescue team, there are several skills that an
individual must master to safely work within a high angle environment. Any person interested in
working in this environment must understand and be able to effectively use common PPE of a
rope rescue team member. These basic items include helmets, harnesses, gloves, and glasses, and
are often supplanted with a personal headlight, a whistle, and self-rescue gear. An understanding
of the use and care of various pieces of gear is also an essential basic skill that must be mastered.
PERSONAL PROTECTIVE EQUIPMENT
The minimum acceptable PPE for persons working near a high angle environment is a helmet,
gloves, harnesses, and glasses. Most rescuers leave a headlight mounted to their helmet and a
whistle attached somewhere to their person. Helmets with small brims or no brims are most
common and should be fastened snuggly under the chin. Gloves are generally worn or attached
to personal gear depending upon the conditions and the need for dexterity during operations.
Gloves should be made of durable material but should not inhibit the rescuers’ ability to handle
rope and other equipment. An assortment of slings, accessory cord made into prusik loops, and
carabiners are generally carried to allow for self-rescue if needed, but are more commonly used
to secure the individual to various anchor points or ropes.
Harnesses come in two general rescue configurations and are classified as Type II and Type
III. A Type II life safety harness is a seat harness while the Type III life safety harness is a full-
body harness. Additional details on the composition of these harnesses can be found in NFPA
1983.5 Recreational climbing harnesses are classified as Class C sit harnesses and are designed
by various manufacturers under the EN 12277 and UIAA 105 standards.35
Helmets, harnesses, and all other climbing or high angle rescue gear discussed within this
section should be certified for use in their intended purpose. The Union of International Alpine
Associations (UIAA) and the European Committee for Standardization (CEN, from the French
Comité Européen de Normalisation) are the two organizations that certify equipment used in
recreational climbing (Figure 25.7), while the National Fire Protection Agency (NFPA) sets
standards for protective clothing and climbing gear used in rescue (Table 25.7).
ROPES
Ropes are divided into two main types: dynamic and static. Dynamic ropes are manufactured in
such a way as to absorb force from a fall and dissipate this force along its length rather than
applying the shock of a fall on the climber or their gear, anchor, or bolt. Dynamic ropes are used
primarily for climbing and are governed by the CEN and UIAA standards of manufacture. Static
ropes are stronger than the typical dynamic rope in that they have higher tensile strength. At the
same time, static ropes have less elongation. Static ropes are used mainly for rope access during
rescue scenarios to rappel, ascend, and for protection.
FIGURE 25.7. Examples of UIAA and CE labels on climbing gear. Courtesy of R. Bryan Simon.

Table 25.7 Certifying Organizations for Climbing and Rescue Apparel and Gear
Union of International Alpine Associations (UIAA) www.theuiaa.org
European Committee for Standardization (CEN) www.cen.eu
National Fire Protection Agency (NFPA) www.nfpa.org

Ropes used for rescue purposes are also a type of low stretch static rope and standards of
manufacture are governed by NFPA 1983. These ropes are used as life safety ropes and moderate
elongation laid lifesaving rope with the purpose of supporting people during rescue.5 The most
common rope used in the high angle environment is the life safety rope.
Most ropes currently in use are made of nylon due to its superior strength. Other materials
used include natural fibers, polyefin, aramids, HMPE (Spectra), and polyester. Knowledge of the
design and performance characteristics of the various types of rope is foundational and members
of rope rescue teams should be able to identify and use differing types in the proper manner.
Precise care of potentially lifesaving equipment is the standard in rope rescue. All ropes
should be inspected regularly, stored properly, and have a history log to record inspections and
use. Understanding how damage occurs and what it looks like is a core competency. The care
given to ropes should also be given to accessory cord, webbing, and tied slings. Inspections of
personal and team gear should be completed on a regular basis.
HARDWARE
Climbing, belaying, and rescue hardware are the tools used to ascend, descend, and carry out
high angle operations. Generally composed of steel or aluminum, each piece of hardware is
designed to perform specific functions. The carabiner is a metal load-bearing connector that
allows various combinations of ropes, webbing, and other hardware to be combined into a
system for rescue. Carabiners, like other climbing and rescue gear, are certified by the same
agencies (UIAA, CEN, NFPA) and come in many sizes, forms, and functions.
Understanding the shapes, strengths, and use of the various types of carabiners is essential
knowledge for a rope rescuer. Carabiners come in four main shapes: oval, regular “D” shape,
asymmetric “D” shape, and HMS or pear shape. These are subdivided into regular and locking
carabiners and some carabiners (used by recreational climbers) have wire gates rather than the
solid metal gates (Figure 25.8). The anatomy of a carabiner is shown in Figure 25.9.
There are several other pieces of climbing and rescue hardware of importance and their use
must be mastered. These can be categorized into five categories: descending, ascending,
anchoring, belaying, and specialized.
FIGURE 25.8. Carabiners come in a variety of shapes and sizes. Courtesy of R. Bryan Simon.

FIGURE 25.9. Anatomy of a carabiner. Courtesy of R. Bryan Simon.

 Descending devices are best known as rappel devices and are used to allow controlled
descent of a rescuer. Rescuers can lower by using these braking devices to create friction along
the rope as it runs through the device. There are numerous types of descenders, but the most
common include: brake bar racks (J and U) and the figure 8. Recreational climbers will most
often use an air traffic controller (ATC) for rappelling.
Ascending devices, or simply ascenders, are used to move up a fixed rope. There are
numerous brands and types but they all function in the same manner. A rescuer connects the
ascender to a fixed rope. The ascender can slide up the rope, but a portion of the device “grabs”
the rope if a downward force is applied. Rescuers usually use two ascenders to move up a rope in
a rescue situation. Accessory cord can be configured to work as an ascender.
Anchoring hardware comes in a variety of shapes, sizes, and uses. This hardware is used
when no natural anchors are present at the location of an accident. Rather than using trees or
rocks, rescuers must place anchoring hardware into cracks and crevices of rocks. This is a skill
that requires much practice. Types of hardware that are used to create these anchors include:
hexentrics (hexes), stoppers (nuts), spring-loaded camming devices (cams), and a variety of
lesser used items such as tricams (Figure 25.10). This hardware is also used by recreational
climbers to climb in a traditional fashion. Bolts are another type of anchor hardware and are
permanently attached to the rock along with a bolt hanger. The hanger allows for a carabiner to
be attached to this anchor point and integrated into the rescue anchor system.
Belay devices are used to protect a person either ascending or descending a rock wall without
using a fixed line. There are numerous belay devices available and the most common are the
ATC, Petzl GriGri I, and Petzl GriGri II for personal use or a device such as the 540° Rescue
Belay for rescue use. Figure 25.11 shows multiple types of personal belay devices.
There are other types of hardware that are used in high angle rescue. Their usage varies
depending upon the location and needs of the situation. High angle team members must be
familiar with the use and application of all types of hardware. Like ropes and webbing, hardware
must be kept in good condition and regularly inspected. Worn carabiners, belay devices, and
other gear should be discarded and replaced.
Often during rescues, individuals will encounter gear left in the rock. This is often referred to
as “fixed gear.” While it may be tempting to use this gear for protection, it is wise to not trust
any found gear and to place other types of protection. Extremes in temperature, the effects of
sunlight, and the circumstances that caused their placement are all factors to consider regarding
fixed gear. Figure 25.12 shows examples of fixed gear removed by the author. Can you identify
the problems with each?
Understanding the best use, placement, and strength tolerances of all types of gear is a skill
that takes years of hard work, training, and experience to gain. As with advances in medical
technology and practice, climbing and rescue gear continues to evolve and the professional rope
rescuer must stay attuned to the advances in gear and its use.
FIGURE 25.10. Various types of anchor and traditional climbing hardware. Courtesy of R. Bryan Simon.
FIGURE 25.11. Various types of belay devices. Courtesy of R. Bryan Simon.
FIGURE 25.12. Do not trust gear found in the mountains. Courtesy of R. Bryan Simon.

Personal Competencies

1. Knots: Knot craft, or the ability to tie and use appropriate knots depending upon the
situation, is a core personal competency. It is beyond the scope of this chapter to describe
every knot necessary to rope rescue, but the minimum knots that must be mastered by a
member of a high angle rescue team are the figure 8, overhand, bowline, half-hitch, clove
hitch, münter hitch, mule hitch, girth hitch, butterfly, and water knots. To tie and understand
these knots, the rescuer must also understand the descriptions used by texts and trainers in
the instruction of these knots such as a turn, bight, loop, and twist, as well as terminology
related to rope use such as a standing line or end or a working line or end. More specific
details about WEMS knots are included in Chapter 24.
2. Improvised harnesses: The ability to apply and secure patients with an improvised seat and
chest harness using webbing and slings is an important skill. There are multiple methods to
create each type of harness. Rescuers should practice these techniques and be able to apply
an improvised harness from the front or back of a patient.
3. Movement in high angle terrain: The ability to move safely and recognize hazards is another
critical facet for rope rescuers. Moving slowly and smoothly when operating near vertical
 edges, recognizing hazardous terrain or conditions, and staying outside of the safety
exclusion zone unless needed are all aspects of safe movement. Terrain at the cliff edge is
rarely uniform and often sloping downward toward the vertical drop. An individual must
focus on good foot placement and use trees or handlines to assist in safe movement toward
the cliff edge. Recognizing unsafe terrain and creating exclusion and hazard zones are basic
techniques to insure safety near vertical edges.
4. Climbing: Climbing is not about strength, but instead is more about movement. Combining
smooth controlled movement and good footwork with a touch of strength added is the key
to climbing better and more safely. Confidence in the ability to negotiate steep terrain and
composure while ascending are important psychological factors that assist in a person’s
ability to climb. While recreational rock climbers wear specialized climbing shoes or
mountaineering boots to scale vertical cliffs, most often rescuers wear sturdy boots which
can make scaling cliffs more difficult. Always aligning your center of gravity above the legs
and feet allow for better foot purchase on the rock, regardless of the degree of incline.
The best method to get better at climbing is to climb (Figure 25.13). Gaining a better
understanding of your center of balance, getting a feel for hand holds, and mastering
footwork techniques takes time and practice. There are multiple climbing books available
that discuss numerous techniques and are a good introduction to the sport of rock climbing.
Climbing instruction and practice should be an integral part of training within high angle
rescue teams.

FIGURE 25.13. Climbing takes practice, focus, and agility. Courtesy of Steve Kraft.

5. Belaying: Belaying is all about keeping the climber safe. A belayer uses a belay device
(ATC, GriGri) or a münter hitch to manage the rope and catch a falling climber. The
responsibility of belaying a climber is enormous and attention to the climber and potential
hazards to them is critical (Figure 25.14). This responsibility is not relinquished until either
the climber is back on the ground, or they are secured into an anchor and verify that they are
 off belay. Communication between the climber and belayer must always be clear. From
correctly threading the rope into the belay device, to proper positioning at the base or top of
a cliff, to catching a fall, these techniques must be performed with precision to prevent
injury to a falling climber.

FIGURE 25.14. An attentive belayer can save a climber’s life. Courtesy of R. Bryan Simon.

Rescue belaying is the next step in mastery of this skill as the systems involved are
much more complex than the normal climber/belayer system. Loads are varied depending
upon terrain (high vs low angle) and equipment used. The tandem prusik belay system and
devices such as the 540° Rescue Belay are commonly used.
6. Rappelling: Rappelling can be accomplished using several devices mentioned earlier (brake
bars, figure 8 descenders, ATC) or by running the rope around the body in various
configurations (arm, body) to create friction. This allows for a descent to the patient that is
controlled by the rescuer. Sometimes known as abseiling, this maneuver is a skill that
should be mastered early, practiced often, and always conducted in a safe manner (Figure
25.15). Rappelling using friction created around the arms and body is rarely used and only
on low angle terrain. Being comfortable in transitioning from cliff top to the vertical wall is
often the most difficult portion of learning how to rappel. Good body control, confidence in
high angle terrain, and good footwork at the edge makes this transition easier. Controlled
 descent is the standard for rescuers. Large, bounding jumps are the stuff of movies, not
professional rescue, and create conditions that could cause loss of control, falling rocks or
other debris onto the patient, and place a greater load on the anchor.
Many accidents occur during rappels. In 2014, 16 injuries or deaths were reported in
ANAM due to rappel errors.6 This is a relatively easy skill to learn and use. Complacency,
failure to check and double-check procedures that are critical to a safe rappel, and not using
back up rigging are often the reasons for injury.
7. Ascending: Like rappelling, being able to safely and quickly ascend a rope is a basic
essential skill of a rope rescuer. The skill of ascending the rope without assistance is critical
for self and patient rescue. There are many methods to ascend, but most use ascending
devices (whether hardware or a friction hitch) to alternate or inchworm up a fixed rope. This
technique is often awkward at first, but with practice becomes easier, even when wearing
and carrying gear. As with climbing, belaying, and rappelling, good form and body position
is necessary to ascend quickly and efficiently. After mastering basic ascending techniques,
rescuers must learn how to pass knots, move over the edge at the top of a cliff, and rapidly
switch from ascending to rappelling.

FIGURE 25.15. Rappelling is a foundational skill in high angle rescue. Courtesy of Bill M. Campbell, MD.

Rescue Competencies

1. Anchors: Identifying and establishing anchor points for technical high angle rescue rigging
 systems is the lynchpin of operations and requires good assessment of the natural features
that an area contains. Anchors must be solid, redundant, equalized, or in common parlance,
“bomber” or “bombproof,” in order to begin assembling the rigging system to allow for
rescue. Anchor points come in all shapes and sizes, but in the WEMS setting they are
usually comprised of natural anchors such as trees and rocks or hardware anchors using the
hexes, nuts, and camming devices discussed earlier. Positioning of anchors, placement of
directionals, and anchor backups must also be determined.
2. Pickoff rescues and the use of litters/baskets: Once a rescuer is over the edge and on vertical
terrain, they must now rescue the patient. The two primary methods to rescue a patient is by
a pickoff rescue or, if needed, by loading and securing them into a litter. Extent of injuries is
the primary factor in the decision between a pickoff of a conscious or unconscious person or
the need for a litter. A quick head to toe assessment can be conducted to determine the
status of the patient. For those with minor injuries and no obvious life-threatening issues, a
pickoff is suitable. Unconscious patients should almost always be packaged and moved
using a litter. An exception to this would be if environmental conditions threatened the life
of the patient and rescuer or if a life-threatening condition is identified and must be treated
promptly.
The use of a rescue litter in a vertical environment is common (Figure 25.16). Many
types of rescue litters are available but the most common is a metal basket litter, often called
a Stokes litter. Litters can also be composed of plastic or composite materials. Rescuers
must be able to maneuver to the patient with the litter, assess the patient and quickly treat
injuries as needed, move the patient into the litter, package them in a manner as to protect
them from the elements, secure them and either lower or raise both themselves and the
patient out of the vertical terrain. Once off of the cliff, rescuers must transition to low angle
or flat terrain and transfer the patient to definitive care. These scenarios can be complex and
rescuers with good medical and technical training are needed to conduct these operations.
FIGURE 25.16. Preparing to rescue a patient. Courtesy of Karsten Delap.

3. Lowering and hauling systems: Once a patient is secured, either using a pickoff or secured
within a litter, the terrain usually dictates whether the rescuer and patient can be lowered or
if they must be raised. Each system has its own advantages and disadvantages and there are
multiple techniques to effect rescue in either situation. This is a complex topic that
combines all the knowledge listed within this technical section and requires sound medical
and technical assessment of the patient and situation by the rescuer.
4. Additional Competencies: High angle rescue team members should be prepared for
contingencies in a WEMS setting. Coordination with helicopter evacuation is common in
some areas of the United States and lesser used skills such as executing tyrolean traverses
may be needed depending upon the rescue situation (Figures 25.17 and 25.18). A detailed
terrain assessment of a team’s operational area can identify potential landing zones for
helicopters as well as terrain that might necessitate use of a tyrolean traverse. Skills needed
to interface with helicopter EMS (HEMS) teams is covered in Chapter 6, and helicopter
operations are covered in more detail in Chapter 28.

MEDICAL INTEGRATION

Medical Care in High Angle Terrain

Medical care in the wilderness setting is difficult due to limited resources, challenging terrain,
and environmental hazards. It is even more constrained when working within an area containing
high or low angle vertical terrain. Due to the technical nature of this environment, specialized
equipment and systems must be employed in order to accomplish a patient rescue. These systems
add a complicating factor to providing medical care and a careful balance must be made between
a safe and efficient technical rescue and the delivery of on-site medical care to the patient in
need. A “one-size-fits-all” approach to training and integration of medical care, while much
easier to plan and prepare for, is difficult to apply in practice in WEMS and high angle terrain.
The ability of teams to have members with technical skills who are also qualified at varying
levels of medical training is a key aspect in maintaining the balance between technical rescue and
medical care. This is the best method to adapt medical knowledge to the reality of the rescue
environment.

FIGURE 25.17. Patients are often evacuated by helicopter in the mountains. Courtesy of R. Bryan Simon.
FIGURE 25.18. Tyrolean traverse is a specialized skill. Courtesy of Karsten Delap.

What is the current state of medical training within high and low angle terrain rescue teams
within the United States? Research studies have been conducted over the last 10 years to identify
the current capabilities of teams. Overall, there is a diversity of levels of medical training within
teams and no current standard approach among them. A study conducted of member institutions
of the IKAR found that 67% of teams had a standardized approach to medical training with this
training being a requirement for membership. Of those that required medical training to become
a member, 61% was due to local or national laws, and 36% was due to team standards.36 While
this study focused on organizations across the globe, another study that included only SAR teams
in the intermountain western states found that 67% of teams did not require medical training to
join and that 79% of teams provided at least basic first aid and cardiopulmonary resuscitation
(CPR) training.37 Both these and other studies found that medical training varied considerably
within teams and between teams and that for many, the amount of wilderness-related training
was very low. The western states study found that 66% of SAR team members surveyed were
trained in only CPR and/or basic first aid, 10% as EMRs, 3% as emergency medical technicians
(EMTs), 2% as paramedics, and 1% as registered nurses. Only 23% of responders received any
additional formal training in wilderness medicine.37 Additionally, of the surveyed teams, only
41% had formal physician medical oversight.
So what is the ideal goal of medical training within high angle rescue teams? Various states
have established minimum requirements for medical training within general SAR teams. A good
goal for all teams would be to aspire to have members attain the EMR level of training. Ideally,
this standard could then be augmented by integrating additional training focused on wilderness
medicine, climbing medicine, and care considerations in high angle terrain. The NFPA 1006 and
1670 both state that there is a requirement of medical training for responders and most fire
departments use the EMR level as the standard minimum certification. The EMR certification
was recently created to replace the First Responder certification developed in the 1990s and is
the middle ground between the basic first aid/CPR level and the EMT level of training.
While the EMR level of training for all team members is a good baseline, the difficulties that
surround wilderness rescues and high angle environments require an understanding of the
introduced complexities that these areas create for medical care. To address these training needs,
a wilderness medicine/climbing medicine component should be included in all training for
members of high angle rescue teams. This additional training can be conducted in-house if the
team has providers trained in wilderness medicine or teams can contract with outside wilderness
medicine instructors to conduct training that integrates their protocols and procedures. There are
multiple companies with expertise specifically to climbing and mountain medicine that conduct
this type of specialized training.
While standardized training using existing programs and certifications and an additional
component of wilderness medicine should be the baseline standard for team medical training,
each team should additionally focus on common injury and illness types in high angle rescue and
on types of injury and illness specifically identified within their geographic operations area.
Based upon the epidemiological information presented earlier in this chapter, subjects who
should be routinely covered in medical training and retraining are included in Table 25.8.
As trauma from falls is the leading cause for activation of high angle rescue teams, members
should be well trained in identification, assessment, splinting, and fracture management.
Attention to the difficulties of medical and trauma care over prolonged periods and in resource-
limited environments should be considered during all trainings. Refresher training should be
conducted on a regular basis with a rotating curriculum that takes these difficulties into account.
While initial certification training primarily takes place in a classroom environment with
practical hands-on sessions occurring outdoors, refresher training should be conducted in as
realistic of an environment as possible. There is no need for medical training to be conducted
separately from technical training. Medical aspects should be included during technical training
to assist team members in navigating the difficulties created by terrain and during the use of
rescue equipment. A secondary benefit of conducting training concurrently is that it prevents the
development of the “rigger vs. medic” division that can occur within a team (Table 25.9).
In addition to the difficulties that the terrain creates for rescuers, medical care is also often
hindered by the technical equipment used to extricate patients in a vertical environment. The best
method to identify potential issues between care of the patient and utilization of equipment is
again to integrate medical and technical training scenarios. By conducting realistic training,
teams can identify and overcome problems prior to an actual rescue. An example of this is the
securing of patients in a litter. The method of internal lashing can create difficulties in
performing treatments or accessing a patient’s injuries. Depending upon the litter used, lashing
can be accomplished in a variety of fashions. Webbing can be put to great use in improvising
restraints that allow rescuers to secure the patient while allowing access to injured areas for
assessment and treatment.

Table 25.8 Medical Topics of Importance for High Angle Rescue Teams
Assessment skills (ABCDEF) Cardiopulmonary resuscitation
Management of fractures Control of hemorrhage
Management of head trauma Management of spine injuries
Management of chest/abdominal trauma Identification of internal injuries
Management of cold injury/hypothermia Management of heat injury/hyperthermia
Lightning accidents High altitude illness (if applicable)

Table 25.9 Medical Topics of Importance for Refresher Training of High Angle Rescue
Teams
All topics covered in certification classes Training on common injuries in area
New equipment New medical technology
Pain control CPR recertification
Changes in care protocols Reviews of past rescues

Medical training and implementation of care in a high angle environment is complicated and
hazardous. A focus on safety of the team and reducing delays in care and transport through
efficient, balanced application of technical and medical skill sets is key to good outcomes for
patients.

IMPLICATIONS FOR PRACTICE LEVELS

High angle terrain creates a dynamic and difficult environment to apply medical and technical
skills in the care of patients. Patients must be located, assessed, stabilized, and transported from
the scene of the accident in a safe and efficient manner. These patients can often have
complicated injuries from fall-related trauma and may have been exposed to poor weather
conditions over a lengthy period of time. Thorough assessment and care must be balanced with
the technical aspects of the situation in order to effect rescue.
Care providers of all levels must be technically proficient within the vertical environment
and be able to properly assess a patient based upon their medical knowledge. Additionally,
rescuers must be able to perform core medical competencies at their training level and
communicate their findings to other members of the team. Mountain rescue assessment,
treatment, and evacuation is conducted much the same as in other WEMS situations after
transitioning from the high angle environment. All rescuers must only use the equipment and
medications that they are familiar with and are authorized to use. While a complete assessment is
mandatory for all patients, this chapter will focus exclusively on elements of assessment that deal
with the most common injury types for patients in a high angle environment.
While there are many methods used to conduct assessment, one mnemonic lends itself well
to rescues in vertical environment. The ABC method is well known and focuses the rescuer on
the three most common areas that represent a threat to life: Airway, Breathing, and Circulation.
A continuance of this method, DEF, is extremely useful when dealing with the common patient
in a high angle rescue, namely, a person who has suffered traumatic injuries from a fall or from
rock or ice fall, a person who is stranded on a cliff in poor weather, or a patient who has
succumbed to a fall with subsequent exposure to the elements. The DEF portion represents
Disability/Damage to the head and spine, Exposure to the elements, and Fractures (Table
25.10). In addition to these injuries, rescuers should recognize the signs and symptoms and
prepare for patients suffering from suspension syndrome. This subject is covered thoroughly in
Chapter 23.

Table 25.10 Assessment in High Angle Terrain

A Airway open?
B Breathing?
C Circulation?
D Disability/Damage to head or spine?
E Exposure to the elements?
F Fractures?
All completed during technical rescue!

While injuries and illnesses of any type can be sustained by climbers, cavers, and
canyoneers, the following section will discuss the “DEF” of injuries sustained in a vertical
environment and discuss the difficulties of assessment, treatment, and evacuation during rescue
in high angle terrain.

First Aid
For the first aid level provider, assessment and stabilization is the most important aspect to focus
upon reaching and securing the patient. Identification of life-threatening conditions and
application of first aid principles in conjunction with CPR (if needed) is the first priority.
Communication of initial findings to members of the team with higher levels of training should
be completed as soon as possible to expedite higher levels of care if needed.
With focus on the DEF of assessment, the “D” portion of this assessment focuses on the
responsiveness of the patient using the common mnemonic AVPU (see Chapter 21). Quick
identification of a head injury is key to the survivability of an injured climber. These types of
injuries are associated with other life-threatening conditions and the rescuer must also address
airway, breathing, circulation, and possible injury to the cervical spine. Particular attention must
be paid to maintaining a patient’s airway as well as protecting the cervical spinal cord.
Exposure to the elements should be addressed as soon as possible and is the “E” portion of
assessment. Even for patients who are uninjured from traumatic falls, exposure to rain, snow, and
colder temperatures can quickly move them toward hypothermia. Rescuers should address this as
soon as possible after completing earlier portions of the assessment, if not at the same time.
Exposure within this environment includes not just weather, but the potential of losing purchase
upon the rock or of rockfall. Rescuers will address the former by securing the patient upon
reaching them, but should protect from the latter by moving or shielding the patient from areas of
continued danger. Further discussions of these types of environmental risks are included in
Chapter 13 (Cold Injuries) and Chapter 14 (Management of Heat Illnesses).
Only after life-threatening emergencies have been ruled out should the rescuer attend to
fractures. The most common location for fractures in climbers is the lower extremity and the
most common fractures in this region are of the talus and calcaneus within the foot/ankle joint38
(Figure 25.19). This is due to the impact of most falls being absorbed by the feet. Fracture
assessment and treatment should be conducted per protocol with one important exception.
Most wilderness medicine texts discuss using the shoe or boot as part of a field expedient
splint. In the case of climbers, the climbing shoe normally worn in a rock environment should be
removed. These shoes are routinely sized smaller than normal shoes and often shape the foot to
allow for better footing on the rock. It is common for shoes to have a downward turn with toes
pressed or curled up at the front and the heel tightly cupped in the back (Figure 25.20). In most
cases, removing these tight-fitting shoes brings relief to a climber suffering from fractures within
the foot or ankle and does little to support a fracture or sprain.

Basic Life Support

Ideally, most members of a high angle rescue team seeking to also provide medical care will
have at least an EMR certification. The focus of assessment for these providers should mimic
that of the first aid trained rescuer, only at a higher level of understanding. These rescuers should
apply the advanced principles learned within their level of training to implement treatments that
fall within their scope of practice. Detailed information regarding assessment and treatment is
provided within the management of wilderness medical conditions portion of this text.

FIGURE 25.19. Talus and calcaneus fractures are common in climbing falls. Courtesy of R. Bryan Simon.
FIGURE 25.20. Climbing shoes are sized much smaller than normal shoes for the same size foot. Courtesy of R. Bryan Simon.

Evacuation of patients in a high angle environment will often occur concurrently with
assessment and treatment depending upon the severity of injuries. Rescuers with higher levels of
medical and technical training will prioritize the most essential elements of each to stabilize and
move the patient out of the vertical world and toward definitive treatment.

Advanced Life Support

All of the assessment and treatments described should be completed by this level provider in
addition to a higher level ability to interpret and understand assessment findings. Depending
upon the protocols of the team, advanced life support personnel should be able to administer
medications in response to assessment findings and relay more detailed findings to rescuers
outside of the high angle environment.
The nature of accidents and injuries and the terrain dictate what can be done prior to moving
out of high angle and into low angle or flat terrain. Advanced level practitioners should apply all
measures available to address life-threatening injuries and work to move the patient to terrain
where advanced care can be conducted. As with other providers, quick identification and
completion of available treatments, communicating patient needs to other rescuers so that they
may prepare for advanced care, and safe and efficient movement from vertical to the horizontal
terrain is the priority.

Clinician
Clinicians less often are deployed on the working end of the rope and at the patient’s side in high
angle terrain. When they are, it is often due to the provider being present during training when an
accident occurs nearby or if they are enjoying a day of recreational adventure when the call
comes through the emergency dispatch center. However, as board-certified EMS physicians
become more common and their ethic of field deployment increases, this is likely to change. The
only significant difference between an advanced life support provider and a clinician is possibly
the deployment of certain prescription-only medications atypical for EMS protocols to be used in
high altitude environments. These are discussed in more detail in Chapter 11 (Wilderness EMS
Pharmacology) and Chapter 15 (Management of Altitude Illnesses). The development of
protocols allowing rescuers to complete a variety of treatments is as important, if not more so,
than conducting the treatment onsite. The same is true of organization of training for team
members. The roles and responsibilities of a WEMS medical director are detailed in Chapter 4.

EQUIPMENT SUMMARY

Considerations in Development of Basic and Advanced Field Medical Kits

Due to the nature of accidents within the high angle environment, rescuers must be prepared for
lengthy access and evacuation times, hazardous conditions, and difficult terrain. Team members
will be responsible for carrying technical and medical gear throughout this environment.
Appropriate selection of medical items is essential to properly treat patients during prolonged
periods while not carrying unnecessary items that will not be used and further weigh down the
rescuer. Many factors go into selection of gear carried by basic and advanced medical providers
within a team. Understanding the nature of accidents and resulting injuries from epidemiological
data within a region should always be considered along with applicable laws for the area.
Rescuers must be trained and know how to use the equipment provided. Items selected for
inclusion in a basic or advanced field medical kit should be weighed for benefit to the patient.
Selection of medical packs or backpacks used to carry medical supplies for a team is based
upon team preference and items selected. Functionality of the chosen container system is an
important factor along with durability and internal organization. The system used should secure
items and allow for easy access. Due to the nature of rope rescue and the limited resources
available for rescuers, the loss of equipment must be prevented and thus well designed and
secured medical kits is essential. All basic or advanced medical packs within a team should be
organized similarly to allow ease of use by any team member. Many teams use a modular system
to carry medical supplies. This system allows the weight of these items to be distributed between
team members and then reassembled once the patient is located. Weight of items is of
importance due to the often lengthy approaches to the location of an accident. The centralized
and modular systems of medical gear storage and carry have positives and negatives and teams
should consider each when deciding upon the pack system to use.
Once medical kits are built, routine inspections must be conducted on all battery-operated
equipment contained within each kit. Medications should also be checked on a regular basis to
prevent expiration. Kits should be kept from extremes of heat and cold as some medications can
become ineffective or break down in these conditions. After each rescue operation, all gear bags
and medical kits used should be inspected and broken or used equipment or medications should
be replaced.
Every team must identify the items for inclusion in basic and advanced medical kits
weighing the benefits of each item for the patient, the ability of the team to use the equipment
provided, the weight and durability of items and the kits as a whole, and the organization and
adaptability of the pack itself. Financial costs of medical gear can be high and this is the final
consideration when developing field medical kits. A study conducted of mountain rescue teams
within Europe, the United States, and Canada identified common trends among all teams
regarding the medical equipment and medications carried. Based upon this information, the study
created a recommended list of medical equipment and medications for a basic mountain rescuer
and a mountain rescuer with more extensive medical training.39 The recommendations gathered
in this study are included in Tables 25.11 and 25.12 for use as a starting point to compare
existing medical kits and to build new kits for high angle rescue teams.

Medical Technologies Used in the High Angle Environment

Advances in medical technology occur at a very fast pace with new equipment appearing yearly
within hospital systems and EMS services across the United States. This is also true for the
WEMS and high angle rescue environment. Teams must stay on the cutting edge of development
in this area to keep up with the latest advances and improvements. Many of these advances are
due to the recent wars in Iraq and Afghanistan and the hard-won knowledge gained by medics
and advanced practitioners while treating combat wounded.

Table 25.11 Common Medical Items in a Basic Field Medical Kit for High Angle Rescue
Splinting materials Rescue/Emergency blanket
Wound dressing materials Bag/Valve mask
Oxygen Blood pressure monitoring equipment
Suction device Automated external defibrillator

From Elsensohn F, Soteras I, Resiten O, et al. Equipment of medical backpacks in mountain rescue. High Alt Med Biol.
2011;12(4):343-347.

Table 25.12 Common Medical Items in an Advanced Field Medical Kit for High Angle
 Rescue
All items in Basic Kit, except rescue blanket Tracheal intubation equipment
Pulse oximeter Thermometer (Epitympanic/Esophageal)
Suturing material ECG monitoring equipment
Combitube Nasopharyngeal tube
Capnography monitor Manual defibrillator
Amputation kit Thoracotomy kit
Laryngeal mask Mechanical ventilator
Medications

From Elsensohn F, Soteras I, Resiten O, et al. Equipment of medical backpacks in mountain rescue. High Alt Med Biol.
2011;12(4):343-347.

Examples include the changes in carry and use of tourniquets by field medical providers, the
rapid advance in hemostatic dressings containing fibrin or chitosan, and the availability of a
variety of small and relatively inexpensive electronic monitoring devices such as SpO2 monitors
and wristband heart rate monitors. There are now automated external defibrillators (AEDs) that
are weatherproof and ruggedized for wilderness use. As with contents of field medical kits,
teams must return to the common injuries they treat and determine if a new device is useful or
needed in their care environment. Inclusion of tourniquets and hemostatic dressings would pass
this test in most locations, but the likelihood of need of an AED in the high angle environment
may not, though IKAR recommends the inclusion of an AED within an advanced practitioner’s
pack.39,40
Devices that pass the needs test must also pass field tests before inclusion with team medical
kits. These field tests should include durability tests with a focus on ease of use, weight in
comparison to the replaced item, cost, and battery life. Battery life is a principal concern as an
item becomes an expensive paperweight when the batteries die. Recent studies have found an
increasing reliance on battery-powered technology for navigation without a low tech backup for
climbers in the wilderness.41 This trend is alarming and may lead to additional rescues in the
future, but more importantly, is a reminder to not lose focus on priority of care in favor of the
latest high tech devices.
The use of tools for medical care is discussed in more detail in Chapter 22 and for trauma
care in more detail in Chapter 21. Equipment considerations in general, including medical kits,
are discussed in more detail in Chapter 7.

Advances and Updates to Accepted Medical Practice

Like technology, research-driven advances in care occur frequently and alter the use and can
change the implementation of equipment and medications in high angle environments. Recent
studies in wilderness use of femoral traction, spinal cord protection, care of suspension
syndrome, application of tourniquets, and the use of hemostatic dressings have all been
addressed and updated. Staying current with medical literature is essential to keeping wilderness
and high angle rescue medical protocols and treatment as up to date as possible. Changes in
knowledge can have a profound effect on what gear and medications are carried within field
medical kits and how they are used to advance the care of patients in the WEMS environment.
SUMMARY
Providing medical care is complex in the highly technical environment that is inherent in high
and low angle rescue. Members of these teams must be comfortable in exposed situations, have
the technical and medical skill sets to work in extreme conditions, and be focused on their own
and their patient’s safety. The steep terrain, weather, and potential hazards from rockfall or
icefall add to the difficulties experienced. Through proper preplanning, detailed risk assessments,
good communication, and thorough training in technical and medical skills, high angle rescue
personnel and teams can enter this perilous environment, operate with safety, and effectively
evacuate patients to definitive care.

ACKNOWLEDGMENTS
Special thanks to Dougald MacDonald, Executive Editor at the American Alpine Club, and
Bonny Armstrong and Rich Breisch, current and past editors of the National Speleological
Society’s American Caving Accidents, for their assistance with epidemiological data for this
chapter.

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INTRODUCTION
Since the late 1960s, recreational river use has increased, and continues to do so. Equipment has
become more user friendly, and skill development and experience has correspondingly grown.
Classification of whitewater rivers has matured, and recreational users have been going further
into remote places to navigate ever more difficult whitewater.
Swiftwater rescue was born out of a need to help ourselves and those traveling with us on
rivers. As discussed in Chapter 16 (Management of Submersion Injuries) and Chapter 27 (Open
Water Rescue), drowning is a leading cause of death worldwide. Currently, development in
swiftwater education has led to the creation of swiftwater teams preparing for flood rescue
around the world.
Swiftwater is unique, as its environment becomes more violent and challenging to navigate
with increasing speed of current, steepness of elevation in the river bed, and increased volume of
water. Drowning is often due to reasons beyond poor conditioning, medical emergencies, and
lack of swimming skills. Drownings in swiftwater are commonly tied to long swims in difficult
currents, entrapments while swimming and in watercraft, lack of equipment, inappropriate
equipment usage, and lack of experience in swiftwater conditions.1
There are unique skill and equipment requirements for rescuers in swiftwater conditions.
Specialized training accompanied with experience in swiftwater conditions is essential to rescue
success. Much like the management of motor vehicle accidents, extrication will take precedence
over medical care. With a focus on scene awareness and rescuer safety, most medical care will
take place once the patient and rescuers are out of the water on the river shoreline.

Definition
Swiftwater rescue (also called “whitewater rescue”) is a subset of technical rescue focused on
whitewater river and flood conditions. Moving water, obstructions, and numerous currents and
undertows require specially trained personnel. They must use specialized tools and equipment to
maintain their own safety as they locate, access, and extricate subjects unable to remove
themselves from the water.

Scope of Discussion
In this chapter, we will discuss in further detail the swiftwater environment and the rescue
philosophy that this environment demands. We will discuss common group and personal
equipment along with on water communications. Shoreline and water-based rescues, along with
an abbreviated version of incident command, will illustrate the unique nature of swiftwater
rescue. Note that incident command in WEMS operations is discussed in more detail in Chapter
3. Formal training and personal experience in swiftwater conditions is paramount to success with
swiftwater rescue skills. This chapter serves as an academic overview for this area of special
rescue, but cannot replace hands-on training, and ideally certification in a standardized
swiftwater rescue curriculum, such as Swiftwater Rescue Technician. In closing, we will
integrate the understanding of medical care provided by swiftwater responders.

PREVALENCE
As mentioned in Chapters 16 and 27, drowning data in the world have discrepancies in the
language used, methods for collecting data, and categories used to funnel that data. We know
that the World Health Organization (WHO) and United States Centers for Disease Control
(CDC) have identified drowning as a leading cause of death, with numerous causal categories
ranging from bathtubs to the ocean. WHO reports over 327,000 persons per year die from
drowning, and CDC asserts that the percentage of drownings in natural water settings, including
lakes, rivers and oceans, increases with age. More than half (57%) of both fatal and non-fatal
drownings among those 15 years and older occurred in natural water settings.2 Drowning
prevention in the United States focuses on prevention measures that include learning to swim,
barriers for swimming pools, and increased supervision by lifeguards for medical emergencies
such as seizures. Unfortunately, these drowning prevention factors are not as common in the
remote swiftwater environment. This is unfortunate, as strainers and sieves, flush drownings,
poorly fitted lifejackets, and low head dam entrapments remain at the top of the list of causes of
death and disability in whitewater as reported by the American Whitewater Association (AWA).3
The AWA has kept data on river accidents since 1973. The data further reveal that fatalities in
the recreation whitewater boater population has risen and fallen over that period, with a large
spike in 1999, an all-time low in 2004, and then the highest recorded incidence in known history
in 2012. Conclusions from analysis of their data suggest an increase in accidents and fatalities in
years when local rainfall has been exceptionally heavy.

Care Environment
Rescue in the swiftwater environment can be broken down into whitewater (or “swiftwater”)
rescue and flood rescue. Although there are numerous similarities, the flood environment is less
predictable in its crosscurrents, and moving obstructions and human-made debris making it more
challenging to navigate for the rescuer. Whitewater river environments have recognizable
features such as waves, hydraulics, eddy currents, confluences with additional streams of water,
undercut rocks, boulder piles, trees, and vegetation that create obstructions. These features are
also more predictable in that they change less often, whereas by definition flood features may be
recently formed by flooding and may rapidly change.
Water follows the path of least resistance and seeks the lowest point of gravity. It weighs
8.33 lb per gallon, making any fully or partially submerged object much heavier than it would be
empty on the surface. Additionally, water volume in a river bed is measured in cubic feet per
second, or cfs, which is calculated by the following formula: width × depth × speed. Monitored
streams will have nationally available reports of flow or volume in cfs. Often the cfs expressed
by river gauges that are referencing a specific river section do not precisely correspond to the cfs
at the rescue site; nonetheless, they will provide a foundation of river conditions to be expected.
As speed doubles, the force of water quadruples, making fast water very powerful as it moves
through a high gradient. The higher the volume, the greater the gradient, and the larger the
obstructions, the greater the whitewater hazards.
Rescuers must be familiar with reading the water in the river environment. This
understanding helps the rescuer make navigation decisions in the water and aids in the
anticipation of outcomes with specific technical skills. The following are common terms used to
describe river features.
Eddies are a horizontal reversal of water flow where the pressure of current along an obstacle
(such as a rock) causes the water behind the obstacle to reverse flow upstream (Figure 26.1).
These are rescue staging and break areas along the river flow. Eddies create eddy lines—obvious
lines in the river where current moves in opposite directions on each side of the line (Figure
26.1). This current differential between an eddy and downstream current ranges from a gentle
surface line to a wall of water dropping around the obstacle and recirculating horizontally.
Swimming and paddling require the understanding of eddy lines, so they can be crossed
efficiently.
A hole or hydraulic (Figure 26.1) is a vertical reversal of water flow where the pressure of
the current falling over a gradient (such as a dam) causes the channel water at the base of the
gradient to be forced downward into a loop style reversal and back to the surface. At the surface,
part of the water continues downstream and part reverses back upstream to the base of the
gradient. This reverse flow tends to be hazardous, because it can cause an object to be
recirculated (stopped or kept) in the hydraulic—hence the commonly used name stopper or
keeper. The churning whitewater of a hole consists of between 40% and 60% air. As a rule of
thumb, when you look downstream, a frowning hole is a natural hydraulic whose outer edges
curve upstream. When viewed from upstream, it has the appearance of a frown. A frowning hole
tends to be a keeper by recirculating on itself. In contrast, a smiling hole is a natural hydraulic
whose outer edges curve downstream. When viewed from upstream, it has the appearance of a
smile. A smiling hole tends to flush a patient or object free due to the downstream current at its
sides.
Standing waves are a rhythmic series of waves caused by the convergence of main channel
currents as the result of rising river water, or underwater obstacles or ledges.
Increasing river gradient or increased volume converts the hydraulic effect of holes to a wave
or series of waves that form downstream from the gradient. A downstream “V” in the river
creates a hydraulic effect in the form of a “V” pointing downstream (Figure 26.1). This is caused
by the convergence of downstream water flow into the channels of least resistance. The largest
series of “Vs” pointing downstream indicates the main channel. By contrast, an upstream “V”
creates a hydraulic effect in the form of a “V” pointing upstream which is caused by downstream
water flow up and around an obstacle (Figure 26.1).

FIGURE 26.1. Basic hydrology. Courtesy of Dave Bradford and Landmark Learning.

Strainers, sieves, and undercut rocks are river entrapment hazards. Strainers are a buildup of
tree and shrub debris that may run deep in the water restricting downstream flow (Figure 26.1).
Sieves are a buildup of boulders, sometimes mixed with strainers, that restrict downstream flow
(Figure 26.1). Both of these entrapment hazards shift with high water and cannot always be
readily seen from the surface of the water. Expect that after high water these obstructions may
have shifted in the river to the outside of river bends. When rocks are carved by the force of
water over time, a submerged hazard is created. An undercut rock is defined by water flushing
under the rock, often with the absence of a water pillow on the face of the rock and an eddy
replaced by downstream current on the backside of the rock (Figure 26.1). These hazards may
drag an unsuspected swimmer under the rock along with other debris that may be held there.
A confluence is a flowing together of streams where two bodies of water converge (Figure
26.1). This feature could be hazardous at high water levels causing a disorganized and powerful
current. What initially may be disguised as an eddy ends up being a forceful crosscurrent
creating undertow as it forces its way downstream.3
The International Scale of River Difficulty, as described by the AWA, categorizes rivers
based on their difficulty to navigate. Class I rapids are described as fast-moving water with
riffles and small waves. Few obstructions are present, all of which are obvious and can be easily
avoided with little training. Risk to swimmers is slight; self-rescue is easy.
Class II rapids are straightforward rapids with wide, clear channels which are evident
without scouting. Occasional maneuvering may be required, but rocks and medium-sized waves
are easily avoided by trained paddlers. Swimmers are seldom injured and group assistance, while
helpful, is seldom needed. Rapids that are at the upper end of this difficulty range are designated
“Class II+.”
Class III rapids become more challenging to navigate, with moderate, irregular waves that
may be difficult to avoid and are capable of swamping an open canoe. Complex maneuvers in
fast current and good boat control in tight passages or around ledges are often required; large
waves or strainers may be present but are easily avoided. Strong eddies and powerful current
effects can be found, particularly on large-volume rivers. Scouting is advisable for inexperienced
parties. Injuries while swimming are rare; self-rescue is usually easy, but group assistance may
be required to avoid long swims. Rapids that are at the lower or upper end of this difficulty range
are designated “Class III−” or “Class III+,” respectively.
Rescuers will find that Class IV rapids test the limitations of most rescues. In Class IV
rapids, intense and powerful but predictable rapids requiring precise boat handling in turbulent
water. Depending on the character of the river, it may feature large, unavoidable waves and holes
or constricted passages, demanding fast maneuvers under pressure. Rapids may require “must”
moves above dangerous hazards. Scouting may be necessary the first time down. The risk of
injury to swimmers is moderate to high, and water conditions may make self-rescue difficult.
Group assistance for rescue is often essential but requires practiced skills. Rapids that are at the
lower or upper end of this difficulty range are designated “Class IV−” or “Class IV+,”
respectively.
Class V rapids are extremely long, obstructed, or very violent rapids which expose a paddler
to added risk. Drops may contain large, unavoidable waves and holes or steep, congested chutes
with complex, demanding routes. Rapids may continue for long distances between pools,
demanding a high level of fitness. The eddies that exist may be small, turbulent, or difficult to
reach. At the high end of the scale, several of these factors may be combined. Scouting is
recommended but may be difficult. Swims are dangerous, and rescue is often difficult or
impossible even for experts. Because of the large range of difficulty that exists beyond Class IV,
Class V is an open-ended, multiple-level scale designated by subdivisions using Arabic numerals
and decimal classifications, such as 5.0, 5.1, 5.2, etc. Each of these levels is an order of
magnitude more difficult than the last; for example, increasing difficulty from Class 5.0 to Class
5.1 is a similar order of magnitude as increasing from Class IV to Class 5.0.
At the extreme end of river navigation are Class VI rapids. These runs have almost never
been attempted and often exemplify the extremes of difficulty, unpredictability, and danger. The
consequences of errors are very severe and rescue may be impossible. These rapids should be run
by teams of experts only, at favorable water levels, after close personal inspection and taking all
precautions. After a Class VI rapids has been run many times, its rating may be changed to an
appropriate Class 5.x rating.3 This scale of difficulty leaves much room for subjective
assessment, making one person’s Class III another person’s Class V.
Time in the river environment in different conditions aids in evaluation and judgment of
river conditions, which may change with melting ice, rainfall, or dam breaches far upstream. Be
aware of steep canyons below large land masses that have histories of flash flood. Steep rivers
and creeks may create a need for vertical or low angle rescue skills in addition to the other
hazards described previously. High and low angle rescue is specifically discussed in Chapter 25.
Rivers that are not dam controlled but dependent on natural flow may be less predictable
than standard flows on dam-released rivers under normal weather conditions. In dam-released
rivers, the water will have a designated start and shut off time, which could be adjusted in the
time of emergency to assist the rescue effort. In addition, dam-released rivers can be used for
WEMS training, with releases timed and engineered to generate flow characteristics and cfs
volume to replicate various operational situations.
Consider that air temperature and wind speed will have a rapid cooling effect on both
patients and rescuers, turning a functional rescuer into a patient quickly. Finally, inadequate
lighting due to the time of day or angle of light in deep river gorges may limit visibility and
shorten the window of rescue potential.

Environmental Teams
Swiftwater teams commonly take two forms:

1. rescue teams made of persons traveling on the river (referred to in the following as
“recreational rescuers”); and
2. professional teams made up of rescuers who are associated with county, state, or federal
rescue agencies.

Both teams are important in the niche of swiftwater rescue.

Recreational rescuers are often at the scene when the event occurs, making their timeliness
for action a great benefit for preventing fatalities. These rescuers are commonly adept at quick,
low tech rescue with few resources, and their accident assessment and river navigation skills may
actually exceed those of professional rescuers.
Professional rescue groups benefit from increased personnel numbers, specialized
equipment, and transportation resources. In addition, these professional rescuers, as formal EMS
responders, are part of a larger rescue and medical system able to call for air medical support,
and mutual aid from neighboring counties, states, or other federal agencies.
The downfall of professional rescuers in this setting may be lack of training, experience, and
comfort in the whitewater environment. Additionally, these specialized teams will take time to
physically form before deploying to the rescue scene.4 When speed makes the difference between
a rescue and body recovery, the recreational rescuers may be the only personnel capable of
intervening quickly enough (remember, as discussed in Chapter 16, that fatal drowning occurs
after only minutes of submersion, often before a professional WEMS team can be deployed).
Often when recreational rescuers are unsuccessful, professional rescue teams are deployed for
body recoveries.

RESCUE SKILLS
Technical rescue skills used in river rescue are dependent on experience, training, continuity of
training, water conditions, and access from shore. Swiftwater rescue ranges on a scale of simple
patient assists to technical rescues requiring specialized equipment and coordination with other
rescuers. Rescuer safety is paramount and must remain a focus for all rescuers in this
environment. Well-intentioned persons and sometimes trained rescuers are killed in the line of
rescue due to inappropriate equipment or overwhelming environmental conditions.4 Rescuers in
this setting do well to develop a sense of “river judgment” through training, practice, and
personal and group experience. Good decisions are often born from previous bad experiences.
Technical Discussion
Next we will discuss swiftwater rescue philosophy, basic rescue equipment, and common
rescues, stemming from simple to complex.

Swiftwater Rescue Philosophy

The premise of all rescues is that the rescuer safety comes first, then other rescuers, bystanders,
and then patients. We make sure equipment loss is our last priority.
Rescue strategies that are quick and require little technical skill are best, although at times
may include an element of danger to the rescuer. We prefer to avoid strategizing rescues that are
slow, highly technical, and pose great risk to the rescuers and or the patient.
Rescue priorities start with self-rescue. Forms of self-rescue include swimming, wading,
rolling or uprighting decked watercraft, and uprighting and reentering watercraft while it
continues downstream. If the patient has the experience and practice to perform a self-rescue,
then often bystanders will not know a need for rescue ever existed.
If self-rescue is not completed or possible, a rescuer must engage in the rescue. A common
priority system to organize various levels of rescue, from least risky and involved to most, is
reach-throw-row-go-helo. In general, rescuers should use the earliest feasible element of this
sequence, saving those later in the sequence to be used only when necessary due to their
increased risk and complexity.
Rescuers can reach with their voices over the sounds of the river to get the attention of
persons in the river that are unaware of a need to take action to perform their own rescue. An
example would be yelling “Hey, swim over here” to someone swept away by river current and
unsure of how to react. Other reaching tools may include a paddle, tree branch, or a short section
of river rope. Often rescues that are recognized early can benefit from a reach. In such cases,
patients are either close to shore or close to rivercrafts. An example would include a rafter falling
from a raft into the river, then quickly pulled back into the raft by the person sitting behind them,
with the raft and raft guide continuing on their course downstream. Reaches are commonly
referred to as simple assists.
Throwing skills are quintessential to swiftwater rescue skill sets. Learning how to throw a
river rope from shoreline or even sometimes from rivercraft creates an extension to the rescuer’s
reach. We will discuss throw bag skills later in this chapter.
Rowing refers to moving a water craft into close proximity of the patient for a boat-based
rescue. The bow and stern of rivercraft make great adjuncts for rescue when the patient can
participate in their own rescue. Inflatable rivercraft such as rafts and inflatable kayaks provide
opportunities for the rescuer to remove the patient from the water placing them inside the boat
and then continuing to navigate the river.
Go implies that rescuers physically enter the water to approach the patient. Examples of
these rescues include wading, swimming, and tethered swimming rescues. These rescues
obviously require more physical ability, experience, practice, and risk on the part of the rescuer.
This is our last priority for an on-scene rescuer, as it exposes the rescuer to the same conditions
that required the rescue in the first place. However, with patients who are not able to participate
in their own rescue, a hands-on rescue in the water will be required. Chapter 27 introduces this
category as “Go (Don’t Go)”, emphasizing the risk entailed in “Go” and the importance of a
rescuer not entering water if the risks of such entry exceed the potential benefit – specifically,
creating two drowning deaths rather than one due to insufficient rescuer training for that specific
water environment.
In some areas, helicopter assets—helo in this mnemonic sequence—are available to assist
with swiftwater rescue and, even more often, flood rescue. Not only is this obviously a new level
of operational complexity and cost, but also usually exceeds the specific resources of the on-
scene swiftwater team, meaning another agency must be engaged to perform this service.
Helicopter operations are not covered further in this chapter, but are covered more specifically in
Chapter 28 (Vehicle and Helicopter Rescue). Skills needed for an on-scene swiftwater WEMS
team to interface with a helicopter team are discussed in Chapter 6.
When patients are “heads up,” or their face is out of the water to breathe, we want keep them
heads up. When the patient’s head is underwater, our reaction time will need to be quick,
knowing that most persons will either pass out and involuntarily inhale water, or choose to inhale
water, within 30 seconds to a minute underwater. It is critical that we gather a large picture of the
scene, identifying hazards to rescuers and the patient as we make designs for rescue attempts.
First we identify the patient’s location, then the best means for quick access. Our responsibility
to the patient starts when we put our hands on them and stabilize their head above the water,
ensuring they breathe. Our last consideration is how we will extricate or remove the patient from
the water. Consider access for outside medical care and transport when moving the patient out of
the water. If there is road or railroad access on one side of the river, that side of the river may be
best for extrication, in an attempt to move the patient as little as possible.

River Communications
In the swiftwater environment, the movement of water rushing downstream against obstructions
causes a significant amount of noise making communication with others difficult, even when
rescuers are in close proximity. We’ll use whistle blasts or low tone yelling to get the attention of
others, and then focus on hand and paddle signals to convey the details.
American Whitewater, the largest recreational whitewater sports association, supports the
use of “Universal River Signals” (Figure 26.2) which have come from historical use in
recreational river use. With one hand we tap the top of our helmets to ask the question “are you
OK?” and also to answer, “yes I am OK” in response. We raise one arm facing or vertical paddle
blade facing the recipient of our communication to signal “clear, come on downstream or over to
me.” Both arms straight out or paddle held perpendicular to the rescuer above the rescuer signals
“Stop.” We use either arm or a paddle to point in the direction we want persons coming
downstream to travel. A rescuer waiving arms or a paddle above their head signals “help.” Three
whistle blasts repeated in a row signals “help” as well. Hand signals and paddle signals are
mirrored between the rescuers communicating with each other to confirm that the message has
been received. Many rescue groups have created additional signals to communicate common
needs within the group. It is important that before entering the water for recreation or rescue, you
understand and can emulate the signals being used by your group.
FIGURE 26.2. The river signals. Adapted from American Whitewater Safety Code.

Use of satellite and cell phones or handheld radios is questionable. They may not reach
service from a whitewater scene and risk damage in this wet environment. On the other hand,
multiple floating, ruggedized, and waterproof cases are available.5 As discussed in Chapter 7, for
their weight, significant communications capabilities (including not only direct communication
but also documentation apps and medical resources) can be made available on electronic devices.

Swiftwater Incident Command Systems

The challenge of communication and the dynamic nature of river rescue will require an
abbreviated version of the Incident Command System discussed in Chapter 3 and an anticipation
of multitasking roles. It would be best if the incident commander was able to stay close to the
rescue operation and gain a view of the entire scene and remain hands-off. However, the incident
commander may be required to be hands-on due to experience, ability, and time management.
The incident commander is ultimately responsible for safety decisions, technical rescue plans,
and monitoring the maintenance of other designated roles. Rescuers are prepared to enter the
water and make access to the patient with various technical skills. Riggers are the rescuer support
teams that provide rope management, build anchors and technical systems, and provide belay for
the rescuers. Safety members are staged upstream to warn oncoming river traffic of our rescue
scene, and staged downstream to provide our final safety at the scene. Additionally, we will
reserve some personnel on the shoreline near the incident commander to deploy them in
additional roles as needed. Extra personnel can always be added to the downstream safety.
WEMS incident command is discussed more comprehensively in Chapter 3.

Rescue Techniques
Swiftwater techniques are defined as basic and advanced. Most basic skills are individual skills,
and advanced skills most often require the support of other rescuers and sometimes specialized
equipment. Let’s start with the basic skills of swimming and wading.
We swim when the water is at the level of our personal flotation device (PFD) and wade
alone or with others when the water is causing us to bob or bounce losing our contact with the
river bottom. Swiftwater swimming requires the intellectual and physical understanding of
current and river hydrology. When swimming in moving current, you use similar techniques as
when paddling a rivercraft. Considering your body as the hull of the boat, you plane, turn, and
propel yourself with your arms and legs.
We focus on protecting our face and neck on water entries, adjusting our arm swing for short
strokes, and keeping our faces out of the water as much as possible for breathing as well as
destination planning. Much as with rivercraft, we rarely turn our bodies perpendicular to the
current, as this leads to being pushed underwater and downstream. As humans have less power
swimming than when paddling rivercraft, we have to anticipate starting a swim well upstream of
our target.
Most of our swims will focus on “aggressive swimming,” which is a front crawl stroke using
the river to move us laterally by setting ferry angles to the destination. To set ferry angles and
use the current, we need to face upstream and angle 20 to 30 degrees to the destination while
swimming aggressively. Swimmers turn their faces to the side and hold their breath when they
encounter waves, planning to breathe on the back side of the wave.
Entering a drop or hydraulic in the river may require swimmers to grab their knees and tuck
their heads into a ball. Hydraulic escapes may require changing shape and identifying
downstream flow for an exit.
In “defensive swimming,” swimmers float on their backs with their face and toes on the
surface, floating feet first downstream with feet together in an effort to use our feet as bumpers
on obstructions in the river. Defensive swimming does not help us cross the river, but rather
helps us assess the environment for hazards, breathe, and prepare for shallow water. Arching the
back raises the buttocks, which can serve as a brake or anchor in shallow conditions.
Trees or rock piles in the river create obstructions that we must (preferably) avoid or swim
aggressively over. In “assertive swimming,” much like aggressive swimming, we face
downstream on our stomach, in anticipation of the moment to take on aggressive swimming
techniques. Aggressive and assertive swimming are the primary modes of swimming for rescuers
with specific target goals in mind.
Once we reach water shallow enough that we can do a push up in the river in slow moving
water, we can transition to wading or walking in the river (Figure 26.3). Wading maybe the
fastest movement one can make in moving water that is below your waist but above your knees.
In addition to the depth of water, the speed of the current and composition of the river floor are
factors in wading success. Mud and slick or large obstructions may hinder wading attempts.

FIGURE 26.3. Wading photo. Courtesy of Lynn Willis and Landmark Learning.

Single person wades are aided by a paddle, pole, or stick, making three points of contact. The
rescuer, facing upstream, shuffles their feet, maintaining two points of contact with the river
bottom at all times. Two rescuers increase the points of contact to four. The two rescuers face
each other and move one at a time, using each other for stability. A “line of stern” can be made
of several rescuers in a line with the first facing upstream and aided with a paddle.
Communication within the group is echoed forward to the line leader as each member moves and
then is “set” in position. Wades must be practiced to be efficient, and can include additional
designs with more rescuers.
Once the water level is waist level or higher, waders will turn into swimmers. It is common
for river rescuers to traverse the river environment with combinations of swimming and wading.
Ropes are most commonly thrown from pre-packed throw bags from shore and occasionally
from rivercraft. Practice with throw ropes is essential for persons involved in river rescue
(Figure 26.4).
When rescuers are in an area on shore in a rivercraft where there are no obstructions above
their heads they can throw overhand. Underhand throws require that there are no obstructions
below the waist, including the water a rescuer may be standing in. Side arm throws are used for
conditions where there are barriers simultaneously above the rescuers’ heads and below their
waists.
Positioning for the best opportunity to have the first throw be successful is important. Often
throw baggers are placed on the side of the river where the downstream flow is pushing, below
the rescue operation. When in doubt it is best to place multiple throw baggers on both sides of
the river. Throw baggers provide security for patients and rescuers who are aware of their
surroundings and understand how to receive the rope. Another point of success is gain the
recipient’s attention by shouting “rope,” then throwing the rope directly at the head and
shoulders. If you can hit the person with the rope, that is best. Ropes ahead of the patient may
float out of their reach, while ropes hitting the water just above the patient may float down to
them, but behind them, out of their view.

FIGURE 26.4. Throw bagging. Courtesy of Lynn Willis and Landmark Learning.

The first throw out of the bag should be the most rapid but also planned. The next throw
becomes more cumbersome, with repositioning of the throw bagger and throwing a coiled rope.
Throwing out of the bag and throwing with coils must be practiced for success.
Persons receiving a rope in the river need to receive the line and bring it to the opposite
shoulder from which is was thrown, often called the “far shoulder.” This sets a ferry angle using
the current to assist the patient’s movement toward the anchored throw bagger.
Once the rope loads downstream with the recipient’s weight and the addition of river current
pressure, a hip, buddy, or tree belay will be required for ferrying the recipient to shore. Finally, a
bend in the rope, pulling straight to shore and positioned closer to the swimmer than the belayer,
creates a vector. This will provide an additional force that pulls the patient across strong eddy
lines and serves to shorten the rescue if there are other hazards just downstream.
Being able to successfully throw a rope to a target in the river is a foundation to many
swiftwater rescue skills. The rescuer’s first throw is the one that needs to be successful! Once the
patient passes the downstream safety without rescue to shore, the event escalates into a chase
downstream.
FIGURE 26.5. Tethered rescuer rescue. Courtesy of Lynn Willis and Landmark Learning.
FIGURE 26.6. Quick release harness.

Tethered swimmer rescues are a combination of throw bag skills and swimming skills
(Figure 26.5). This advanced skill uses the quick release (QRS) harness system (Figure 26.6) on
a rescue PFD to tow the rescuer and patient back to shore. The swimmer serves as a “human
throw bag”—a rope that propels itself in the water and has hands for grabbing and securing
patients and/or equipment in moving water. The rescuer can perform this rescue as a preplanned
operation or a spontaneous intervention for patients unable to receive a rope in the river. The
rescuer ties into the back of the rescue harness (usually at a D or O ring) with a figure 8 knot and
locking carabiner, then from the carabiner, takes about 15 or 20 ft of rope into their downstream
hand. A belayer and backup belayer angled and prepared for a downstream load anchor the rope.
This rescue may be the most important downstream rescue at the rescue site. Injured patients
with damaged limbs or altered mental status may require this type of rescue. It is critically
important to understand the QRS component of the PFD in this type of rescue. It is axiomatic in
swiftwater rescue that knots are never placed from which rescuers cannot immediately extricate
themselves. In this case, a QRS built into the webbing attaching the knot to the rescuer from the
belayer always needs to be present for this procedure to be safe. This is usually a “bingo” system
that is activated by pulling on a ball hanging from a friction clamp along the webbing.
Anytime we need to get a rope across the river we will need to consider “line ferry”
techniques. Options include throwing, swimming, wading, paddling rivercraft, messenger lines,
rope line cannons, and a tethered rescuer as a receiver on the receiving side. As with swimming,
the rope will need to start far upstream of the destination, staying above the rescuer swimming or
boating the rope across the river. Rescuers will also need twice as much rope as they initially
evaluate to account for drag in the water. Keeping the rope out of the water over a tree limb or
paddle can reduce the amount of rope accessible to current. Anytime rope is placed across the
river, rescuers need an upstream safety person to be in position to identify downstream traffic
coming toward the outstretched rope. This person is responsible for either stopping the
downstream traffic or communicating to the rope handlers to raise, lower the rope below the
waterline, or abandon the belay from one side reducing the hazard for the downstream traffic.
Belayers holding ropes across the river must always be prepared for downstream traffic that does
not respond to communication attempts or lacks the ability to control their movement
downstream.
Tethered rescuer “V” lowers can be useful for entrapments in a downstream “V” of current.
In this rescue technique, we need at least two belayers on either side of a “V” creating a belay
angle less than 90 degrees. The rescuer, tied into the QRS rescue harness with a figure 8 knot,
arches their back to stay on the surface. The rescuer must communicate with the belayers with
hand signals pointing in the direction of travel high above the water. This rescue does best
lowering downstream and moving left and right. Moving upstream is challenging for the belay
team and may require additional rescuer personnel.
A wade or swim may help the rescuers position as close to the patient as possible to
minimize the distance of the rope work. The rope will have to be tensioned and pulled
underwater toward the patient. Belayers will need to create a “V” in the rope under the patient’s
arms or across the chest. Dropping the angle to below 90 degrees is critical for stability and
function of the belayers. Rescuers have to drop the angle to reduce the force of the load on the
rope.
Once rescuers have the stabilization line in place, and hopefully the patient’s head is above
water, they will need to perform a cinch. A cinch is a lasso or other encircling rope that is now
placed around the patient in addition to the stabilization line. The cinch and stabilization lines are
now used to pull the patient upstream and then to shore.
Entrapments are much like shoes, you remove them the way you put them on. So, in this
case, upstream is where rescuers are starting with the belayers. Systems like this can easily use
many rescuers—as many as four belayers per rope.
A rivercraft or wading team may be able to reach the patient and assist in keeping them
“heads up” until other rescuers can release them. This same concept is used when a person is
entrapped in a rivercraft. Rescuers secure the rivercraft first, stabilize the person, then consider
the extrication plan. An additional stabilization line for the patient may allow the patient to self-
extricate.
Rivercraft may be used by rescuers to transport rescuers, patients, and equipment around the
river. Rivercraft may also be staged at the bottom of a rapid or rescue scene as a “chase boater”
designated to go after patients or rescuers that are swept past the downstream safety teams.
Strong boat handling skills and specific craft experience in a multitude of river conditions are
key to successful rivercraft use in rescue.

Equipment Recovery
Equipment recovery in swiftwater rescue becomes a priority after the rescuers, bystanders, and
patient(s) are safe from harm. Personnel managing downstream safety can serve as the monitors
for equipment that broke free of control at the rescue scene. Common equipment that may need
to be recovered includes ropes, paddles, and rivercraft.
Balance, force, and friction are the common variables that pin or entrap rescue equipment.
Unsettling these variables will help rescuers to free the equipment and recover it to the shoreline.
The first objective is to access the equipment and connect a stabilization line from the equipment
to shore while monitoring the safety and potential for entrapment with the equipment. Getting
injured, becoming a patient, or creating patients while recovering equipment is unacceptable.
Again, anytime rescuers stretch ropes across the river they need to be prepared for traffic
coming downstream that may not heed communication signals. Once the stabilization line is in
place, personnel on shore need to create an anchor for their end of the line. Then the rescuer at
the equipment can try to move the equipment into the current, staying out of the line of travel for
the rope and equipment. The rescuer at the equipment needs to identify an escape route away
from the equipment movement in the event it is freed.
If simple movements do not free the gear, then they may at least help identify a direction of
pull from the personnel on shore after the rescuer at the equipment has moved. Placing a
“damper” close to the equipment is a good practice to ensure that if the equipment breaks under
the pressure of pulling from shore, the broken bits stop short of the rescuers that are pulling.
Additionally, rescuers on shore should wear their helmets and PFDs and face away from shore at
moments when high tension may release or there may be projectile risk. A change of direction
for the rope would further move the pulling rescuers “out of the line of fire”; the addition of
mechanical advantage systems and anchors will be further discussed in Chapter 25 (High and
Low Angle Rescue).

Medical Integration
River rescue skills are dependent on training, practice, and experience. Rescue skills and
extrication come first, and then providers medically assess and care for patients. Personnel
available who are the most medically trained and experienced in out-of-hospital emergency care
should attend to the patient.
Once the extrication is complete, the sensation of rapid response should slow down and
human contact and care should begin. After we have assessed the patient and performed any care
required by a standard primary and secondary survey, we need to make more definitive care and
transportation plans. Given that the swiftwater environment is usually far from frontcountry
medical care resources, rescuers must start planning for further evacuation and transportation as
soon as they have an understanding of the patient’s disposition.
IMPLICATIONS FOR PRACTICE LEVELS
Injury in whitewater can be a range of common bruises and minor lacerations, to fractures,
dislocations, altered mental status, respiratory difficulty, and cardiac arrest. Anticipate that all
trauma and river patients will be hypothermic.
If respiratory or cardiac arrest has come into the scenario, then rescuers must act first on
airway and breathing management. Cardiopulmonary resuscitation (CPR) should begin
immediately on a rigid surface with the patient as flat as possible parallel to the shoreline.
Previous attempts at resuscitation focused on trying to remove the water from the lungs. Very
little water actually enters the lung and the water that does enter the lungs combines with
surfactant to produce large volumes of non-cardiogenic pulmonary edema (foam). Rescue
breathing/positive pressure ventilations will assist in delivering oxygen to the lungs and the
brain. Recognition of the difference between aerosolized surfactant fluid that presents as foam
from the lungs is important to our management. We need to remove vomit from the airways with
all means possible, as it may disrupt our oxygenation and ventilation efforts. The presence of
foam should not disrupt positive pressure ventilations. The resuscitation of drowning patients is
described in more detail in Chapter 16 (Management of Submersion Injuries).
Defibrillation is rarely indicated for patients with respiratory arrest as asystole is the most
common rhythm for respiratory arrest. The body system needs oxygen, not electrical therapy.
The equipment needed for definitive airway management, oxygen therapy, and electrical therapy
is rarely readily available in the short window in which it is critical in remote places.
Furthermore, absent other indications to cease resuscitation, CPR in remote environments should
continue for thirty minutes and then should be terminated if there is no return of spontaneous
circulation.6 The time of death should be documented in EMS records and available at the time
of body transfer.
Spinal precautions are often considered or ruled out based on the mechanism of injury, which
may not be clear in the swiftwater environment. It will be important that ABCs, CPR, and
extrication are prioritized over spinal stabilization. Spine boards and other spinal movement
restriction devices may put the patient at great risk during movement across a river if they are
restrained. Patients with clear signs and symptoms of cord injury should be moved with caution
and further stabilized when the shore is reached.7 Spine boards and similar rigid devices may be
useful for carrying patients once on shore up steep river banks. More and more selective spinal
cord protection protocols, or discontinuation of thoracic and lumbar spinal cord protection
altogether, are being employed by urban EMS systems, which provide an assessment that may
allow the provider to negate the mechanism of injury as a sole indication for immobilization.
Wilderness medicine education and protocols have long taught similar assessments to help
prevent unnecessary immobilization. This skill set is of great resource for medical persons
providing care in remote and dynamic swiftwater environments. The management of cases where
there is suspected vertebral fracture or spinal cord injury is discussed in more detail in Chapter
21 (General Management of Trauma in the Wilderness); patient packaging, including spinal cord
protection, is discussed in more detail in Chapter 24 (Principles of Patient Packaging).

First Aid
The First Aid-trained rescuer should be prepared to recognize breathing problems and altered
mental status. Skills at this level of care include stopping bleeding, CPR, recognition of when
and how to contact higher trained medical personnel, basic splints, and recognition and basic
treatment for cold and heat emergencies. In the United States there is a wide gamut of curriculum
that is labeled “First Aid,” making the standard broad and vague.

Basic Life Support

Personnel trained and tested at the national or state level of Emergency Medical Responder or
Emergency Medical Technician (EMT) are expected to provide organized physical assessments,
gain serial sets of vital signs, gather patient medical histories, perform initial patient care medical
documentation, and recognize when and how to contact higher trained medical personnel. EMTs
will also be expected to perform and assist with oxygen therapy, nebulizer treatments, basic life
support (BLS) and basic airway management to include use of bag valve mask and supraglottic
airways when available. Use of airway tools may be difficult without adequate suction available.

Advanced Life Support

Advanced life support (ALS) skills and assessments are dependent on technical equipment,
which is rarely available in the river environment. Without the appropriate tools, this level of
care will focus on the same resuscitation goals discussed in the BLS section above. Helicopter
access, when possible, may be the most practical way to get advanced providers to the scene with
their equipment. However, it is worth noting in the case of drowning or major trauma that air
medical resources are not used for missions where the patient is in cardiac arrest.

Clinician
As with lower level ALS providers, there are few clinician-level practices indicated in the
management of swiftwater emergencies other than securing an airway through advanced or
surgical techniques if basic techniques are inadequate.

EQUIPMENT SUMMARY

Common Basic Equipment

For our discussion, equipment for swiftwater rescue is broken down into two categories: personal
equipment and group equipment (Figure 26.7). We will not discuss equipment that will likely be
unavailable in remote settings such as motor craft on rivers, fire ladders, fire hoses, and hydraulic
winches mounted on rescue vehicles. These items have value when they are accessible, but that
is not the context of this discussion. A further discussion of vehicle-based rescues is included in
Chapter 28.
FIGURE 26.7. Basic river rescue equipment. Courtesy of Lynn Willis and Landmark Learning.

Personal equipment starts with an appropriately fitted PFD or lifejacket. 15 lb of flotation

would be a minimum. Specialized rescue PFDs commonly have 17 to 25 lb of flotation to aid the
rescuer in staying on the surface in turbulent water. If you don’t stay on or close to the surface
you are not able to accomplish your own rescue, much less that of others. Modern rescue PFDs
are equipped with a quick release system (QRS) that allows the rescuer to tie into a rope tethered
to a belay on shore for retrieval back to shore during rescue efforts. It also allows for people and
boat tows, aid to self-rescue in entrapment settings, a belay point for scene scouting along the
river edge, and assistance in wading retrieval and rope line ferries across the river. Tethered
rescues may be one of the best options when the patient is unable to participate in their own
rescue due to injury or illness.
Whitewater helmets provide protection for unintentional falls in the river and for head
protection during swimming. These helmets are designed to minimize the energy absorption
from the outside of the helmet to the human skull. Suspension systems and technology have
greatly increased over the years. In addition, these specialized helmets are lightweight, shed
water, reduce risk of helmet-based pins, and have tensioning systems that keep the helmet from
affecting the vision of rescuers in turbulent water. The death of Lucas Turner on the North Fork
of Idaho’s Payette River in 1998 spurred many of these safety innovations. Turner, 22, was in the
middle of one of the river’s dangerous rapids when his kayak flipped, and he was killed by a
fatal blow to his forehead. Turner’s father Gil began to look at what had gone wrong as Turner
had been wearing a helmet commonly used in whitewater settings. Ultimately, Gil Turner came
to feel that helmet wasn’t adequately designed for the unique demands of rushing water. He
contacted Johns Hopkins, where an engineering project was launched in response, ultimately
completely redesigning whitewater helmet design and industry safety standards.8
 Thermal protection is next on our list. There is a myriad of thermal protection options
available, including neoprene, spray tops and pants, dry suits, and poly underlayers that hold
body heat when wet. Each of these materials has benefits and performance limitations. Neoprene
and spray gear focus on keeping wind off the rescuer’s skin and trapping body warmed water
close to the rescuer. Dry suits, on the other hand, offer a sealed garment that prevents water from
entering the suit, keeping the rescuer dry in their under insulation of poly layers. Caps that fit
under helmets, gloves, and shoes are often made of neoprene or membranes that have a similar
function to neoprene. Thermal clothing should be loose enough on the rescuer to provide
freedom for movement without being cumbersome. When the hands and feet of a rescuer
become cold and loose circulation, the rescuer can easily become a patient.
Personal rescue equipment includes a knife for cutting rope, webbing, small tree limbs,
clothing and plastic. Lock blades or fixed blades are common, with a dull point and one cutting
edge that is serrated for hacking. High visibility handles are preferred as often we employ knives
underwater. It is important that access to this knife can be made with either hand without the help
of the hand. Imagine that the rescuer may have to use one hand to hold their position in the river
while they access the knife.
Pre-tied prusik loops are useful as quick anchors and are also used in mechanical advantage
systems. Two of these loops accessible with one hand in the rescuer PFD is preferred. Varying
the tied loops in size is supportive of their use.
Tubular webbing, commonly in 1” widths, is used for anchors on shore and in the water and
when carried on the rescuer creates versatility for anchor selection. Two 12-ft sections are
recommended, in bright colors to enhance visibility.
Two locking carabiners that also fit securely in the rescuer’s PFD are the standard for each
rescuer. Aluminum construction is preferable in water conditions.
Throw bags are lengths of floating rope from 60 to 75 ft that fit inside of bag for easy
carrying and deployment into the river. There are numerous types of rope that have high
visibility.
Finally, the whistle, a controversial piece of equipment on the river, is the historical
mechanism that we have used to get the attention of others on the river. However, if the rescuer
can reach and use their whistle they could also yell in a low voice over the river to gain the
attention of others, making the whistle potentially unnecessary. Whistles may also prove to be an
entrapment hazard on the lifejacket. If you choose a whistle, pick one with a high decibel output
of 100 decibels or more with a high visibility construction, using a pea-less construction for
functionality in the water environment.9
A small medical kit pre-built for airway and breathing management, musculoskeletal
injuries, and hemorrhage control is important for all persons. This gear can be kept in watertight
dry boxes or dry bags.
Group equipment may include additional personal gear items such as throw bags, locking
carabiners, tubular webbing, pulleys and helmets, PFDs, and thermal protection. Inflatable boats
such as rafts and inflatable kayaks make great rescue platforms that can be controlled by tether
from shore. River boards, stand up paddleboards, and Bellyaks are rigid boats that can also serve
as tools for rescuers to gain access to patients and then transport them across the river (Figures
26.8 and 26.9).
A group medical kit should focus on airway management and breathing devices that group
members are trained to use. A simple pocket mask with a plastic one-way valve and a tall mouth
piece, such as the “Big Easy” rescue breathing mask, is a necessity. Oxygen and possibly
continuous positive airway pressure devices, when available, will be supportive of worst-case
scenarios. Hypothermia management equipment, stoves for hot water, sleeping bags, sleeping
pads, tarps, and extra food will be supportive of patients and rescuers alike. Simple emergency
shelters are manufactured to be lightweight and packable. Cell phones and satellite phones are
used more often as their technology and service have increased. Expect that remote river canyons
will generate challenges in communicating to the outside world. Other group gear may include
larger ropes for haul systems, rope guns, and messenger lines to help bring larger ropes across
the river as needed, as well as light systems to allow work in darker conditions.

FIGURE 26.8. Bellyak rescue. Courtesy of Annie Bartl and Landmark Learning.
FIGURE 26.9. Vertical kayak pin photo. Courtesy of Justin Padgett and Landmark Learning.

USING THE RESOURCES OF THE RIVER

Recreational boaters who spend days on end in river play and navigation could be the expert that
a WEMS rescue group needs. There are some obvious challenges with trying to integrate a
civilian into a regimented rescue team. But first compare training hours. A recreational boater
who has twenty to thirty river days per year for 5 to 10 years has some experience and to some
degree has developed a swiftwater or whitewater judgment. These persons react appropriately in
this setting.
Swiftwater-trained teams may not exist in rural rescue systems due to the lack of funding
resources. Many teams rely on a certification training that exposes them to swiftwater rescue
skills over an intensive class lasting a few days. Then these persons participate in annual or
sometimes more regular in-house trainings. Swiftwater skills for many rescue groups is only one
set of rescue skills they maintain. When water rescues are few and far between, rescue skills and
equipment readiness understandably wanes.
When an organized rescue team funded by tax dollars is on the scene, there is an expectation
of their standard of care by the patient(s) and general public. If a non-rescue team member was
injured or killed assisting in the rescue, the rescue group may be held accountable. It is difficult
to vouch for someone’s skills and abilities on face value. The rescue group would be liable for
negligence on the part of the non-rescue team member in the event that it became pertinent. A
mix of equipment use in which the other party is unfamiliar may prove hazardous or ineffective.
As discussed in Chapter 1, across the United States we face funding challenges and
decreased volunteerism in our county and regional rescue groups. Is it possible for rescue groups
to market their membership to recreation groups? Will the recreationists be motivated to
participate regularly with the rescue teams? It is time to start talking more about this issue in the
context of all specialized rescue. We are at a point in history where the equipment available and
increased skill development of outdoor athletes make them prime candidates for rescue services.

SUMMARY
“The number of recreational river accidents is climbing as river sports become more popular in
the United States.”1 Remote river environments and disaster flood settings present similarly for
the application of swiftwater rescue skills. As with all rescue, sound safety philosophy and
environment familiarity are paramount for rescuer success. Specialized rescue skills, special
equipment use, and maintenance of physical fitness require practice in challenging conditions
regularly. Rescuer preparedness for safety is a cornerstone including thermal protection,
available water and food high in carbohydrates, appropriate personal equipment, understanding
of personal limitations, experience and comfort in whitewater environments, and training and
practice with equipment used.
In swiftwater rescue, extrication will be our focus, with medical assessment and care saved
for the shoreline. Strong BLS skills are important for all rescuers with basic equipment for
airway management easily accessible. Decisions on evacuation should be made early as contact
with outside resources may be difficult and access for those rescuers to your location may be
time consuming and hazardous.

References
1. C. Walbridge. (personal communication, August 19, 2016)
2. Centers for Disease Control and Prevention. Home and Recreational Safety > Unintentional Drowning: Get the Facts > Risk
Factors: What Factors Influence Drowning Risk?: Location. Available at:
https://www.cdc.gov/homeandrecreationalsafety/water-safety/waterinjuries-factsheet.html. Accessed Jan 1, 2017. Page last
updated April 28, 2016.
3. Padgett J. Landmark Learning Swiftwater Rescue Manual. Jackson County, NC; Landmark Learning; 2016:11-12.
4. Franklin RC, Pearn JH. Drowning for love: the aquatic victim-instead-of-rescuer syndrome: drowning fatalities involving
those attempting to rescue a child. J Paediatr Child Health. 2011;47:44-47.
5. Hawkins S. Unbreakable: Smartphone Cases. Wilderness Medicine Magazine. September 9, 2015. Available at:
http://wildernessmedicinemagazine.com/1161/Unbreakable-Smartphone-Cases. Accessed December 10, 2016.
6. Forgey WW. Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care. 5th ed. Guilford, CT: Globe
Pequot Press; 2006.
7. Watson RS, Cummings P, Quan L, et al. Cervical spine injuries among submersion victims. J Trauma. 2001;51:658-662.
8. Johns Hopkins University. Headlines@Hopkins News Release: Whitewater Death Inspires Students to Create Safer Helmet.
Available at: http://pages.jh.edu/˜news_info/news/home02/may02/helmet.html. Accessed December 10, 2016.
9. Ostis N. NOLS River Rescue Guide. Mechanicsburg, PA: Stackpole Books; 2015;5:63-89.
INTRODUCTION
Drowning is a leading cause of injury death worldwide. As with other injuries, prevention is key
in decreasing morbidity and mortality. The prevention of drowning usually takes the form of
swim lessons, proper barriers around vulnerable bodies of water, and the utilization of proper
flotation devices. When these measures fail, rescue of the patient early in the drowning process
becomes the next priority. This chapter will focus on the procedures and techniques necessary to
complete safe and effective rescues in the open water environment.
Throughout the chapter, the safety of the rescuer is stressed. As discussed later, while the
open water environment is categorized separately from “swiftwater,” conditions are often
similar. (Swiftwater rescue and medical care is discussed in Chapter 26.) Well-intentioned
rescuers can easily become patients if proper planning and training are not in place. The
technical discussion section will be divided into “basic” and “advanced” procedures. The
decision of a team leader to utilize the different levels of techniques must be made based on the
team’s physical capabilities, resources, and local conditions, and not on the level of medical
experience or certification. While rapid delivery of high-quality medical care is paramount to
decreasing morbidity and mortality in drowning patients, it cannot take place without, first, the
rescuer and patient being brought safely to shore.

Definition
For the purposes of this chapter, the term “open water” will refer to large bodies of water in
which a significant distance can be gained between a swimmer and shore, primarily oceans and
lakes. While the currents, tidal shifts, and waves in these bodies may create complex
environments, open water is still considered distinct from swiftwater. The rescue of patients from
swiftwater environments, primarily those created by the constant, longitudinal flow of rivers,
was discussed in Chapter 26.
Scope of Discussion
While the rescue of persons drowning in open water is pertinent to any medical responder in the
wilderness setting, the actual practice of technical rescues in these environments should be
restricted to those with formal training. This chapter will provide both basic principles for the lay
rescuer and advanced techniques for the professional rescuer. To date, there is very little
evidence describing the effectiveness of different open water rescue procedures. Rather, the
equipment and techniques used in different areas are based on geography, tradition, training and
certification, and financial resources.
While the term “open water” can technically refer to any part of a large body of water,
including the middle of the ocean, the techniques and procedures discussed in this chapter will
pertain to those used in the rescue of patients who are primarily within a recreational distance
from the shore. These are patients who either swam out in the water, were pulled away from the
shore by a current, or are otherwise at a distance visible from the shore, and that is achievable by
a rescuer from the shore, either by swimming or by a small craft. The discussion of rescues made
farther out in large bodies of water is beyond the scope of this chapter, as it often involves law
enforcement, fire departments, or military participation.

PREVALENCE
Drowning and submersion injury as a medical phenomenon is discussed in more detail in
Chapter 16. As discussed there, data pertaining to drowning, especially non-fatal drowning, are
lacking in quantity and quality. Currently, the World Health Organization estimates that around
372,000 people die from drowning annually around the world, although this number does not
take into account many important subgroups like suicides, homicides, or natural disasters, and
the overall quality of data collection in many countries is very poor. More importantly, the true
burden of non-fatal drowning, which can often have more devastating effects on a society, is not
currently well understood.
In the United States, the location of drowning deaths varies depending primarily on age.
While children less than 1 year of age most commonly fatally drown in bathtubs, and from 1 to 4
years most commonly fatally drown in pools, after 4 years of age, open water quickly becomes
the most common location. This remains true throughout the rest of a life span, with some
countries displaying a higher risk of bathtub death once a person reaches elderly age. In an open
water environment, the subject age range a provider is most likely to perform a rescue on is 15 to
29 years. In terms of mortality, from 1999 to 2010, the Centers for Disease Control and
Prevention reported a total of 20,912 drowning deaths for ages 0 to 29 years, 8,885 (42%) of
which occurred in open water or while boating.1

Care Environment
The discussion of open water rescue is separate from that of swiftwater rescue. While open water
refers to large bodies of water which may often be fairly stagnant, these environments can vary
greatly depending on geography and weather activity. A specific phenomenon of open water
environments which leads to a significant number of drownings is a rip current. Rip currents
commonly occur when water on the shore preferentially flows back to a large body of water
through an area of lower ground, causing a stream of deeper, faster water which may pull bathers
away from the shore. These can also occur along fixed structures like rock jetties or piers. In this
instance, the rescue environment may mimic a swiftwater environment, although these currents
quickly abate once they reach deeper water. Open water environments can also vary greatly
based on the surrounding geography. For instance, a rescue launched from a sandy beach will
likely require less resources than one that requires a descent down a cliff face to reach the water.
For this reason, many open water rescue teams located near steep terrain have either formal
training in technical rescue or interagency agreements with another agency with the training and
equipment to carry out such rescues. High and low angle rescue is discussed in more detail in
Chapter 25.

Environmental Teams
The members of a team performing open water rescues will vary greatly depending on location,
the structure of the responding agency, and training. This is a high-risk environment in which
untrained, well-intentioned rescuers are all too often injured or killed during attempts to save
drowning patients.2 For this reason, any team faced with the possibility of performing open water
rescues must have members who are specifically trained in the use of rescue equipment and who
possess the physical capabilities to carry out rescues in this environment. In the United States,
most open water rescue operations within swimming distance from the shore are performed by
open water lifeguards employed by local lifeguard agencies. Currently, all open water lifeguards
who work for agencies certified by the United States Lifesaving Association (USLA) must be
able to swim 500 m in 10 minutes or less.3 It is important to understand that this is a minimum
standard, and does not take into account the ability to perform in rough water or handle specific
rescue equipment. Any team member who will be charged with carrying out open water rescues
should, at a minimum, meet this swimming requirement, and be tested in the use of any relevant
equipment in both calm and rough environments.

OPEN WATER RESCUE

The techniques used to perform a rescue in an open water environment are dependent on rescuer
training and experience, the number of patients, and the condition of the environment at the time
of rescue. An unfortunately high number of rescuer deaths are reported in the literature resulting
from well-intentioned bystanders attempting rescues without the proper training or equipment.2
For this reason, the use of any techniques or equipment discussed in the following sections must
be preceded by repeated training and practice in varying conditions.

Technical Discussion
This section will discuss possible techniques and equipment to be used in the event of an open
water rescue. These will be divided into “basic” and “advanced” procedures. The basic
procedures are meant for lay rescuers or minimally trained rescuers, and are focused on
noncontact rescue techniques to ensure rescuer safety. The advanced procedures utilize
equipment and techniques which require proper training and experience to master.

Basic Procedures
The steps to perform a basic rescue of a drowning patient in open water follow the age-old
mantra: “Reach, Throw, Row, Go (Don’t Go).” This simple saying highlights the importance of
keeping a safe distance from a patient to ensure rescuer safety. A panicking patient can easily
take themselves and the rescuer underwater in an attempt to keep their airway above the surface.
By keeping a safe distance from the patient, utilizing communication and buoyant or long-
reaching objects from the surrounding environment, the rescuer can have the best chance of
avoiding injury.
Reach: A rescuer should scan the surrounding environment for any object which can be used
to reach the patient. This may include a pole, branch, rope, or clothing. While doing so, the
rescuer should maintain communication with the patient, giving simple directions and instilling
confidence. The benefit of this technique is that it keeps the rescuer out of the water, maximizing
safety. The weakness of this technique is that it requires close proximity to the patient, which
often isn’t possible in an open water environment and a conscious and coherent patient who is
able to remain calm and follow directions.
Throw: If the patient is too far from the rescuer or there are no objects to be used for
reaching, the next option is to throw a buoyant object to the patient. This may include a
specifically designed rescue apparatus (ring, buoy, etc.), cooler, beach ball, or raft. For farther
distances, equipment like throw bags are designed to be easily deployed, although these often
require at least basic training in their use. The benefit of this technique is that it allows access to
a patient who is farther from the rescuer. Similar to reaching, the weakness is that it requires a
patient who is conscious and coherent enough to follow directions and grasp an object.
Row: If reachable or throwable objects are not available, or if a patient is too far from the
rescuer, the next option is to “row” a craft to the patient. In this context, the term “row” can
represent any means to pilot a buoyant craft to the patient, whether that be row a boat, paddle a
surfboard, or drive a motorized boat. With the latter, extreme caution must be used in piloting a
motorized boat to a patient (see Chapter 28), as the patient may not have the physical or mental
capacity to avoid the craft or motor in the event that a wave or current brings it too close to the
patient. The benefit of this option is that it brings a relatively stable and buoyant surface to the
patient and allows for the rescue of those who may not have the strength or mental clarity to
grasp an object that has been reached or thrown to them. The weakness is that the skills
necessary for this technique can border on advanced; a panicking patient can capsize a small boat
or surfboard leaving the rescuer vulnerable. In addition, the act of safely lifting a tired or
unconscious swimmer onto a craft requires experience and training. It is best to only “row” to a
patient if you have sufficient manpower to assist and a large enough craft to minimize the chance
of capsizing, or if the patient is conscious and coherent enough to hold on to the side of the craft
and not require lifting into it.
Go (Don’t Go): This phrase highlights the importance of avoiding contact rescues with a
drowning patient without proper training and experience. If the previous options don’t work, and
would-be rescuers lack the proper training for advanced techniques, or the environment is unsafe
for your experience or equipment, the safest step is to contact local advanced rescue personnel.
However, this stage becomes “Go” for trained providers, as a final personal resort. As discussed
in Chapters 16 and 26, some systems add “Helo” as a final system resort, but this is more often
used for swiftwater than open water rescue, with the exception of flood disasters.

Advanced Procedures
Advanced procedures can be classified into two categories: noncontact and contact. Noncontact
rescues include those techniques in which the rescuer does not make direct contact with a patient,
usually using a buoyant rescue apparatus (buoy, ring, etc.). Contact rescues include those in
which the rescuer is forced to make direct contact with the patient, either through holding their
body or grasping an extremity, piece of clothing, or hair. Rescuers with the proper training and
equipment may attempt these rescues as long as the open water environment and number of
patients are deemed safe for the rescuer’s experience and physical capabilities. These rescue
techniques vary greatly based on training, available equipment, water condition, and local
protocols. This section will cover the basic principles and common techniques.
Although the decision to perform an advanced rescue has been made, steps to ensure rescuer
safety must still take place. As the patient is approached, verbal communication should be used
in an attempt to direct and calm the patient. Often, just by talking to a patient and letting them
know that someone is there to help, they can gain enough confidence to calmly swim toward
safety under the guidance of the rescuer. If available, a buoyant rescue apparatus should always
be taken by the rescuer, as this can improve rescue effectiveness and provide a measure of safety
for both the rescuer and the patient. If a patient is unable to swim but conscious enough to grasp
the apparatus, the rescuer should keep a safe distance from the patient and advance the apparatus
to them, instructing them to grasp it and rest. The rescuer can then either pull/push the patient
toward safety or call to shore for more assistance. During the remainder of the rescue, it is
important for the rescuer to maintain visual and verbal contact with the patient to ensure they are
able to hold on and to instill confidence. This is also an opportunity to question the patient about
additional persons who may be submerged.
If a rescuer reaches a patient who is panicking and unable to cooperate with the rescue, the
safest plan is to call to shore for additional help and stay by the patient, continuing efforts to
verbally calm them. If these attempts are unsuccessful and the patient is unable to grasp the
rescue apparatus, it may be safest to wait until the patient tires out to the point that you can safely
perform a rescue. Only rescuers with proper training and experience should attempt a contact
rescue of a panicking and uncooperative patient, and even then it should be made with extreme
caution as many cases exist of very experienced rescuers perishing during such attempts. Most
commonly, contact rescues are performed by either holding the patient across the chest or
abdomen or by dragging the patient by the armpit or extremity; clothing or hair can also be used
in dire situations. Proper technique keeps the patient’s airway out of the water, often at the
expense of the rescuer, who must support the weight of the patient and attempt to remain
horizontal for efficient movement through the water.
A specialty area of open water rescue is the rescue of patients engaged in SCUBA activities.
While the rescue of those in distress while deep water diving is covered in Chapter 17, one may
be called upon to rescue a patient who has surfaced after becoming incapacitated under water. In
this situation, the approach to the rescue follows the same basic and advanced steps mentioned
before. As a possible aid, the diver’s buoyancy compensator may be manually or automatically
inflated to provide flotation. Conversely, the various straps and tubing as well as the weight
systems commonly used may be a hindrance to rescue attempts. If a provider is known to work
in an environment where SCUBA activities are common, familiarity with the basic function of
SCUBA equipment can greatly improve rescue efficiency and safety. Care for this WEMS
specialty niche is discussed in more detail in Chapter 17.

Medical Integration
Drowning is a process defined by systemic hypoxemia (lack of oxygen). The primary goals of
treatment are focused on its reversal. The full extent of drowning resuscitation and treatment is
covered in Chapter 16. This section will review some of the medical aspects pertinent to the
rescue phase in the open water environment.

In-water Resuscitation
As hypoxemia is the primary cause of morbidity and mortality in drowning, it makes sense that
the earlier in the rescue that ventilations can be performed, the better the outcome. This belief
has led some lifesaving organizations and rescue agencies to advocate for the use of what is
known as “in-water resuscitation” (IWR). IWR focuses on providing ventilations, usually mouth
to mouth, while still in the water. Currently, there is no evidence to support the effectiveness of
attempting chest compressions in the water. Also, there is very little evidence describing the
survival or neurologic benefit of IWR.4 However, based on its theoretical benefit, it is currently
practiced by some lifesaving organizations. Current European Resuscitation Council (ERC)
guidelines call for attempting IWR if the rescuer’s training and conditions permit, if a buoyant
rescue apparatus is available to assist in holding the patient, and if the patient is a significant
distance from the shore.5 After initiation of IWR, either progress should be made toward the
shore without further delay, or IWR should continue in place if additional resources (boat,
paddleboard) are on their way to the rescuer. It is important to understand that the guidelines
recommended by the ERC are based on very little evidence; there is concern that by spending the
time in the water performing ventilations, the time to cardiopulmonary resuscitation (CPR)
initiation will likely be delayed. Manikin-based studies have found IWR to increase total rescue
time and rescue difficulty for both lay rescuers and professional lifeguards.6 Agencies must take
this knowledge, as well as local conditions and rescuer training, into account when deciding
whether or not to include IWR in protocols.5

Cervical Spine Motion Restriction

While the drowning process often begins with a swimmer who becomes tired or overwhelmed by
the water conditions, concern always exists for the possibility of a preceding cervical spine
injury. This often leads rescuers and medical personnel to prioritize cervical spine
immobilization techniques over proper resuscitation with ventilations. Retrospective studies have
found a low prevalence of cervical spine injuries in drowning patients (0.5% to 5%).7,8 Factors
which place a patient at a higher risk of cervical spine injury are known fall from height or high-
risk activity (boating, jetski), obvious facial or neck trauma, or an altered mental state. Patients
with these high-risk factors may be considered for cervical spine motion restriction, but not at the
expense of proper resuscitation. Rescuers must consider the possible adverse effects of spinal
cord protection including shifting of the focus away from treatment goals, delay in transfer to
advanced care, and increasing risk for patient aspiration due to emesis. Patients in cardiac or
respiratory arrest should not undergo spinal cord protection, but rather rapid transfer to advanced
care. Note that in the past “spinal immobilization” was a desirable goal for those with suspected
cervical spine injury, but we do not feel this is now ever an appropriate goal in a WEMS setting.
If there is a high suspicion for cervical spine injuries in open water patients, inline stabilization
can be maintained with spinal cord protection. A more complete discussion of the difference
between immobilization and motion restriction, and the indications for initiating or not initiating
spinal cord protection, are presented in more detail in Chapters 21 and 24.
IMPLICATIONS FOR PRACTICE LEVELS
The skills needed for the rescue of patients in open water environments are not dependent upon
the level of medical training, but rather training and experience in rescue techniques. There are,
however, some differences in the medical care of patients which may occur in concert with
rescue operations.

First Aid
The effectiveness of a First Aid provider in the treatment of an open water drowning patient will
rely heavily on the level of exposure the provider has had to CPR training and the type of CPR
certification held. With the push toward increasing bystander CPR for out-of-hospital cardiac
arrest patients, many basic training programs have moved toward the practice of “compression-
only CPR.” While this may improve provider willingness to perform, it does not address the
primary pathophysiology of drowning (hypoxemia). First Aid providers who are expected to be
functioning in and around open water environments should undergo CPR training and
certification at a level which includes the traditional ABC approach, including ventilations. This
will allow the provider to perform adequate initial resuscitation while advanced providers are en
route.

Basic Life Support

Most of the medical techniques necessary to carry out an effective initial resuscitation of a
drowning patient are within the practice scope of a basic life support (BLS) provider. The
primary focus of resuscitation is providing positive pressure ventilations (mouth to mouth, mouth
to mask, bag valve mask) with supplemental oxygen, if available, and high-quality chest
compressions as indicated.

Advanced Life Support

Even with additional training in advanced life support (ALS), providers at this level should focus
on the same resuscitation goals discussed in the Basic Life Support section above. If advanced
airway equipment is available, and the provider is well trained in its use, this may be utilized as
indicated, with the understanding that placement of a supraglottic device or endotracheal tube
may be difficult due to airway foam and emesis. If positive pressure ventilations provided by
BLS techniques are adequate, and transport time is short, it may be best to continue these to
ensure continued reversal of hypoxemia.

Clinician
As with ALS providers, clinician effectiveness will only be as good as their BLS skills. There are
few clinician-level practices indicated in the treatment of open water drowning other than
securing an airway through advanced or surgical techniques if basic techniques are inadequate.
Oftentimes, the unique role of a clinician in a WEMS open water environment is to serve as
medical director or to provide operational medical oversight in an Incident Command System
structure. In this context, being familiar with the most up-to-date principles in drowning and
EMS care and research is critical to serve that role effectively.

EQUIPMENT SUMMARY
The equipment used to perform the rescue and initial resuscitation of an open water drowning
patient will vary greatly based on location, resources, protocols, and rescuer training and
experience. This section will highlight some of the more common rescue and medical equipment
which have been used during the rescue phase in open water environments. The benefits and
weaknesses of each will be discussed to help guide equipment selection decisions for wilderness
activities.

Rescue Equipment
Ring buoy: solid condensed foam ring with rope handles and, often, a long length of rope
attached (Figure 27.1).
Benefits: throwable to moderate distance. Can support multiple patients.
Weaknesses: not compact. Foam may not last long in rugged environment.
Rescue can: hard, plastic, torpedo-shaped buoy with molded handles on side and back. A length
of rope is secured to the front with an attached strap to be worn around the rescuer’s chest
(Figure 27.2).
Benefits: rugged material. Can support multiple patients. Allows for efficient swimming by
rescuer.
Weaknesses: not compact. May cause impact injuries.
Rescue tube: soft, flexible, condensed foam approximately 1 m in length. Often with rope
attached to end with an attached chest strap and buckles on ends to facilitate securing around the
patient (Figure 27.3).
Benefits: low chance of impact injuries. Can support multiple patients. Allows for efficient
swimming by rescuer. Can be secured around tired or unconscious patient.
Weaknesses: not compact. May be damaged in rugged environments.
Throw bag: long length of rope collected in a bag with a handle to facilitate throwing (Figure
27.4).
Benefits: compact. Throwable to long distance.
FIGURE 27.1. Ring buoy. Courtesy of Max Ervanian, EMT-B.

FIGURE 27.2. Rescue can. Courtesy of Max Ervanian, EMT-B.

FIGURE 27.3. Rescue tube. Courtesy of Max Ervanian, EMT-B.

FIGURE 27.4. Throw bag. Courtesy of Max Ervanian, EMT-B.

Weaknesses: training and practice needed for efficient use. Does not support tired patient.
 Patient can become tangled in rope.
Rescue paddleboard: long, buoyant craft similar to surfboard, but large enough for two persons
(Figure 27.5).
Benefits: rapid movement through water. Provides excellent buoyancy and platform to
assess/treat patient. Can accommodate multiple patients.
Weaknesses: not compact. Specialized training needed for efficient and safe use. Not suited for
high-wave conditions.
Kayak: paddle-powered craft of varying designs and sizes. Often with enough room for multiple
persons and to carry other rescue equipment.
Benefits: rapid movement through water. Provides excellent buoyancy and platform to
assess/treat patient. Can accommodate multiple patients.
Weaknesses: not compact. Specialized training needed for efficient and safe use. Not suited for
high-wave conditions.

FIGURE 27.5. Rescue paddleboard. Courtesy of Max Ervanian, EMT-B.

Medical Equipment
Pocket mask: Various designs and sizes ranging from foldable plastic sheet to non-collapsible
facemask with inflated seal. Common components are a barrier and one-way valve (Figure
27.6).
FIGURE 27.6. Pocket masks. Courtesy of Max Ervanian, EMT-B.

FIGURE 27.7. Bag valve mask. Courtesy of Max Ervanian, EMT-B.

 Benefits: compact and simple.
Weaknesses: difficult to hold in place while in water. Relies on rescuer’s breathing for
ventilation. Provides patient with little protection against aspiration.
Bag valve mask: System consisting of collapsible reservoir bag, one-way valve, and mask with
inflatable seal (Figure 27.7).
Benefits: Provides positive ventilations through compression of bag. Able to be attached to
supplemental oxygen.
Weaknesses: Requires specific training in use. Difficult operation for single rescuer. Provides
patient with little protection against aspiration.
Supraglottic device: airway tube of various designs meant to be placed blindly into airway, with
design components to allow positive ventilations into trachea (Figure 27.8).
Benefits: depending on design, may provide some level of protection from aspiration.
Weaknesses: requires specific training in use.

SUMMARY
Drowning in open water environments accounts for a large proportion of injury and death,
especially in the 15- to 29-year-old age range. While this environment is often thought of as
more controlled than swiftwater environments, geography and shifts in weather cause similar and
even more dangerous conditions. As with any rescue operation, rescuer safety is paramount, and
the experience, skills, and equipment of team members must be taken into account to avoid
rescuer injury or death. Rescuers without experience or training in the open water environment
or with the associated equipment should stay within the confines of the “Reach, Throw, Row,
Go” mantra and activate advanced rescue personnel early. Some systems may have the option of
deploying “Helo” as a final stage in this mnemonic, but this is more common in flood operations
or swiftwater operations.
FIGURE 27.8. Supraglottic devices. From left to right: i-gel by Intersurgical, Combitube by Nellcor, air-Q by Cookgas. Courtesy
of Max Ervanian, EMT-B.

Rescuers who will potentially be charged with carrying out advanced rescue operations in
open water must be proficient in specific techniques and in the use of rescue equipment. These
will vary greatly depending on agency and conditions, but an in-depth knowledge of contact and
noncontact rescue techniques as well as equipment designed specifically for the rescue of
drowning patients are a must for all situations. The choice to start reversing hypoxemia while
still in the water by means of IWR can only be a personal one for the rescuer, based on
experience, conditions, and physical capability. Along the spectrum of a rescue, all components
must be focused around rapidly and safely transporting the rescuer and patient to the shore for
medical treatment to commence.

References
1. Centers for Disease Control and Prevention. Racial/Ethnic disparities in fatal unintentional drowning among persons aged
≤29 years-United States, 1999–2010. MMWR. 2014;63:421-426.
2. Franklin RC, Pearn JH. Drowning for love: the aquatic victim-instead-of-rescuer syndrome: drowning fatalities involving
those attempting to rescue a child. J Paediatr Child Health. 2011;47:44-47.
3. USLA Lifeguard Agency Certification Program. United States Lifesaving Association. Available at: http://www.usla.org.
Updated February 2014. Accessed April 15, 2016.
4. Szpilman D, Soares M. In-water resuscitation—is it worthwhile? Resuscitation. 2004;63:25-31.
5. Truhlář A, Deakin CD, Soar J, et al; Cardiac arrest in special circumstances section Collaborators. European Resuscitation
Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation. 2015;95:148-
201.
6. Winkler BE, Eff AM, Ehrmann U, et al. Effectiveness and safety of in-water resuscitation performed by lifeguards and
laypersons: a crossover manikin study. Prehosp Emerg Care. 2013;17:409-415.
7. Watson RS, Cummings P, Quan L, et al. Cervical spine injuries among submersion victims. J Trauma. 2001;51:658-662.
8. Hwang V, Shofer FS, Durbin DR, et al. Prevalence of traumatic injuries in drowning and near drowning in children and
adolescents. Arch Pediatr Adolesc Med. 2003;157:50-53.
INTRODUCTION
Wilderness emergency medical services (WEMS) providers do not have a choice where
accidents and disasters occur. When their traditional fleet of ground vehicles can’t reach a
patient, the needed supplies are too difficult to transport by pack, or the distance by foot is too far
in a time-sensitive situation, they may be required to employ nontraditional transport options. In
this case, “transport” can refer to transport of gear or providers to a patient or transport of a
patient from a scene. All-terrain vehicles (ATVs), utility task vehicles (UTVs), all-terrain
ambulances, WEMS response vehicles, and helicopters are among those nontraditional transport
options. ATVs and UTVs are capable of traveling over terrain impassable by traditional ground
emergency medical services (EMS) vehicles, carrying stretchers and additional gear, and can be
modified to enable room to provide care with patient transport in the wilderness setting. All-
terrain ambulances and WEMS response vehicles provide a rapid means of bringing lifesaving
care and a provider to a patient that may outperform the response of traditional ambulance
response in a time-sensitive environment. Helicopter use in WEMS is an unmatched means of
covering large areas quickly, grossly increasing direct vision for a scene or search from the sky,
and able to perform an active role in search and rescue (SAR) and EMS response. Helicopters in
WEMS, when employed appropriately and safely, can enable initial patient stabilization,
treatment, and transport to definitive care hours to days faster than any other methods of patient
transport (Figure 28.1). The application of off-road vehicles and helicopters in WEMS response
enables an added advantage to prompt lifesaving access to our patients, but it must never be
forgotten that the emergency is the patient’s and deliberate attention to provider safety be
practiced.
FIGURE 28.1. AS350-B3 A-Star helicopter landing at ~4,300 m (~14,000 ft) camp in Denali National Park to provide WEMS
support for an ongoing SAR mission. Courtesy of Brian M. Scheele.

Scope of Discussion
In this chapter, we will discuss the following:

What defines ATVs versus UTVs and all-terrain trailers

Introduce all-terrain ambulances and WEMS response vehicles
Air medical and helicopter-based WEMS operations in comparison with traditional
helicopter air ambulance (HAA) operations, regulations, and risk management
Where EMS agencies are utilizing ATVs, UTVs, and helicopters for rescue
How WEMS providers can operate and understand ATVs and UTVs and work as a team
member on a helicopter during WEMS response
How using these vehicles may affect your particular practice and what to know before
getting aboard

Definition
Off-Road Vehicles
ALL-TERRAIN VEHICLES
ATVs are small, nimble vehicles, fast and versatile with limited storage capacity, and can be
upgraded for patient transport and towing options. They are off-highway motorized vehicles
designed to travel on four low-pressure tires, having a seat designed to be straddled by the
operator and handlebars for steering control, and intended for use by a single operator and no
passenger or by an operator and a passenger with a designated seating position behind the
operator. ATVs are often referred to as “quads” due to their four wheels. Typically, ATVs have a
combustion engine, although there are models with electric-powered motors. Sport models are
built for high performance and recreation with two- or four-stroke engines, manual or automatic
clutch, and gear ratios for quick acceleration. In contrast to the sport model, utility ATV models
are more often employed for work such as pulling loads or shoveling snow, although often used
in recreation as well. Utility ATVs are more rugged and typically have larger tires, stiffer
suspension, skid plates, cargo racks, towing hitches, four-stroke engines, lower-end torque, and a
driveshaft (Figure 28.2).

FIGURE 28.2. Two Burke County (NC) ATVs being prepared for deployment. Note saddle seats and handlebars distinguishing
these as ATVs. Courtesy of Wes Taylor.

UTILITY TASK VEHICLES

UTVs are tough; rugged; able to carry personnel, patients and gear; and capable of crossing
terrain and distance too difficult for cars, trucks, or ambulances. They are sometimes referred to
as recreational off-highway vehicles or multipurpose off-highway utility vehicle and “side-by-
sides.” The common “side-by-side” term comes from the UTV’s nonstraddle seat, where the
operator and a passenger sit side by side in a bench or bucket seat, in comparison with the solo-
operator or front-and-back seating arrangement of the ATV. UTVs are off-road, off-highway
vehicles with four or more tires, two or four tracks or a combination of four or more tracks and
wheels, steered via a steering wheel, a nonstraddle seating, seat belts, and occupant-protective
structure with engine displacement up to 1,000 mL. Unlike ATVs, UTVs can have more than
four wheels, a steering wheel instead of handlebars, nonstraddle side-by-side seating, greater
safety features in place such as seat belts and an occupant-protective structure, and a minimum
cargo capacity of 350 lb (Figure 28.3).
FIGURE 28.3. (A) Ocean rescue UTV with Medlite©. Courtesy of Kimball Johnson, Kimtek Corporation, Orleans, Vermont. (B)
Argo 8 × 8 Frontier 650 UTV being prepared for deployment. Courtesy of Matt Chandler, ARGO XTV, New Hamburg, Ontario,
Canada.

ALL-TERRAIN TRAILER
All-terrain trailers (ATTs) or rescue trailers are two- or four-wheeled off-road trailers designed to
safely transport sick or injured persons from off-road locations behind a UTV to an ambulance,
helicopter, WEMS response vehicle, or definite care. ATTs offer an option for patient transport
when a UTV is not configured for patient transport and the patient must remain in the supine
position, or a UTV is configured with medical or rescue gear in the bed. ATTs require two
personnel at the minimum, one operating the UTV and trained in the use of ATTs and the other
attending to the patient.
LEGALITY OF ATVs AND UTVs
ATVs from the factory rarely meet state law standards for operation on paved roads, although in
certain states modifications can be made to meet those standards. In comparison to UTVs,
although generally not meant for the highway, these are closer in design to vehicles meant for
paved roads, and simpler modifications may meet the standards for travel on paved roads. Laws
and agencies that regulate ATVs and UTVs vary greatly state to state. Variations include laws
regarding registration and licensing certification, title requirements, plates and decals, age
restrictions, helmet and eye protection use, passengers, public versus private property use, paved
roads or highway use, state park or forest land use, road crossings, and headlights and taillights,
just to name a few. Finding your state’s laws on ATV/UTV use can generally be found by
contacting the state Department of Motor Vehicles or locating the United States Consumer
Product Safety Commission website on state ATV information.1
ALL-TERRAIN AMBULANCES
All-terrain ambulances are four wheel drive (4WD) vehicles modified to incorporate the core
components of an ambulance while maintaining the dynamic properties of their base vehicular
chassis (eg, Ford Ranger, Toyota Land Cruiser). Dynamic properties like 4WD, all-wheel drive,
stability protection, and antilock brakes retained from their base vehicle and smaller width allow
for travel where traditional ambulances may be limited secondary to size, terrain, or weather.
Modifications of a chosen base vehicle may include light-emitting diode (LED) lighting, exterior
design, and sirens for recognition. In some models, the chassis may be mounted with custom
aluminum box body design similar to traditional ambulances for patient care or the rear of the
vehicle ergonomically designed and equipped to care for patients in a more confined space
(Figure 28.4).
WEMS RESPONSE VEHICLES
WEMS response vehicles are all-terrain ambulances designed to provide emergency rapid
response by enabling the arrival of personnel and equipment to a scene in the unpredictable
wilderness environment. WEMS response vehicles are civilian 4WD vehicles that can be
modified for EMS work specifically. Lightbars, navigation systems, exterior lighting and
spotlights, radios and communication equipment, medical storage compartments, patient care
areas, and even solar power can be built to create a customized WEMS response vehicle. EMS
response times have been shown to impact mortality,2 and challenges faced during certain
WEMS response may be addressed by appropriate application of nontraditional WEMS response
vehicles.
FIGURE 28.4. WEMS response vehicle. Courtesy of John S. Payne. In Hawkins SC. The Green Machine: development of a
high-efficiency, low-pollution EMS response vehicle. J Emerg Med Serv. 2008;33:7.

Traditional ambulances cost, maintenance, and environmental impact in the modern setting
of government regulations and environmental legislation may draw financial burden and
undesired scrutiny if not addressed by EMS agencies. It has been suggested that fuel efficiency
and decreased environmental impact of hybrid suburban utility vehicles, electrically powered
vehicles, and the use of biodiesel fuel may decrease cost, maintenance, and the environmental
impact of EMS resources when compared with traditional ambulance services in the wilderness
or rural environment. This cost and impact, however, must be viewed in contrast to the different
operational capacity of energy-efficient response vehicles and traditional EMS vehicles.3

Helicopter WEMS
Helicopters have directly powered main rotors, usually a jet engine with a transmission linkage
to the rotor blades, and some helicopters have internal combustion engines as their power supply.
Some have single engines and some have dual engines for redundancy. Helicopters are lifted by
horizontal rotor blades rotating around a mast and are referred to as rotary-wing aircraft.
Grasping their primary advantage via their blades, helicopters can lift into the air without moving
forward, enabling takeoff and landing vertically without the need for runways. Helicopters have
either a single horizontal rotor and a tail rotor to compensate for torque or a dual horizontal rotor
system with torque compensated by rotor rotation in opposite directions. Landing gear in a
helicopter comprises of skis, skids, wheals, or floats (Figures 28.51 and 28.6).
Helicopters can operate over open ocean, at high altitude, and environments at the extremes
of temperature on Earth although not without challenges. Aviation is a highly regulated industry
secondary to the risks associated with flight. Density altitude has a significance effect on
helicopter performance. Helicopters are used throughout the United States across multiple
institutions involved in the application of WEMS. Risk management strategies decrease risk in
aviation and aid in the decision-making process during planning and operations. There are
numerous technical considerations while working with helicopters and specific considerations
with mission types that are applicable during WEMS response that we will discuss.

FIGURE 28.5. Rescue helicopter landing in Whistler, British Columbia, at a snow-covered landing zone. Courtesy of Brian M.
Scheele.
FIGURE 28.6. CH-47 “Chinook” at the Kautz helo-base within Mount Rainier National Park. Courtesy of Brian M. Scheele.

HELICOPTER USE, REGULATION, AND RISK

Helicopters are a platform for urban and rural HAA operations, SAR, firefighting, and broad-
reaching military operations. When the capabilities to provide medical care in the wilderness
setting are coupled with those of a helicopter, their versatility becomes unmatched in WEMS
response. Helicopters do, however, have limits; although helicopter accidents in civilian SAR are
rare, fatalities are significantly higher in civilian SAR helicopter accidents when compared with
commercial helicopter accidents in the United States.4 In response to an unacceptable amount of
civilian helicopter accidents in the United States the Federal Aviation Administration (FAA) in
February 2014 issued a final rule that requires helicopter operators, including air ambulances, to
have stricter flight rules and procedures, improved communications, training, and additional
onboard safety equipment. The FAA examined HAA accidents from 1991 through 2010 and
determined 62 accidents that claimed 125 lives could have been mitigated by the new ruling.5
Helicopter crews operating in the wilderness environment include qualified pilots, technical
crew, medical providers, engineers, and ground crew. Appropriate training, continuing
education, up-to-date qualifications, and the practice of risk management are required to make
wilderness helicopter operations safe and reliable. Helicopters are an outstanding EMS response,
evacuation, and rescue tool, but helicopters and humans have limitations, and consequences for
pushing the limits can be quick and fatal.
HELICOPTER OPERATIONS—RISK MANAGEMENT AND THE DECISION TO FLY
Numerous models of calculated risk management are practiced across federal agencies and the
aviation industry. Risk management during an operation is a continuous, cyclic, and systematic
process. Ongoing communication and situational awareness exercised by all members
throughout the duration of an operation are paramount. A risk management model is used to
identify and control risks during planning and operational execution of a mission. Unnecessary
risks are never acceptable, and necessary risks are potentially acceptable when benefit outweigh
calculated risk. Preflight risk analysis is mandatory and must include, at a minimum:
flight considerations, to include obstacles and terrain along the planned route of flight,
landing zone conditions, and fuel requirements;
human factors, such as crew fatigue, life events, and other stressors;
weather, including departure, en route, destination, and forecasted;
a procedure for determining whether another HAA operator has refused or rejected a flight
request; and
strategies and procedures for mitigating identified risks, including procedures for obtaining
and documenting approval to cancel a flight when a risk exceeds a predetermined risk
level.6
Risk management models are varied and agencies have predetermined models that must be
utilized. An example risk management process is given below:
Identify mission/tasks
Identify hazards
Assess risk
Identify options
Evaluate risk versus benefit
Execute decision
Monitor situation
WEMS helicopter assets are valuable when:
Conventional EMS response is impractical, intensive, or arduous
Patient status is time critical and expedited management is necessary to preserve life, limb,
or eyesight
Patient location is remote with critical injury or illness
Benefits of WEMS helicopter asset outweigh calculated risk (Figure 28.7)
FIGURE 28.7. Risk management must be performed continuously throughout your mission. National Park Service ranger looks
over the terrain out the window of a CH-47 “Chinnok” while involved in a search and rescue on the slopes of Mount Rainier.
Courtesy of Brian M. Scheele.

PREVALENCE

ATV/UTV Prevalence
Anecdotally, after the observed FDNY EMS use of UTVs and ATVs during their response to the
attack of September 11, 2001 in combination with increased funding by the federal government,
and the creation of the Department of Homeland Security, ATV and UTV use among EMS
agencies has grown nationwide. Although data regarding the prevalence of ATV and UTV use
across EMS agencies is not widely available, the number of their units sold in the United States
is significant. ATV sales in the United States from 2012 to 2015 were steady at around 230,000
units per year. That contrasts to the 2015 UTV sales of around 400,000 units, of which 55% were
intended for commercial use. The greatest number of UTVs is purchased in the southern United
States followed by the midwest, west, and finally the northeast. Users in Texas, California, and
Ohio purchased the greatest numbers by individual state.7

Helicopter WEMS Assets

Helicopter WEMS assets function within commercial organizations such as air ambulance
services or local, tribal, state, and federal government in addition to the military. Private, for-
profit, and not-for-profit organizations provide HAA operations in the wilderness setting with
contractual relationships with hospitals and government agencies across the United States. Fire
departments, local city, county, and state law enforcement agencies are also involved in WEMS
as part of their HAA programs or SAR services. Federal agencies have developed a National
Search and Rescue Plan (NRP) for the United States for coordinating SAR services to meet
domestic needs and international commitments.8 Helicopter WEMS assets are often fundamental
to the operation of SAR and make excellent SAR platforms for insertion or extraction of
personnel, visual and electronic search, ground personnel direction, and equipment and personnel
transfer.9
The U.S. National Search and Rescue Committee (NSARC) is responsible for the NRP and
its member agencies include Department of Homeland Security (eg, U.S. Coast Guard, Federal
Emergency Management Agency), Department of Transportation (eg, Federal Aviation
Administration, Maritime Administration), Department of Defense (eg, U.S. Air Force, U.S.
Pacific Command), Department of Commerce (eg, National Oceanic and Atmospheric
Administration), Federal Communications Commission, National Aeronautics and Space
Administration, and Department of the Interior (eg, National Park Service). The NSARC
members all have unique responsibilities with a combined objective to improve cooperation in
providing expeditious and effective SAR services.8
Federal military arrangements with civil agencies provide their fullest practicable
cooperation when military helicopter assets are requested provided these maintain
noninterference with their military duties. The Air Force Rescue Coordination Center (AFRCC)
serves as the agency responsible for coordinating on-land federal SAR activities in the
continental United States carried out by the Civil Air Patrol primarily, and the Alaska Rescue
Coordination Center (AKRCC) coordinates inland Alaskan SAR activities carried out by their
Air National Guard Units primarily. Both the AFRCC and the AKRCC coordinate response, and
the missions themselves are carried out by available deployable assets. The United States Coast
Guard (USCG) is the SAR coordinator for other maritime areas governed by the federal
government as well as the State of Hawaii. Upon civilian request for additional helicopter assets,
the coordinating center will determine a mission go/no-go on the basis of whether there is a
threat to life, limb, eyesight, or undue suffering and arrange assistance with available local, state,
regional, and national assets.8

TECHNICAL DISCUSSION

ATV/UTV/ATT Technical Discussion

ATV and UTV use is technically similar. For that reason, we will discuss both simultaneously
here while pointing out the differences when applicable. ATV and UTV use for wilderness, fire,
EMS, law enforcement, and federal agencies require training and certification before official use,
and that training is agency dependent. In this section, we will describe the basics of operating
ATVs and UTVs, with emphasis on use in the wilderness setting.
Again, agency certification before use of ATV/UTV should be required by all personnel.
Additional training and certification is recommended for any personnel towing an ATT behind
their ATV/UTV before official use. ATT accidents can occur while loading or offloading
patients and during towing over rough terrain. Both ATV/UTV and ATT certification should be
checked before deployment on a rescue mission or EMS response. Annual recertification for
personnel who respond to wilderness emergencies should demonstrate their off-road ATV/UTV
operating skills on an approved course. This recertification should include loading and unloading
from a trailer, assembly and coupling of the ATT to the tow vehicle, and safe towing of the
trailer with rescuer and patient on board over rough terrain.
It is critical to understand how to operate an ATV or UTV before professional use. The
Consumer Product Safety Commission received reports of 13,617 ATV-related deaths in the
United States between 1982 and 2014.10 According to the United States Centers for Disease
Control and Prevention (CDC), there were 7,231 deaths from ATV accidents between the years
2000 and 2007 in the United States.11 Additionally, a study with data obtained from the Bureau
of Labor Statistics’ annual Census of Fatal Occupational Injuries indicated there were 129 work-
related ATV deaths between 2003 and 2006.12 Regarding UTVs, the Consumer Product Safety
Commission documented that, between January 2003 and August 2009, 68% of UTV injuries or
deaths were a direct result of roll-over without a preceding accident.13 Recognizing the risks
associated with the use of these vehicles, recalls of UTVs and ATVs have occurred, and
manufacturers and regulatory agencies have made efforts to modify production standards and
increase the safety profile of these vehicles.
We recommend full compliance and adherence to manufacturer safety recommendation and
requirements. The set of safety rules published in the Standard Operating Guidelines for
ATV/UTV/ATT trailers during off-road SAR missions and/or EMS were made to fit the mission
of off-road emergency response.14

Always wear an approved helmet (and other protective gear as required by the mission).
Never ride on public roads, unless the mission requires it, and then only with an escort.
Never operate any ATV or UTV under the influence of alcohol or drugs.
Never exceed the number of riders the ATV or UTV was designed to carry.
Never permit underage operation of an adult-sized ATV or UTV.
Supervise new and underage operators as they learn to safely operate ATVs and UTVs.
Ride only on designated trails, unless the mission requires cross-country travel.
Complete an ATV/UTV operator’s safety training course before driving an ATV or UTV.

Additional recommendations for ATV/UTV use include the following:

Always wear seatbelt in any UTV with Roll-Over Protection Structures (ROPS) except
during water crossings
Ensure headlights and warning light illumination during emergency response
When towing any patient trailer equipped with an attendant or rescuer seat, if no patient is
present, then no attendant is necessary; if a patient is present, then that patient must have an
attendant

Personal protective equipment (PPE) during ATV/UTV operation is mandatory, and

specifics vary with circumstance. Requisite PPE in all environments include helmet, gloves
appropriate for the environment, shoes or boots for the terrain, and eye and face protection.
Proper clothing (for example, long-sleeved shirts depending on potential limb exposure to
hazards or cold weather gear depending on expected weather) are mission specific. Additional
mandatory items for some agencies include a communication device or radio, a tool kit, fire
extinguisher, and the operating manual for the machine. Other recommended items may include
hearing protection, a GPS receiver, map and compass, extra food and water, fire starter kits,
flashlight, sunscreen, or any additional survival equipment.
 We do recommend a preride check of the vehicle. This is often known in the industry by the
mnemonic T-CLOC: tires, control, lights, oil, chassis15 (Box 28.1).
ATV/UTVs can themselves be towed behind an appropriate vehicle, or carried in an
appropriate vehicle bed. When towing, see the owner’s manual of the towing trailer for the gross
combined weight rating (GCWR) of that vehicle. The GCWR is the maximum allowable weight
of the vehicle, loaded trailer, cargo, and passengers. Some agencies recommend never exceeding
75% of the GCWR when transporting. Ramps are needed to load ATV/UTVs onto trailers or into
vehicle beds. Remember the ramps must also be rated to support the combined weight of the
vehicle, operator, cargo, and equipment. Ramps must be tied down without slack; material for
tie-down must be rated to support the weight if need be. Loading the vehicle onto the ramp and
trailer must be done with caution, on operator, with seat belt fastened, and with cargo removed.
If unable to remove cargo and unbalanced, one can use counterweights (eg, sandbags) placed on
the front to balance appropriately and avoid accident. Four-point tie downs must secure your
ATV/UTV to the trailer, two in front and two in back. Ratchet-type tie downs in good condition
with minimum weight capacity of 2,500 lb must be used.16
When towing a patient trailer or ATT, the operator should remember it is never how much
one can tow that matters, but it is how much one can tow and safely stop that matters. The
operator is responsible for the safe towing of the vehicle at all times. When a patient attendant
seat is installed on an ATT, rider configuration must have either a patient and an attendant or
neither if they are arranged in a side-by-side fashion. One must always communicate with the
attendant regarding upcoming hazards like low-hanging branches, rough terrain, or slopes. When
in doubt about trail conditions it is best to stop and scout out the hazard before proceeding.16

BOX 28.1 T-CLOC

T: Tires. Check pressure, condition, wheels, bolts, nuts, and axle-and-wheel bearings.
C: Controls and cables. Locate and check controls. Check brake pedal adjustment and fluid and inspect the shifter.
L: Lights and electronics. Check the lights, the ignition switch, and engine stop switch and ensure all gauges are functioning.
O: Oil, fuel, fluids, and air filter. Check oil, fuel, and coolant levels. Inspect for leaks and ensure air filter is clean, not
blocked or torn.
C: Chassis, suspension, driveshaft, and external equipment. Check the underside for damage. Shake the chassis and
suspension, making sure nothing is loose and the shocks are functioning. Check cargo boxes and racks for damage and
tighten fasteners. Check the driveshaft for leaks or missing nuts and bolts. Inspect the winch if present, its cables, hooks, and
function. If trailer hitch is present, check size and security. Check tool boxes and other equipment for condition, and proper
loading, making sure they are secure.

Helicopter Technical Discussion

In the following paragraphs, we will discuss the general requirements and must-know
components for the WEMS provider’s integration into the flight crew. We will focus on the
general, field, and SAR knowledge, skill, and abilities needed to function as a member of the
crew. Consistent focus will be on crew resource management; this being a method for optimizing
the human–helicopter interface and related interpersonal communication, which may include
information sharing, problem solving, decision making, and the maintenance of situational
awareness. A constant focus for the flight crew is the use of all available resources to achieve a
safe and efficient flight operation. Although this discussion focuses on WEMS providers
imbedded on a helicopter team, it is important to remember that even more WEMS providers
will interface routinely with helicopter staff even if not part of the helicopter team. Therefore,
helicopter awareness is crucial even for ground EMS (GEMS) providers if they frequently work
with helicopters. It has been suggested that GEMS patient packaging and helicopter operational
awareness can significantly impact helicopter EMS (HEMS) operations.17 More information on
the interface between ground-based WEMS teams and helicopter teams is found in Chapter 6.

WEMS Helicopter Provider Training and Education

For their inclusion as part of the flight crew, wilderness EMS personnel requires a formal
education that is agency dependent and to be determined by the authority having jurisdiction
over the personnel. Agency training will have standardized training before becoming a crew
member on a WEMS helicopter in addition to their traditional basic life support (BLS), advance
life support (ALS), or physician qualifications. In additional to formal training and
qualifications, one’s agency-specific organizational structure must be understood to perform his
or her role in the organization effectively.
To perform as a crewmember and working full or part-time performing WEMS helicopter
operations, adequate training is necessary and specific training should include but may not be
limited to the items listed in Box 28.2.18

Suggested Initial SAR/Wilderness Technician Training Helicopter

BOX 28.2
Operations

• Trained and current certification as BLS, ALS, or physician provider

• Preflight procedures
• Aircraft fueling procedures
• Aircraft fire guard/safety
• Proper use of equipment and operational checklists
• Sterile cockpit procedures
• Passenger briefing: Loading and unloading, seatbelts and shoulder harnesses, hazards of loose objects, aircraft door
operations, emergency exits, passenger intercommunication systems
• All standard unit operating procedures
• Terrain and weather
• SAR and flight risk assessment
• Hazard mitigation
• Multiaircraft operations
• Ability to assist pilot with navigations and communications
• Crew resource management (CRM)
• Safety management systems (SMS)
• Proper wearing and use of PPE and survival equipment
• Environmentally appropriate survival
• Landing spot and helispot management
• Mission-specific training
• Search, rescue, and recovery operations and equipment
• Human and nonhuman external loads such as hoist, short haul, and rappel
• Aerial search techniques
• Aircraft ingress and egress during operations
• Medical operations during SAR missions
• Incident Command System (ICS)
• Emergency procedures training
• Emergency egress
• Water egress
• Location and use of aircraft emergency/survival equipment
• Emergency radio communications
• In-flight fire considerations
 • Special rescue considerations (line entanglement, hoist failure, etc.)
Data courtesy of the Public Safety Aviation Accreditation Commission (PSAAC), March 2015.

Basic Safety In and Around Helicopters

Approach and depart the helicopters from the front or the sides.
Have visual contact with the pilot, or approach only after a predetermined signal (flashing
of headlights); if unsure, do not approach.
Never approach or depart toward the tail of the helicopter; beware of the tail rotor.
Approach and depart from the downhill slope.
Use aircraft door latches as instructed.
Wear your seatbelt, and buckle it before exiting the helicopter.
Carry gear below waist level.
Secure all internal and external equipment and secure patients—no loose items.

Personal Protective Equipment19

Fire-resistant clothing, gloves, boots

Hearing protection for you and your patients
Flight helmet and eye protection
Personal Survival Equipment19

WEMS-Specific Helicopter Safety

Familiarity and proficiency with all rescue adjuncts: harnesses, straps, litters, baskets
Familiarity and proficiency with all mission types and landings to be performed
Clothing, footwear, and eye protection appropriate for anticipated weather on scene

Regulations—Visual Flight Rules (VFR), Instrument Flight Rules (IFR), Weather, and
Nighttime
All pilots are bound by the limitations set forth by Title 14 of the US Code in the Federal
Aviation Regulations and, if operating within the jurisdiction of the Department of the Interior,
the Interagency Helicopter Operations Guide of the Office of Aviation Services. These
regulations specify VFR, IFR, as well as limits during weather and nighttime helicopter
operations. VFR and IFR are effected by terrain (mountainous vs. nonmountainous), pilots
visibility, weather, and other flight hazards.

Helicopter Performance
It is essential that nonpilot users of helicopters have a basic knowledge of helicopter capabilities
and limits.
Ground Effect—A condition of improved rotor system performance encountered when the
helicopter is hovering near the ground.20
Hovering in Ground Effect (HIGE)—Occurs when a helicopter is hovering approximately
less than one-half the rotor diameter distance from the ground, creating a “cushion” of air
beneath the helicopter.20
Hovering out of Ground Effect (HOGE)—Occurs when the helicopter exceeds about one-
half of the rotor diameter distance from the ground, and the cushion of air disintegrates and
greater power is needed to lift the aircraft.20
Translational Lift—Translational lift occurs when the helicopter approaches 15 to 18 mph
indicated airspeed and when hovering with a 15-mph steady headwind and is felt as a transition
from hover to forward flight.20
Autorotation—Autorotation is a nonpowered flight condition in which the rotor system
maintains flight revolutions per minute (RPM) by reversed airflow. It provides the pilot a means
of safely landing the helicopter after an engine failure or other mechanical emergency.20
Density Altitude—Density altitude refers to a theoretical air density that exists under
standard conditions of a given altitude, with factors affecting density altitude being atmospheric
pressure, temperature, and humidity. High elevation, high temperature, and high moisture
content all contribute to high density altitude conditions and lessen performance and blade
efficiency. When operating from a high density altitude location, the appropriate flight manual
must be consulted to determine the maximum weight allowed for the aircraft under the
conditions of altitude, temperature, wind, and runway.20,21
Weight and Balance Theory—Two elements are vital in the weight and balance
considerations of an aircraft. The total weight of the aircraft must be no greater than the
maximum weight allowed by the FAA for the make and model of the aircraft. The center of
gravity, or the point at which all of the weight of the aircraft is considered to be concentrated,
must be maintained within the allowable range for the operational weight of the aircraft.21
Load Calculations—Load calculations must be completed for all flights to ensure that the
helicopter will perform within the limitations established by the helicopter manufacturer, without
exceeding the gross weight for the environmental conditions where the helicopter is to be
operated.22

Helicopter Types
In order to safely and successfully complete a mission, the helicopter must be capable of meeting
the performance required for the mission (Table 28.1).

Preflight Briefing
Before any flight, or as soon as practical if involved in an urgent helicopter operation,
crewmembers should receive a passenger safety briefing by the pilot or qualified personnel. This
should include in-flight emergency procedures, location of the exits, crash positions, location of
the fire extinguishers, emergency fuel and battery shut-off switches, and instructions on how to
enter and exit the aircraft. Approach and departure paths from the aircraft should always be from
the downslope side, usually at 3:00 and 9:00 positions while crouching, not running, and one
should never approach the tail of the aircraft. Approaching and departing from an aircraft should
be discussed with the pilot or crew members before initiating either of these movements, as these
activities done improperly could lead to rotor contact with the human head.

Table 28.1 Type Specifications for Helicopters22

Useful Load at 59°F at Sea Max Gross Takeoff/Landing
Attributes Level (lb) Passenger Seats Weight (lb)
Type 1 5,000 15 or more 12,501+
Type 2 2,500 9–14 6,000–12,500
Type 3 1,200 4–8 Up to 6,000

Communication Onboard
Communication between flight crew members, medical personnel, and pilots within the same
aircraft is accomplished through a handheld radio plugged into a microphone jack and the
helmet/headset jack. Communication is key. A “sterile cockpit,” limiting communication over
the radio only to include essential communication, is employed to promote safety and decrease
accidents. The sterile cockpit is most valuable during takeoff, taxi, approach, and landing and
should be maintained unless a safety issue arises. Good situational awareness within the
helicopter is paramount and while flight personnel are not providing direct patient care or other
operational activities, all eyes should be outside of the helicopter, scanning their visual fields for
potential hazards such as birds, other aircraft, wires, fences, or trees. If a danger or hazard is seen
and has not been mentioned over the cockpit radio and affirmed by the pilot, it is the
crewmembers’ job to state what they see and where they see it in relation to the helicopter. Think
before transmitting and speak clearly, as communication of information needs to be received,
understood, and transmitted. If a communication was received and understood, the receiving
crewmember should reply with confirmation. It is imperative that all those on board a helicopter
can identify and mitigate flight and mission hazards and speak up when concerned. When
communicating with personnel outside an aircraft over very high frequency (VHF) radio, wait
for a period of silence on radio traffic, press to talk, state your identity and the message to be
communicated, then release the button and await a reply.
Hand signals are used when communicating with aircraft from the ground. An agency’s hand
signals should be understood by all who may be interfacing with that agency and should be
applied when necessary. Four simple hand signals are demonstrated in Figure 28.8.23

Mission Types
Mission-specific wilderness helicopter operations outside of the normal HAA spectrum may
include missions involving rappel, hoist, short-haul, low and slow swimmer deployment, and
unconventional landings such as single-skid, toe-in, and hover. These mission types and landings
expand the capability of the helicopter in the wilderness setting and may enhance safety,
efficiency, and effectiveness of the operation.
RAPPEL OPERATIONS

Rappel allows descent via static ropes to a controlled location rapidly. When ground evacuation
is dangerous, limited by distance or time, one can attach a rappel rope to the helicopter and insert
personnel quickly and cover long distances. A rappel bag is deployed from the helicopter and
uncoils before exit from the helicopter and descent is achieved with a rappel device over the
rope. Most commonly used in firefighting, it is available as an insertion operation in WEMS.
Rappelling requires a trained and qualified pilot, rappel spotter, and rappeller as well as
specialized rappel equipment. Line entanglement and emergencies can occur, and a spotter is
always present to instruct rappellers and communicate overhead to keep the operation safe, yet
they are prepared to cut the rope in the case of emergency.24
FIGURE 28.8. Hand Signals. Communication between ground personnel and pilot is often achieved through the use of hand
signals from the ground. Adapted from Hawkins SC, Simon RB, Beissinger JP, Simon D. Appendix B: how to communicate with
helicopters and preparations for helicopter evacuation. In: Vertical Aid: Essential Wilderness Medicine for Climbers, Trekkers,
and Mountaineers. New York, NY: The Countryman Press; 2017.

HOIST OPERATIONS
Hoist operations provide a controlled means of descent as well as ascent for patient extraction
and can be performed on land, in heavily forested terrain, and at sea. Hoisting from the
helicopter is controlled via a motor by a crew member or pilot, with the operator having access to
an emergency cable with cut capability in case of emergency. Operators must understand the
limitations (eg, maximum load, cable shear procedures, general control and function, emergency
procedures) of the rescue device being used during hoist operations. Rescue devices used to
perform a hoist operation include a climbing harness, jungle penetrator, stokes litter, rescue net,
or a rescue strap. The use of a tagline, deployed from the helicopter to surface personnel, should
be considered especially when hoisting with a stokes litter, to prevent pendulum or swinging
motion of the rescue device.
A climbing harness and sling with carabiner attached directly to the hoist cable is often the
most efficient means of insertion and extraction via hoist. A provider deployed with a climbing
harness is then able to properly assist or load patients onto an additional hoist rescue device (eg,
stokes litter, rescue net, rescue strap). A rescuer deploying via climbing harness as an attendant
alongside a patient in a stokes litter is called the barrelman hoist technique. The jungle penetrator
is capable of providing seats for three people and as its names suggests is capable of penetrating
heavily forested scenes but can be used in any land terrain and in water. The rescue net is a
stainless steel tube frame and polypropylene netting, is simple to deploy, and is thus a good
choice when patients are unfamiliar with the jungle penetrator or rescue strap. The stokes litter is
constructed of mesh and lightweight steel tubing that holds a survivor immobile in a supine
position. The rescue strap (“Horse Collar”) is a buoyant device constructed of fiber filling and a
waterproof cover attached around one’s chest to provide a harness that can be used on land and
water with up to three rescue straps deployed at one time depending on load calculations. Rescue
straps are less useful in the forested environment because they can snag on branches, and they
should not be used with injured patients because they provide insignificant cervical and spinal
support.
When performing a hoist operation, one must be aware of dangers that occur secondary to
excess slack, shock loading the device, static electricity buildup without touchdown of rescue
device and avoidance of touchdown neared spilled fuels, the potential for severe oscillations and
pendulum, and special considerations during night operations. Appropriate training before
performing hoist operations is necessary as improper application of any hoist rescue device can
result in fatality (Figure 28.9).24
SHORT-HAUL OPERATIONS
Short-haul is a technique of transporting personnel beneath a helicopter while suspended on a
fixed rope and permits insertion and extraction from a site where a helicopter could not typically
land. In comparison with a prolonged hover time during rappel, short-haul technique limits hover
time and can be used for insertion of rescuer and extraction of rescuer and patient.
Spotters and short-haulers are an essential component of the team in conjunction with
qualified pilots when performing short-haul operations. These team members are knowledgeable
regarding inspection and care of equipment, rigging and safety checks, emergency procedures,
and loading short-haul personnel with and without cargo (eg, a rescue litter) and have the ability
to work with the pilot and understand risk assessment and mission structures. Spotters should be
located in the aircraft and on the ground during short-haul operations with clear communication
with the pilot throughout the operation. The spotter communicates the status of the short-hauler
with the pilot throughout the operation while the short-hauler follows standard operating
procedures for this operation. The spotter and the short-hauler can communicate with each other
via hand signals that are well established and predetermined.

FIGURE 28.9. National Park Service rangers practice hoist operations with the jungle penetrator inside a CH-47. Courtesy of
Brian M. Scheele.
FIGURE 28.10. Short-haul preparation at Camp Muir, Mount Rainier National Park. Courtesy of Peter Ellis.

Short-haul equipment include anchoring systems, ropes, harnesses, patient extraction

equipment, carabiners, and a knife. All components of this equipment have various regulatory
agencies that set standards for their manufacturing and use and should be understood before use.
Risk assessment is a subjective ongoing analysis of hazards to arrive at a go/no-go decision
while attempting a short-haul rescue. All personnel involved in the operation play a role, with the
pilot retaining the final authority when safe operation of the aircraft is a factor (Figure 28.10).25
DANGERS OF RAPPEL, HOIST, AND SHORT-HAUL OPERATIONS
Line entanglement can become fatal in either rappel, hoist, or short-haul operations. Special care
should be made with proactive planning to avoid the lines or a hook from a hoist attaching to a
fixed object on the ground. The hoist operator in the helicopter or the spotter during a short haul
or rappel should maintain a visual reference with the hoist, short-hauler, or rappeller at all times
during flight. A redundant cable cutter system should be in place in case of emergency, with one
controlled electronically by the pilot and one controlled manually by the spotter or hoist
operator.
FREEFALL SWIMMER DEPLOYMENT (LOW AND SLOW DEPLOYMENT)
Freefall swimmer deployment is a method of delivering a rescuer, litter, or equipment to a person
or location in the water. This requires specialized gear and training. Freefall deployment from a
helicopter is ideally performed 10 ft above water level at 10 knots and a rescuer exits without
force from the side of the aircraft into the sea. Visibility before deployment, communication
within the helicopter, timing of helicopter exit, and exit body position and water entry procedure
must be well understood.24
SAR OPERATIONS
It is important to understand the general tactics of aerial SAR. SAR operations include
environments such as wilderness areas (Chapter 30), open oceans (Chapter 27), swiftwater
(Chapter 26), deserts, caves (Chapter 29), and mountainous terrain (Chapter 31). Terrain may
determine the type of search pattern needed. Grid-based searches promote uniformity yet
repeated searches of an area are almost always necessary to increase the cumulative probability
of success as differing terrains or tree coverage alters the probability of detecting your search
subject. Aerial SAR operates quite differently: the terrain has much less impact on the search
strategy as searchers are flying over the terrain rather than moving through it. Civilian, military,
and federal agencies have qualifications regarding being a crew member on an aircraft when
conducting SAR.
STEP: SINGLE-SKID, TOE-IN, HOVER, EXIT/ENTRY PROCEDURE
Unconventional helicopter landings are occasionally needed when operating in the wilderness
environment and may include toe-in, hover, or one skid/wheel landings. Unconventional
landings require training, commonly known as STEP (single-skid, toe-in, hover exit/entry
procedure) training, and usually require authorization before application in the field unless in
life-threatening circumstances. Single-skid landing is a maneuver where one skid touches down
on the ground while the other remains above ground on steep terrain while the rotor system
maintains power. Toe-in landing is when the front part of the skids or the toe contacts the landing
surface due to uneven ground while still maintaining rotor clearance. Hover exit/entry is exactly
as the name suggests: in a hover, the helicopter remains relatively stable over a given point
without moving horizontally or vertically, and personnel must exit or enter via use of the skid.
This must be done with good verbal and nonverbal communication with the pilot.22

Medical Integration
ATV/UTV Medical Integration
ATV/UTV use is not always used for EMS response primarily. A vehicle and its cargo may be
prepared for fire or law enforcement missions, so the WEMS provider must consider their EMS
equipment and SAR equipment when preparing for a mission or rescue.
EMS equipment may include straps and foot supports or a sked, a backboard with head
immobilizer, cervical collar, medical and trauma bags and oxygen equipment, an automated
external defibrillator (AED) or cardiac monitor, any additional ALS equipment (if operating at
an ALS or clinician level), splints and other fracture management equipment, as well as body
heat conservation blankets.
SAR equipment may include water for adequate hydration and high-energy-concentrated
food supply for operator, passengers, and patient for the duration of the mission. Additionally,
shelter material (eg, ponchos, cold weather gear, tents, etc.), topographic maps with compass
and/or battery-powered GPS device, radio communications for each team member with extra
batteries, flashlights, whistle, color-coded strips for trail marking when going off trail, and a
shovel or folded-entrenchment tool.
The major point about both EMS and SAR equipment discussed in the context of ATV/UTV
use is that much heavier or bulkier equipment may be carried than might be feasible for a team
depending on carrying all its own equipment. For example, as discussed in Chapter 22, a cardiac
monitor might seem excessive for a backpack-based SAR team, but might be very reasonable for
a SAR team utilizing ATVs or UTVs during their insertion.
WEMS operations where ATV/UTV use may be beneficial include:

search for lost persons on or adjacent to trails, in woods, fields, desert, or tundra;
search for and accessing victims lost while climbing;
subjects involved in ATV, snowmobile, or other off-road vehicular accident; and
subjects involved in aircraft accident.

Searching personnel must be aware of signs or tracks left by lost individuals, occasionally
turn off the vehicle motor to listen, and shout or whistle for lost persons. Once lost persons have
been located, the personnel must secure the area and either establish incident command or report
findings to the incident commander if already established. ATV/UTV operators during SAR and
EMS deployment on steep terrain must remember to avoid crossing the sides of steep hills when
possible and avoid operating on grades of greater than 15 degrees. Operators should remember to
climb straight up steep hill at slow and steady speeds and descend steep hills by proceeding
directly downhill while applying the brakes slightly just enough to maintain control and avoid
descending at an angle. Operators should consult owner’s manual for more details on uphill and
downhill travel.
When faced with water crossing, the operator should communicate with the command
structure for guidance before crossing. The operator should determine the depth and current and
know that the ATV/UTV can only cross water up to their floor boards unless specifically
designed for such crossing (eg, ARGO). Once command structure has given permission for the
crossing, proceed slowly and avoid rocks or obstacles. Be aware the flotation tires may cause a
vehicle to float in fast-flowing water (see Chapter 16 for more details regarding vehicle
submersion management). Complete immersion in water can cause problems for some ATV and
UTVs, and understanding a vehicle’s capability in water before deployment is recommended.

Helicopter Medical Integration

Providing effective medical care within a helicopter can be challenging. Equally or more
challenging is caring for a patient as an attendant on an externally loaded litter or a screamer suit
during a short-haul rescue or hoist operation. Packaging of patients must be well practiced before
application in the field, and special care dedicated to patient safety and comfort is especially
necessary when providing medical operations in conjunction with helicopters. Patient and
equipment must always be secured, and a verbal check overhead conducted before takeoff and
landings.

Checklist and Preflight Considerations

Familiarization with medical equipment and checklists before takeoff must be completed for
safety and consistency. Respect for the unique forces and sensations experienced by a patient
while airborne should be considered before flight. Altitude changes influence a patient’s
physiology and EMS equipment, and a recognition of these facts should be well understood to
avoid complications in care.

Patient Transport and External Loads

Patient must be secured within the helicopter or within an external device as they were designed.
Most helicopters designed for patient transport have a horizontal orientation for the patient. In
certain helicopter evacuations from the wilderness, a nontraditional helicopter may be used, and
an improvisation may need to be made to the traditional horizontal patient arrangement. The
rescuer must be aware of what helicopter resources are available before packaging a patient or
risk the need to repackage. While packaging a patient into a helicopter, the provider must check
all necessary equipment (eg, intravenous access, suction, oxygen, ventilator, etc.) and ensure
proper positioning and functioning before takeoff. In-flight setup or adjustment may be
challenging or impractical. When it is necessary to transport a patient externally from the
helicopter, or to raise a patient via external means, redundant systems must be used.
The checklist and familiarity with one’s equipment is paramount to success under duress. If
responding to a patient via helicopter, all needed equipment on the helicopter must be thoroughly
evaluated and checked for function (eg, plugged-in, battery charged, meds screened for
expiration) before flight. If you are caring for a patient in the wilderness and a helicopter is
responding to aid in evacuation, it is the responsibility of the provider to communicate updates
on the patient’s assessment so that needed patient care resources are available upon the
helicopter’s arrival.
The physiology of flight and the inherent challenges of gravitation and vibratory sensations
within a helicopter will have effects on patients and should be considered before takeoff.
Helicopters by nature vibrate, create noise, and exert gravitational or g-force on their occupants.
As mentioned earlier, altitude and changes in altitude alter the physiology of a patient and the
function of EMS equipment.
G-force, vibration, and movement during flight can cause vertigo, nausea, and vomiting.
Considerations about preemptive antiemetic therapy and patient positioning before takeoff
should occur. Airflow and wind within the helicopter cabin mixed with vomitus will likely
become undesirable quickly, and vomiting may compromise your patient’s airway. The effects of
vibration on a patient packaged on a long spine board may worsen a patient’s respiratory status
and cause pain or ulcers. For this reason, among others, long spine boards are not felt to have a
role in WEMS operations, as discussed in more detail in Chapters 21 and 24. Vibration and
movement can also dislodge monitoring equipment and IV lines or potentially dislodge a clot.
Noise within and around helicopters can be significant. Verbal communication with a patient will
likely become nonexistent after the flight has begun and ear protection, even in unconscious
patients, should be considered. G-force, vibration, movement, and noise within a helicopter can
cause psychological distress, fear, anxiety, or agitation in a patient. Psychological distress can
become dangerous in the confined space of a helicopter cabin, and restraining or sedating
patients should be considered before takeoff.
Altitude and changes in altitude cause physiologic changes in the human body, in the
environment, and on equipment we use as medical providers. Altitude illness is discussed in
more detail in Chapter 15. Here, we specifically discuss how changes in altitude during flight
may affect a WEMS provider’s care.
When descending from higher altitude to lower altitude, the air becomes “thicker” and the
partial pressure of gases (eg, oxygen) rises. In addition, the volume of gases becomes more
“compact” upon descent from altitude. Treatment of some high-altitude illnesses may be cured
simply by descent to a lower altitude, and the increase in atmospheric pressure and partial gas
pressures alone may aid in this resolution of symptoms. The volume of gases decreases as one
descends to lower altitudes, and therefore gas-filled containers may decrease in size. The cuff on
endotracheal tubes (ETTs) may decrease in volume and accidental extubation becomes a
concern. This can be mitigated by filling the cuff with saline instead of air.
When ascending from low to high altitudes in circumstances such as the need to ascend over
a mountain pass or fly above dangerous weather, the partial pressures of gases decrease, the
volume of gas-filled containers increases in size (if the container is malleable), and the
temperatures drop. The decrease in partial pressures of oxygen is altitude dependent, and the
higher the mountain pass the greater the decrease in the partial pressure of oxygen. Continuous
oxygen saturation monitoring should be standard. With ascent to altitude, the FIO2 will not
change but the PaO2 will decrease. Gas trapped in body cavities will expand as altitude increases.
Pathologic gas collections such as pneumothoraces, air embolism, or pneumomediastinum may
expand and worsen physiology during flight. As discussed in Chapter 17, the nitrogen bubbles of
decompression sickness after scuba diving may worsen with increases in altitude. Any gas-filled
container such as the ETT cuff may expand or even rupture—in the case of the ETT cuff, this
situation has the potential to cause endotracheal injury. IV tubing should be placed on a
mechanical pump while in flight as changes in air volume may alter the rate of infusion.
Equipment such as air splints will expand and may cause pain or change shape during ascent and
may need adjustment or deflation. Temperature decreases by 2°C (3.5°F) with each 1,000 ft in
elevation gain, and care should be taken to keep patients warm.

IMPLICATIONS FOR PRACTICE LEVELS

Medical education regardless of level provides each WEMS provider with a certain degree of
expertise. Providers’ experiences are all unique from training onward into the practice of
medicine. They feel a certain comfort or appropriate discomfort with their patients’ pathology,
injury, or illness. Yet when the wheels begin to turn in an ATV or UTV, or the sounds and
vibration of helicopter blades are felt, it is imperative to remain calm and deliberate in the
practice of medicine. Simply because providers feel the need to act and perform their skill set
does not automatically mean they must do so. In the wilderness setting, with powerful machines,
all level of providers must decide what medical interventions are necessary and choose those.
The care being delivered in the wilderness can be lifesaving yet it remains austere. Although
access to an engine can be advantageous, the interventions begun in the wilderness must be
maintained until a patient is transported to definitive care. The WEMS provider’s job is
ultimately to get them there.

First Aid
The practice of first aid is generally unchanged despite methods of patient transport, unless the
presence of a vehicle makes the availability of heavy or bulky equipment like an AED more
likely. Recognition of the presence or absence of vital signs; application of cardiopulmonary
resuscitation (CPR) and AED use; recognition of shock, anaphylaxis, heart attack, stroke, or
hypothermia; and applying pressure to sites of bleeding can be addressed on scene. After
immediate first aid is applied, a communication up the command structure will enable future
planning to address evacuation. It may be that a patient needed first aid and can now be
transferred without additional medical care. It may be decided that immediate patient evacuation
after the application of first aid is the next best step, and transport via ATV/UTV or helicopter or
another means of transport is best suited for the operation. The value of the application of first
aid is the ability to provide potentially lifesaving care and then communicate that information to
the formal WEMS providers who subsequently arrive. In that sense, training first aiders who are
not otherwise EMS providers trained in basic helicopter operations and communication is a
useful public health intervention for a WEMS system. Examples of such general, first aid
audience education exist in both the paddling27 and climbing23 literature.

Basic Life Support

Basic airway clearance and positioning, patient assessment, vital sign assessment, CPR
administration, AED use, recognition of medical emergencies, wound management, and the
prevention of hemorrhage can all be accomplished at the scene regardless of transport option,
unless vehicles such as off-road vehicles, ATVs/UTVs, or helicopters have provided the
availability of more equipment and resources than might normally be available. However, BLS
providers are trained to transport patient most commonly via traditional ambulance. Transport
via ATV/UTV, off-road ambulance, or helicopter requires basic vehicle technical knowledge,
safety considerations, vehicle-specific patient packaging skills, airway and cervical spine
considerations, patient monitoring, hemorrhage control, proficient patient assessment skills, and
the ability to relay that assessment up the chain of command to aid in decision making about the
progression of the operation.
ATV/UTV/helicopter technical knowledge and safety awareness can be gained in brief in the
above technical sections, and a formal agency-specific education should be completed before
their use by a BLS wilderness provider. ATV/UTV or helicopter patient packaging equipment is
discussed in Chapter 24. Lifesaving care should be applied whenever indicated as in any BLS
response.
The most valuable consideration for the wilderness BLS providers is an accurate evolving
patient assessment and their ability to communicate this information up the chain of command.
The wilderness BLS provider’s evolving assessment will determine whether a patient is stable
for BLS transport via ATV/UTV/helicopter or if ALS is necessary for transport. The decision is
similar to decisions made in the urban setting, yet in the wilderness distance may be greater,
terrain may be more difficult to cover, or the injury or illness may be appropriately determined
stable and a helicopter evacuation’s risks may be determined to outweigh the benefits.
 Wilderness BLS skills in combination with ATV/UTV/helicopter evacuation remain the
foundation for all advanced practitioners of wilderness EMS. Technical, equipment, and safety
knowledge are necessary, but BLS skills and patient assessment with good radio communication
are paramount during a WEMS response.

Advanced Life Support

The wilderness ALS provider introduces a new level of sophistication and skill sets when
transporting patients via off-road vehicles or by helicopter. As in wilderness first aid or BLS
provision of care, the ALS provider must possess the needed technical and safety knowledge
plus familiarity with ALS equipment to operate in and around ATVs/UTVs/helicopters. With
additional skills comes increased responsibility and complexity to decision making. Certain
interventions must be considered before patient transport via ATV/UTV/helicopter for patient
and crew safety, but with the recognition that once an ALS intervention has taken place its need
for maintenance will likely remain throughout the operation.
Once technical and safety knowledge is gained and ALS equipment is accounted for and
checked, the first thought of the ALS provider in the wilderness should be “how can I provide
BLS care well.” If appropriate care can be provided, and the patient and the vehicle crew remain
safe, expert practice of BLS decreases the complexity of the ATV/UTV/helicopter transport.
Patient and risk assessment may deem that ALS interventions are needed to decrease risk for the
patient and the crew. The decision to intubate before transport may be lifesaving for the patient
and the crew, especially before flight. Intubation during transport while in a moving vehicle
(ATV/UTV) or in a confined space (helicopter) may prove challenging or fatal. Intubation when
clinically indicated is an easy decision. When clinical assessment concludes that the patient may
deteriorate during flight, intubation should occur before takeoff. When a patient is combative or
suffering from psychosis, sedation (eg, ketamine) should be pursued with appropriate dosage and
continued maintenance during flight and restraints applied.
Preparation before takeoff includes making the decision about if and when to intubate the
patient or secure the patient’s airway by other means. A patient who is rapidly deteriorating may
benefit from intubation, and this decision may make the entire crew safer during transport. An
alternative to intubation in some cases before takeoff may be the use of sedation, notably
ketamine administration, as an aggressive patient in flight is a danger to the entire crew and the
flight operation as a whole.

Clinician
The clinician and the ALS provider have similar roles when providing care in the wilderness
setting during ATV/UTV or helicopter operations. The extended role of the clinician as medical
director or as a fixture within the Incident Command System (ICS) structure as part of a unified
command imparts the responsibility of operational decision making.
When multiple transport options are available, medical direction should decide which
method offers the greatest benefit-to-risk ratio. The patient assessment, either obtained on scene
or obtained by communication with first aid, BLS, or ALS wilderness provider, should be
incorporated into the entirety of the scenario of the operation with considerations regarding the
duration and difficulty of conventional evacuation, provider and patient safety, current and
projected environmental hazards, personnel and available transport modalities, and transport time
to definitive care.26
SUMMARY
Off-road vehicles and helicopters provide greater access to our patients when terrain, weather,
distance, or time limits their access by traditional means in the wilderness environment. High
standards for formal education, continued training, and the practice of risk management during
all nontraditional vehicle WEMS operations is fundamental to positive patient outcomes and the
safety of the wilderness EMS provider.

References
1. United States Consumer Product Safety Commission. State ATV information. Available at: https://www.cpsc.gov/Safety-
Education/Safety-Education-Centers/ATV-Safety-Information-Center/State-ATV-Information/. Accessed December 2016.
2. Wilde ET. Do Emergency medical system response times matter for health outcomes? Health Econ. 2013;22:790-806.
doi:10.1002/hec.2851.
3. Hawkins SC. The Green Machine: development of a high-efficiency, low-pollution EMS response vehicle. J Emerg Med
Serv. 2008;33:108-120.
4. Worley GH. Civilian Helicopter Search and Rescue Accidents in the United States: 1980 through 2013. Wilderness Environ
Med. 2015;26(4):544-548. doi:10.1016/j.wem.2015.08.001.
5. Federal Aviation Administration. Press Release—FAA issues final rule to improve helicopter safety. February 20, 2014.
Available at: https://www.faa.gov/news/press_releases/news_story.cfm?newsId=15795. Accessed December 2016.
6. Pre-Flight risk analysis. Title 14: Aeronautics and space. Operating requirements: commuter and on demand operations and
rules governing persons on board such Aircraft, 14 C.F.R. §135.617; 2014.
7. Imlay M. Utility task vehicles by the number. Specialty Equipment Market Association News, July 2014.
8. National Search and Rescue Plan of the United States. U.S. National Search and Rescue Committee (NSARC). May 2007.
9. Land Search and Rescue Addendum to the National Search and Rescue Supplement to the International Aeronautical and
Maritime Search and Rescue Manual, Version 1.0. U.S. National Search and Rescue Committee (NSARC). November
2011.
10. 2014 Annual Report of ATV Related Deaths and Injuries. Consumer Product Safety Commission USA. November 2015.
11. Helmkamp JC, Aitken ME, Graham J, Campbell CR. State-specific ATV-related fatality rates: an update in the new
millennium. Public Health Rep. 2012;127(4):364-374.
12. Helmkamp JC, Biddle E, Marsh SM, Campbell CR. The economic burden of all-terrain vehicle related adult deaths in the
U.S. workplace, 2003-2006. J Agric Saf Health. 2012;18(3):233–243.
13. Safety Standard for Recreational Off-Highway Vehicles (ROVs); Proposed Rule. Consumer Product Safety Commission.
Fed Reg. 2014;79(223):16 CFR Part 1422.
14. Brady M. Standard Operating Guidelines (SOG) for Using All-Terrain Vehicles (ATV) and Utility Trail Vehicles (UTV)
with All Terrain Res-Q (ATR) Trailers During Off-Road Search and Rescue (SAR) Missions and/or Medical Evacuation
Operations. Available at: www.offroadrescue.com. Accessed May 2016.
15. ATV Safety Institute. T-CLOC Preride inspection checklist. Available at: http://www.atvsafety.org/downloads/tcloc.pdf.
Accessed December 2016.
16. United States Department of Agriculture. Utility-Terrain Vehicle Operator Training Course: Instructor’s Guide. Missoula,
MT: USDA Forest Service; 2011.
17. Hawkins SC, Morgan S, Waller A, Winslow T, McCoy M. Effects of ground EMS and ED personnel on air medical trauma
on-site times. Air Med J. 2001;20(3):32-36
18. Airborne Search and Rescue Standards, Version 1.2. Public Safety Aviation Accreditation Commission. March 2015.
19. Basic Aircraft Safety. Department of the Interior, Office of Aviation Services. May 2013. Available at: www.iat.gov.
Accessed December 2016.
20. Interagency Aviation Training Course S-271: Helicopter Crewmember—Instructor Guide, 2010-12, Unit 5: Helicopter
Performance, Limitations, and Load Calculations. Department of the Interior, Office of Aviation Services. Available at:
www.iat.gov. Accessed December 2016.
21. Aircraft Weight and Balance Handbook. US Department of Transportation, Federal Aviation Administration, Flights
Standard Service. FAA-H-8083-1B. 2016.
22. Interagency Helicopter Aviation Guide. National Wildlife Coordinating Group, National Interagency Aviation Committee.
Available at: http://www.nwcg.gov/. Accessed June 2016.
23. Hawkins SC, Simon RB, Beissinger JP, Simon D. Appendix B: how to communicate with helicopters and preparations for
helicopter evacuation. In: Hawkins SC, Simon RB, Beissinger JP, Simon D, eds. Vertical Aid: Essential Wilderness
Medicine for Climbers, Trekkers, and Mountaineers. New York, NY: The Countryman Press; 2017.
24. United States of America, Department of the Air Force. Pararescue operations, techniques, and procedures. Available at:
http://afpubs.hq.af.mil. Accessed November 2009.
25. Helicopter Short-Haul Handbook (351 DM1). U.S. Department of the Interior. Available at: www.iat.gov. Accessed
February 2010
26. Phillips K. Helicopter operations (Chapter 25). In: Rodway G, Weber D, McIntosh S, eds. Mountain Medicine & Technical
Rescue. Carreg; 2016:415.
27. Bechdel L, Ray S. River Rescue. A Manual for Whitewater Safety, 4th ed. Asheville, NC: CFS Press; 2009.
INTRODUCTION
This chapter provides an overview of cave search and rescue for those who practice wilderness
EMS (WEMS), supervise WEMS providers, or are interested in WEMS but not trained members
of a cave rescue team.

Definition
Cave rescuers divide search and rescue into cave rescue and aboveground rescue (any and all
rescue that isn’t cave rescue). In particular, we must distinguish between mine rescue and cave
rescue. Mines are human-built industrial structures. While caves and mines may both be
underground, the environment and hazards and techniques are almost completely different. Mine
rescue teams and urban search and rescue teams have much more in common than mine rescue
teams and cave rescue teams. However, cave rescue and aboveground wilderness search and
rescue have much in common.

Scope of Discussion
Eighty percent of the skills and knowledge of cave rescue and aboveground wilderness search
and rescue overlap. However, that remaining 20% is critical, and this chapter will provide an
overview of it. The primary differences fall into the following categories:

the cave environment and hazards

caving and cave rescue sociology and politics
navigation and communications
specific cave rescue techniques

Care Environment
Caves Are Dark
This may seem one of those “duh” statements, but a fair number of cave rescues simply consist
in escorting out people whose light sources have failed. Cavers are taught to always carry three
independent sources of light that will support hands-free caving. (Candles are nice for warmth,
especially if inside a plastic leaf-bag heat tent, but purists decry counting them as a third source
of light.)

Caves Are Cold

Caves are cold or warm, depending on the season. Although it seems that way, in reality, it’s
aboveground that gets hot and cold, whereas caves are the same temperature year-round. Yes,
there are a few exceptions, such as the ice caves at the top of Mount Rainier, and Warm River
Cave in Virginia that’s famous for its hot spring. But the majority of caves have developed from
thousands of years of water dripping or flowing through water-soluble rocks such as limestone,
and the caves are at the temperature of the surrounding limestone, which is the average
temperature of the area (Figure 29.1).

Caves Are Wet

There are exceptions—“dead” caves that no longer have water flowing through them—but again,
in general, caves have water dripping or flowing through them.
The fact that caves are wet and cold means that there is always the danger of hypothermia.
Even if it’s 95° and 95% humidity outside, it’s still wet and cold inside the cave. While this may
seem another “duh” observation, it is not at all uncommon for spelunkers to go in the cave and
then become hypothermic. The hypothermia causes clumsiness, and sometimes poor judgment,
causing a spelunker to suffer an injury. It is also possible, especially in wet caves, for spelunkers
who are unprepared to be totally incapacitated or die from hypothermia. See Chapter 13 for more
details on hypothermia and cold illnesses.
FIGURE 29.1. Mean Annual Temperature (°F), North America, 1981–2010. Almost without exception, cave temperatures are,
year-round, the average temperature of the area. This map depicts the temperature you may expect in a cave in a particular
geographic area of the United States. (Map produced by DonaldFerguson, Ph.D, based on data from: AdaptWest Project. 2015.
Gridded current and projected climate data for North America at 1km resolution, interpolated using the ClimateNA v5.10
software (T. Wang et al., 2015). Available at adaptwest.databasin.org.)

Caves Are Dirty and Muddy

Aboveground can be dirty and muddy, but the mud in caves is of an entirely different magnitude,
and as Josef Stalin reportedly once said: “Quantity has a quality all its own.”3 Cavers tend to
wear full body coveralls, either surplus flight suits or mechanics’ coveralls or specially made
cave suits. Coveralls keep the mud from sneaking in around the waist of a jacket/pants
combination. Coveralls, especially those specifically made for caving, also make it easier to twist
your body into the various contortions required while traversing cave passage. Having mud all
over your boots makes you more likely to slip and fall and break an ankle, and while this
sometimes happens aboveground, in caves, muddy boots are the rule rather than the exception.

Caves Are Enclosed

That means that to efficiently traverse a cave, you must use different parts of your body and
different techniques than either climbing or hiking. Counterforce techniques, where you have an
arm or a leg on either side of a small passage, are much more common and using them
effectively takes practice (Figure 29.2).

Caves May Be Vertical

Cavers tend to divide caves into horizontal caves which require neither ropes nor special vertical
equipment, and vertical caves which require them. Unlike rock climbing, where the emphasis is
on lead climbing where you are dependent on your hands and feet to move up the rock, and the
rope is only there for a belay, cavers tend to go down rather than up. Therefore, they tend to
rappel into a cave, and when coming out, simply ascend the rope. Therefore, for cavers, the
emphasis is on what is called single rope technique (SRT): rappelling and ascending. Indeed,
most of the innovations in single rope technique that have moved over into mountain rescue were
developed by cavers (see, eg, our Chapter 31, which does indeed refer to SRT during certain
mountain rescue operations).

FIGURE 29.2. Tight Passage during Cave Rescue. Using counterforce techniques efficiently and smoothly in narrow canyon-
like passages is an important physical skill for cavers to develop, to avoid exhaustion. Crawling through tight passages without
wasted effort or injury also requires practice. For cave rescue, moving litter patients efficiently through canyons and tight
passages is also an important physical skill. Courtesy of Bill Frantz, NSS 11706, used with permission.

Caves May Be Confusing

There is a reason the first text-based computer adventure game, also known as Colossal Cave,
featured the phrase “You are in a maze of twisty little passages, all alike.” Standard instruction
for beginners on cave trips is to look over their shoulders at every intersection, to see what the
intersection looks like on the way back. Navigation in caves is much different than navigation
aboveground. Topographic surface maps and cave maps are almost completely different in all
respects (Figure 29.3). And, for many caves, no cave maps are available. And even for those
caves where cave maps are available, cavers’ emphasis on secrecy keeps these maps restricted;
cavers may even be reluctant to release such maps to cave rescue teams. The map reproduced in
Figure 29.3 is of a commercial (guided-tour), gated cave.

Caves Are Remote

Even if the entrance to the cave is near the road, rather than halfway up the side of the mountain,
once you enter the cave, it becomes remote. Even a short way into the cave can seem very
remote, given that cell phones do not work in caves. Therefore, getting word back out to initiate
a rescue effort can take a long time. For cave rescuers, this can be a big problem, since standard
search and rescue radios do not work in the cave either. There are a few radio systems that can be
used between the surface and deep in the cave, but for the most part these are experimental and
are very large and bulky or only work with Morse code. These are not routinely used for cave
rescue. Instead, cave rescue teams usually use military surplus field phones. Learning how to set
up, use, maintain, and fix these field phones is an integral part of cave rescue training.
FIGURE 29.3. Map of Laurel Caverns Pennsylvania. Navigating in a cave is very different from navigating in an
aboveground wilderness area: completely different navigation skills must be developed. Cave maps, when they are available, are
very different from aboveground topographic maps. Laurel Caverns is a commercial cave with guided tours. Courtesy of Vic
Schmidt and David Cale for Laurel Caverns, used with permission.

Caves May Have Bad Air

Unlike mines, there are very rarely any sort of explosive gases, but carbon dioxide buildup can
be suffocating, and oxygen can be depleted. This is relatively rare, but the author was once in
Ireland to teach at a cave rescue conference and was invited to go on a trip to the most famous
cave in Ireland, Polnagollum. The translation of the name is “the cave of the doves.” It’s a river
cave with lots of small sinkhole entrances. The plan was to go into one of these potholes, get up
into an upper-level dusty crawlway to another part of the stream passage, then wade the stream
passage back to the entrance. As I was crawling through that dusty passage, at the end of the
group, I started breathing heavily. Is it my asthma acting up? No, I only get an asthma attack
when I’m sick, and I’m not wheezing. Maybe I was just jet-lagged? Perhaps. Breathing harder
now. Oh, no, maybe I’m claustrophobic and I’ll never be able to go caving again! We got out
into the main stream passage and I started breathing easier. I mentioned this to the Irish cavers.
“Oh, didn’t we tell you? There’s no air circulation in that passage and the last person through
doesn’t get much oxygen.” Hmph. There was a rescue at Keyhole Cave near Albany, NY in
1998.1 A caver was trapped by his leg in a narrow part of the keyhole passage. There were so
many people in the cave, and they were there for so long, that the CO2 started building up. They
had to start pumping fresh air into the cave.

Caves May Flood

As with the famous slot canyons of Zion National Park and surrounding areas, such as The
Subway and Zion Narrows, the weather above can be sunny and dry, but a large thunderstorm in
a remote region of the watershed can cause the area to flood, making some passages impassable,
or even drowning a group of spelunkers. Most cave passages do not flood; clues to a passage that
does flood include leaves, sticks, and other debris high up on passage walls, or mud lines along
the walls indicating the top of the most recent flood.

Caves Are Delicate

Formations that have taken tens of thousands of years to develop, and are found only in one
particular cave, can easily be destroyed by a careless rescuer. Cavers tend to be fanatic
conservationists, buying deeply into the Leave No Trace4 movement. They even sometimes
argue with the traditional motto of “take nothing but pictures, leave nothing but footprints, kill
nothing but time” because they think that there are sections of caves where there should be no
footprints. In recent years, the bat population throughout North America has been decimated by
white nose syndrome, a deadly fungal infection. Bats like to hibernate in caves, and disturbing
bats while they are hibernating makes them more susceptible to dying from white nose
syndrome. Many caves are gated to keep out casual visitors and permit the landowner to screen
those entering the cave; for caves known to be bat hibernation sites, the gates may be closed all
throughout the bat hibernation season. Even outside of that hibernation season, cavers emphasize
the need to decontaminate caving gear so as not to bring white nose syndrome into the cave.

Caves May Be Psychologically Stressful or Downright Scary

Most people joining a wilderness search and rescue team are those who are comfortable in the
outdoors, and in general are people who really enjoy being in the great outdoors. For some of
these people, going into the cave is just an extension of the great outdoors. But for some, even
those without claustrophobia, a cave is not the kind of outdoors in which they are comfortable.
And being comfortable in the environment is important to top performance. Some mountain
rescue teams are also cave rescue teams, for example the Allegheny Mountain Rescue Group
(AMRG). AMRG expects all of its members to meet not only Appalachian Search and Rescue
Conference standards for Field Team Member and Field Team Leader certification, but also the
more stringent Mountain Rescue Association (MRA) standards. However, meeting the cave
rescue standards, and going into a cave, is quite optional. For any large cave search or rescue
operation, there are plenty of jobs that need to be done aboveground, not just in the coordination
sense, but also things such as rigging the evacuation route from the cave entrance to the road or
helicopter landing zone. More discussion of management of psychological stressors in both
rescuers and patients, and the use of psychological first aid, is included in Chapter 10
(Psychological First Aid) and Chapter 23 (Management of Behavioral and Psychiatric
Emergencies).

Caves May Collapse

There are plenty of reasons for people to fear caves that are listed above, but one of the biggest
ones isn’t in that list: the fear of all that rock and earth above you and the feeling that at any
moment the cave passage may collapse, squishing you like a bug underfoot. As you walk (or
climb or crawl) through a cave, you can see evidence of this: large blocks of limestone that have
broken off the roof of the cave and deposited below. While this is an ever-present danger to
novice spelunkers, experienced cavers don’t worry about this much if at all. Yes, such collapses
certainly occur, but only once every 10,000 years or so. Indeed, most cavers get a comforting
feeling from all that stuff above them protecting them from actually dangerous things like trees
falling on you from a strong wind; there’s a reason that standing dead trees are called widow-
makers.

Cave Rescue Teams and Organizations

Within the search and rescue community in the United States, we speak of cave rescue, not cave
search and rescue, and not cave search and recovery. Perhaps that is because, unlike on the
surface, rescue tends to dominate over search, in terms of the number of occurrences and number
of cave rescuers a large operation uses up. Perhaps this is also because the leading U.S. national
cave rescue organization is called the National Cave Rescue Commission (NCRC).*
It is worth considering NCRC’s role in cave rescue. The NCRC is an internal organization of
the National Speleological Society (NSS). The NSS is the U.S. national organization of cavers
and cave researchers. If you look at the top of the NSS’s website “About” page, it says “we
explore; we study; we protect.” The NSS also produces a unique social aspect of U.S. caving: the
NSS number. When a caver joins the NSS, he or she is issued a unique number. It is not entirely
clear why this should be so, or why NSS numbers seem to be important to NSS members, but
there it is. Having a lower NSS number seems to carry some prestige, so cavers tend to join the
NSS when young, and often can recite their NSS number from memory if asked. Cavers often
identify themselves in publications and communications with their NSS number; see, for
example, the author byline for this chapter includes such a use, as does references to individual
cavers in most of the text and figures.
A local chapter of the NSS is called a Grotto, and most of the respectable caving groups in
the United States are Grottoes of the NSS. Given the most useful resources for any cave search
or rescue are experienced cavers, those with formal cave rescue training are even more valuable.
Most Grottoes and other cave clubs have a callout roster of cavers who are available for cave
rescues. For instance, in the author’s area, the Loyalhanna Grotto and Pittsburgh Grotto support
the AMRG by having rosters of cavers available to respond with AMRG for cave rescues.
Another feature of the caving community is worth mentioning: secrecy. Cave formations
(stalactites, stalagmites, columns, flowstone, rimstone, and the like) take tens of thousands of
years to form. Seconds of vandalism can ruin these priceless natural wonders forever. Therefore,
the locations of most caves are closely guarded secrets. Asking cavers for a cave location will
usually result in silence and a hostile stare. If, however, you mention your (preferably low) NSS
number to them, the expressions will mellow a bit and perhaps—just perhaps—the cave location
will be forthcoming.
Excerpts from the NCRC’s charter2 provide an insight into cavers’ attitudes toward cave
rescue:

1. To act as spokesman for the Society regarding cave rescue. (It shall be understood that it is
the policy of the Society to maintain a low profile during rescue operations to the extent
possible and to avoid bringing awareness of ongoing rescue activities to public notice.)
2. To serve as a technical resource for the Society on matters of cave rescue.
3. To develop and maintain a professional level liaison with federal, state, and local authorities
whose resources or mission may affect cave rescue. In addition, to develop and maintain an
active liaison with organizations interested in cave rescue.
4. To develop a national standard curriculum in cave rescue operations and systems for the
Society members.
5. To develop certification standards for NCRC Instructors to provide qualified persons to
teach Commission-approved training.
6. To assist Internal Organizations and cave rescue organizations in general with the education
and training of their members in cave rescue operations and systems.
7. To coordinate with the Cave Rescue Section to present current cave rescue information to
Society members.
8. To establish and maintain a database of individuals with training in cave rescue.
9. To establish and maintain an inventory of specialized rescue equipment, owned by the
Society or otherwise available, which may be used by the Commission for training or used
for rescue and to report the status of Society-owned equipment to the Society upon request
of the Administrative Vice President.
10. To conduct periodic National Cave Rescue Seminars (Seminars), separate from the Society
convention, and to encourage regional and local cave rescue seminars.

NCRC is probably best known for its cave rescue training. There are three main types of
NCRC training.
First is Small Party Assisted Rescue (SPAR). This is marketed to cavers, and prior caving
experience is expected. A brochure for a SPAR class will say something like this:
Small Party Assisted Rescue is an intensive three-day introduction to cave rescues that can be performed by a party of six or
less persons, using minimal gear normally carried on caving trips. SPAR teaches how to handle most problems that arise
while caving: basic medical skills, how to move patients past obstacles, and how to do so with limited equipment and
personnel. Skills will then be practiced on cliff faces and in caves.

Second is the Orientation to Cave Rescue. This is a one-weekend course, and is marketed to
both cavers and local rescue personnel in cave-bearing areas.
For the first (classroom) part of the class, students are usually split into two groups. Cavers
attend classes about rescue and cave-specific first aid, and local rescue personnel are taught
about the cave environment and specific cave rescue considerations. Then, students join for
aboveground litter-handling practice simulating a cave. The second day is devoted to a mock
cave rescue in the cave.
The third type of NCRC training is a series of intensive weeklong classes known as NCRC
Level 1, NCRC Level 2, and NCRC Level 3. These are marketed both to cavers and to members
of cave rescue teams, and have personal ropework competence prerequisites, assessed on arrival
at the class location: basically, you must be a competent vertical caver or have equivalent
expertise from aboveground vertical rescue training. Level 1 is designed to teach cavers to be
members of a cave rescue team, Level 2 to train leaders of such teams, and Level 3 provides
intensive training in difficult cave-specific rescue techniques.
Note that the NCRC is not a cave rescue response agency. NCRC focuses on training and
resource coordination. The fact that NCRC instructors and staff frequently are assigned
leadership positions during cave rescues does not mean that they are functioning as part of
NCRC during the rescue.
There are designated cave rescue teams. Some focus solely on cave rescue. Some do both
aboveground wilderness search and rescue and cave rescue. The author’s local team, AMRG, is
both a MRA-certified aboveground rescue team and a cave rescue team. Given the dictum that
80% of search and rescue skills and knowledge is common between mountain rescue and cave
rescue, AMRG does not require current NCRC certification for members to go underground
during a rescue. However, the group does strongly encourage members, especially new
members, to attend at least a Level 1 NCRC training session, as an efficient and cost-effective
way to get most of the training they need for Field Team Member status, both aboveground and
belowground.*

NAVIGATION AND COMMUNICATIONS WITHIN CAVES

Cave maps are useful, particularly aboveground for the planning process, but especially given
people’s unfamiliarity with the conventions of cave mapping, they are less useful underground.
Still, cave rescue teams tend to have a cache of maps for caves where rescue is likely, preferably
printed on water-resistant paper. Much more useful is a caver who is familiar with the cave.
Expending considerable effort to find cavers who know a cave may be worthwhile for the base
(command) staff (Figure 29.4).
FIGURE 29.4. National Speleological Society Cave Map Symbols. These symbols add a large amount of information to the
basic map of lines outlining cave passage. Courtesy of the National Speleological Society, used with permission.
 Field teams heading into the cave may want to mark their route, especially if it is in an
unmapped cave, or a cave map is not available. Scratching your initials or directional marks on a
nearby formation is highly discouraged. A common marker to use, as opposed to the bright
plastic surveyor’s flagging tape that aboveground is tied to trees or bushes, is a popsicle stick or
indeed any form of stick with a little bit of Scotchlite or similar reflective tape attached the top.
The reflective tape is easily seen when using headlamps, and the stick can be easily pushed into
mud or dirt which is almost universally found in caves.
On the other hand, flagging tape is very handy to attach to the field phone wire. This makes
it less likely that someone will trip over it and become injured, or disrupt the entire operation by
cutting communications. Learning how to perform an emergency splice on field phone wire is an
essential skill for any cave rescue team member.
Neither setting up nor using field phones is hard but may be more complicated and more
prone to failure than with aboveground VHF and UHF radios. And, for a quick rescue, field
phones may not be needed or yet available. Thus, the ancient military technique of runners with
messages is sometimes employed. It may take hours for a “runner” (not that running is actually
possible in most caves) to get a message from the scene to the entrance. This places a premium
on concise, complete, unambiguous and easy-to-understand writing; here is a critical occupation
best filled by cavers with college degrees in English.

CAVE RESCUE SPECIFICS

Medical Considerations
The medical aspects of technical rescue, which are generally similar for cave rescue and
mountain rescue, are discussed in separate chapters of this book.

Technical Considerations
Nontechnical evacuations and semi-technical evacuations, discussed briefly in Chapter 24
(Technical Rescue Interface Introduction), Chapter 25 (High and Low Angle Rescue), and
Chapter 30 (Search & Rescue), are generally similar in a cave and aboveground. Details of these
types of evacuations, both for cave rescue and aboveground wilderness rescue, may be found in
an online reference.5 Chapter 17 (Management of Diving Injuries) discusses cave-diving rescue,
which has much more in common with dive rescue than with traditional cave rescue.
There are certain cave rescue technical considerations that are worth pointing out here.

Anchors: Drilling holes for bolts is generally frowned upon in rock climbing circles, unless
to place permanent anchors to protect popular climbing routes. But in caves, technical
rescues sometimes require placing bolts for anchors. Having cavers experienced in placing
bolts may be necessity for certain technical cave rescues. This is where the NCRC’s role in
resource coordination may prove helpful in mobilizing such experts.
Litters: Many standard wilderness rescue litters have cross-struts protruding from the
bottom. The Junkin rescue litter is justifiably popular among MRA and other wilderness
search and rescue teams, but for cave rescue, the cross-struts on the bottom make sliding the
litter across dirt or mud cave floors very difficult. For this reason, the Ferno Model 71 litter
(the non-split version) has been the standard for cave rescue for decades. Regardless of the
 specific model (and some new litters are giving the Ferno competition in the cave rescue
world), a litter that is smooth on the bottom can speed up a cave rescue considerably
(Figure 29.5).

FIGURE 29.5. Sliding a Litter. Litters with a smooth bottom such as the popular Ferno Model 71, or for tighter passages, the
less-sturdy, less-protective, but lower profile Skedco Sked illustrated here, slide easily. For cave rescue, they are much easier to
use than litters with crossbars on the bottom such as the Junkin or an older-style Stokes wire basket litter. Courtesy of Bill Frantz,
NSS 11706, used with permission.

Turtling: Seldom used aboveground, turtling is when, usually in a narrow passage, a team
member gets on his or her hands and knees, and crawls while the litter’s weight is partially
on his or her back. This takes some of the litter’s weight off the litter bearers, especially
important when only a few litter bearers can fit into a passage. When the passage is small
enough that you have to crawl on your belly with some of the litter’s weight on your back;
appropriately we call this snaking (Figure 29.6).
Paving: It is relatively common, for instance with a patient with an arm injury, to have the
patient assist with rescue by walking/climbing out of the cave, with rope belay lines
attached to a seat harness fore and aft, and to fill dangerous holes along the route with team
member’s bodies. Team member bodies, mostly backs and thighs, can serve as steps for the
patient as well. Filling holes in this manner is called paving. Team members are much
easier and faster to move than rocks, and much more obliging at fitting themselves into the
proper configuration.
Lap Pass: Sometimes, the bottom of a passage is too irregular to allow a litter to slide, or
the passage is keyhole-shaped and smaller in the bottom. Rescuers can sit down in a line,
and slide the litter along their laps and we call this—you guessed it—the lap pass.
Sling Carry: Sometimes there isn’t enough room for enough litter bearers move a litter—or
move the patient to where you can load him or her into the litter. In this case, litter bearers
 (or patient-movers) can sometimes stand well above the litter or the patient, and use
webbing straps attached to the litter, or passed under the patient, to help lift.

FIGURE 29.6. Turtling a Litter. Given the long small passages that form the bulk of cave rescue evacuation work, techniques
to move the litter rapidly through such passages with the least effort are important cave rescue skills. Shown is turtling a litter:
using the strong back of a rescuer on hands and knees as a support as the litter is passed; or, balancing the litter on the rescuer’s
back as the rescuer crawls on hands and knees. Snaking is the same technique but with the rescuer underneath doing a belly
crawl. Courtesy of Bill Frantz, NSS 11706, used with permission.
IMPLICATIONS FOR PRACTICE LEVELS
There is essentially nothing different about patient care in an aboveground wilderness setting and
in a cave: there are no cave-specific medications or medical techniques. However, the
environment is so different than aboveground mountain rescue or wilderness rescue that
personnel must be adequately prepared, by training and most importantly by some experience, in
the cave setting. Some with aboveground rescue training can quickly pick up the specialized
knowledge needed to deal with the cave environment and will adapt quickly to the psychological
stressors of being underground and in cramped quarters. However, a sizable minority will not,
and a rescuer who is psychologically stressed may have difficulty with even the simplest medical
techniques or decision-making. Perhaps the most common such problem is the urge to get out of
the cave now due to an overassessment of the dangers of the cave environment. This
overestimation of the dangers can lead to inappropriate haste in an evacuation, leading to rescuer
injury, patient injury, or simply skipping an adequate patient assessment. The best preventative
for this is a few enjoyable trips into a wild cave followed by some calm and measured cave
rescue simulations.

EQUIPMENT SUMMARY
From an equipment standpoint, there’s not a lot of difference between aboveground rescue and
mountain rescue. The cave environment may be a bit tougher than the aboveground environment
as far as abrasion, so gear tends to be packaged with perhaps a bit more care for abrasion when
carried underground. But it’s true that much of the time in a cave rescue, the ceiling is close
overhead, and you can’t stand upright; and, there is often not enough room on either side for a
standard set of litter bearers. Thus, the litter tends to move by techniques such as the turtling and
lap pass mentioned above, and because the cave passage varies widely, the method of movement
tends to change from minute to minute. But what tends to remain constant is the need to slide the
litter across rocks, dirt, or mud. So litters with flat, smooth bottoms tend to work much better
than those with ribs across the bottom. Using a litter without ribs on the bottom, compared to one
with ribs, can shave hours off an evacuation. Some cave passages may be too small for any
standard rescue litter, in which cases low-profile somewhat-flexible stretchers such as the SKED
may be needed.* In extreme cases, even a SKED may not fit, and the patient may have to be
dragged on a tarpaulin used as a drag sheet. Some late-at-night hypothetical cave rescue
discussions consider drastic measures such as using a padded hammer or rock to deliberately
fracture a clavicle to fold up the shoulders and fit a patient through a narrow “squeeze,” but this
author has never heard of it actually being attempted.

SUMMARY
Compared to “regular” wilderness search and rescue, cave rescue is a bit different, as we have
discussed above, but by the 80% rule, most of cave rescue is the same as aboveground rescue.
The most important difference is in the environment, and in the rescuer’s ability to adapt to the
environment.
 If you are an EMS provider, or a supervisory physician who may respond to the field, you
should decide ahead of time if you are willing to go in a cave for a rescue. If the answer is yes, or
even maybe, as discussed in Chapter 4 (Wilderness EMS Medical Oversight), you should ensure
that you are safe as an operator in that environment. At a minimum, you must go on at least a
couple of orientation trips. The first one can be a tour of a well-lit commercial cave, but the
second one needs to be a trip, with experienced cavers, in a wild cave. Such familiarization trips
serve two purposes. First, you test yourself to see if you will be comfortable in a cave, and
confirm your decision that you will (or will not) respond to a cave rescue. Second, you will get a
better idea of what personal gear and clothing you need, and at least get a start on learning how
to move through a cave efficiently.
Cave rescue can be challenging, and is usually infrequent, but offers great opportunities for
WEMS personnel to bring their expertise to the patient’s side.

References
1. American Caving Accidents. 1998. Available at: https://caves.org/nss-
business/publications/NSS_News/2000/April_00_ACA%2096-98.pdf#page=48. Accessed February 1, 2017.
2. NCRC Charter. National Speleological Society, 2003. Available at:
http://ncrc.info/Resources/Instructors/NCRC%20Charter. Accessed February 1, 2017.
3. Kansa E, Wells JJ. Quantity Has a Quality All Its Own: Archaeological Practice and the Role of Aggregation in Data
Sharing. San Francisco, CA: The Alexandria Archive Institute. Available at: http://alexandriaarchive.org/blog/wp-
content/uploads/2010/04/KANSA.QuantityHasAQuality.pdf. Accessed August 17, 2017.
4. Leave No Trace Center for Outdoor Ethics. Available at: www.lnt.org. Accessed August 17, 2017.
5. Conover K. Nontechnical and semi-tech evacs. Search and Rescue Topics. May 2014. Available at:
http://www.conovers.org/ftp/SAR-Evacs.pdf. Accessed August 17, 2017.

*Disclosure: the author is Medical Advisor to the Eastern Region of the NCRC, and has been an active staff member and teacher
with this NCRC Region since the 1970s.
*AMRG is in the process of developing a document that integrates Appalachian Search and Rescue Conference (ASRC),
Mountain Rescue Association (MRA), and cave rescue standards for individual credentialing. The current draft is available at
http://www.conovers.org/ftp/Cave-Rescue-Standards.pdf.
*http://skedco.com/product/sked-basic-rescue-system-international-orange/
INTRODUCTION
In this chapter, we provide an overview of wilderness search and rescue (SAR) for those who:

practice or intend to practice wilderness EMS (WEMS),

supervise WEMS providers, or
are interested in WEMS, and are not trained members of a wilderness SAR team.

The chapter focuses primarily on two aspects of wilderness search and rescue that are not
covered fully in other chapters. One is search management. The other is the medical aspect of
force protection: providing incidental medical care to SAR team members to keep them
functioning, and perhaps doing health screening on SAR team members.
It is difficult to know how many SAR operations occur. Information-gathering is spotty at
best. The National Park Service keeps reliable statistics, and they show about 3,000 SAR
operations per year.1,2 However, most SAR incidents probably occur outside of national parks: in
national forests, in state parks, on other public lands, and on private lands. Some of these are
straightforward rescues without much searching, but a significant proportion involves at least
some searching.
The standard model of emergency services training these days, at least in the United States,
tends to follow a four-level training ladder, likely originating in the regulations and four training
levels established for handling hazardous materials by the U.S. Occupational Health and Safety
Administration. The following is an informal interpretation of these levels as applied to other
emergency services specialties.

Awareness: you know enough to recognize the hazards, know enough not get yourself killed,
and know when to call for expert assistance.
Operations: you know enough to complete simple operations in the specialty, if you are
supervised by someone with more experience and training.
Technician: you know enough to complete simple operations without supervision, and to
participate in complex operations supervised by someone with more experience and training.
Specialist: you know enough to run even complex operations.

This chapter reviews the awareness level of wilderness search management, participation
with search operations in the field, tools to interface with the leaders of SAR teams, and concepts
of medical force protection.

TERMINOLOGY: SAR-SPEAK
The English language, as with the Internet, grows without top-level supervision. It’s messy. New
terms emerge, old terms acquire new meanings, and sometimes terms have multiple meanings.
And like any specialty, SAR has its own special terms. Interfacing with SAR teams is easier
when you can “talk the talk.” It also provides you with some credibility with SAR team
members, though perhaps not so much as when you can “walk the walk” and tell stories about all
the difficult rescues you have done. (Some embellishment is expected but it must be done
artfully and with at least a modicum of modesty and self-deprecation.)
Search and rescue itself is one of those terms that has come to mean many different things.
Looking for people trapped in a burning building? That’s search and rescue.
Looking for live people or dead bodies in collapsed buildings? That’s search and rescue.
Looking for and rescuing a downed pilot behind enemy lines? That’s search and rescue.
Using SCUBA gear to retrieve bodies from a bus that went off a bridge into the bay? That’s
search and rescue.
Looking for the wreckage of Malaysia Airlines flight MH370 on the floor of the Indian
Ocean using oceanographic sonar? That’s search and rescue.
Looking to see if anyone was affected by widespread flooding or a tornado? That’s search
and rescue.
Looking for a hunter who has activated a Personal Location Beacon (PLB) or a commercial
Satellite Emergency Notification Device (SEND)? That’s search and rescue.
The difference between “rescue” and “recovery” is critical to understand. In a rescue, the
subject is believed to be a patient who will need assistance and potentially medical care. In a
recovery, the subject is believed to be a body without chance of survival. Significant risks might
be taken to save a life of a patient, but the risk profile of a body recovery operation should be
very low.
The Land Search and Rescue Addendum to the National Search and Rescue Supplement to
the International Aeronautical and Maritime Search and Rescue Manual Version 1.0 (which,
despite the lengthy and impenetrable title, is well worth reading) provides the following
definition of SAR.
 Search: An operation using available personnel and facilities to locate persons in distress
Rescue: An operation to retrieve persons in distress, provide for their initial medical or other
needs, and deliver them to a place of safety.3,*

SAR that best fits the context of WEMS is sometimes called land search and rescue. We
distinguish land search and rescue from air search and rescue, which is (mostly) looking for
downed aircraft from the air. The problem with this definition is that ground teams (“land search
and rescue teams” in some definitions) form a significant portion of the effort to find downed
aircraft, and aircraft are sometimes used to look for lost persons (rather than downed aircraft) on
the ground.
We also use the term land search and rescue to distinguish it from maritime search and
rescue: looking for missing vessels (or aircraft) lost at sea.†
While the term land search and rescue has some currency as the main context where WEMS
is done, you can make a good argument that the Coast Guard, which some would argue is a
maritime SAR agency, also deals with significant amounts of wilderness SAR. In terms of
remoteness, difficult coastal terrain, and length of transport to an emergency department (ED),
many Coast Guard rescues fit the bill for WEMS, and some Coast Guard personnel have been
trained as wilderness EMT (WEMTs) specifically to deal with such issues.
The term land search and rescue is occasionally used, but we most often talk about
wilderness search and rescue as the preferred term for the type of SAR that connects most
directly to WEMS.
You can argue that U.S. wilderness SAR teams only do a fraction of their work in
Congressionally designated wilderness areas, or even state-designated wilderness areas.‡ On the
other hand, a lot of wilderness SAR work is in areas that are at least relatively wild, and the term
seems to get across the idea better than any other. In addition, as discussed in the Introduction
chapter and Chapter 1, the term “wilderness” in the context of medical care is far more expansive
than simple governmental designations.
There are three more SAR disciplines that should be distinguished from wilderness SAR.
The term urban search and rescue (USAR) has famously come to be synonymous with
searching collapsed buildings and trying to rescue people trapped in them. For the most part, this
is not really the type of SAR where WEMS should apply; this is usually in urban areas with
somewhat-intact EMS and medical systems. In severe or widespread disasters, though, the
existing EMS and medical systems may be entirely disrupted, and you can reasonably call it a
WEMS context. If wilderness SAR teams respond to support such operations, which is a
reasonable and likely highly effective response, wilderness SAR team members should have
extra training for the environment and hazards after such a disaster: the hazards are different, at
least in some respects, than the environment for which they train and in which they usually
respond.
Sometimes wilderness SAR teams help manage lost-person searches in urban and suburban
areas. Some such areas contain big parks that are relatively wild, especially at night or in deep
winter or after a bad storm that has toppled many trees. Even if it is in a suburban area without
such relatively wild area, we tend to call this urban search (not USAR which is different). Urban
search has its own specific strategies, tactics and hazards, as does a police missing person
investigation. It is common for wilderness SAR teams with expertise in search management to
assist urban or suburban law enforcement with such an urban search. In some areas, such as the
San Francisco Bay Area, some SAR teams do more urban search than wilderness SAR. A text
and reference on urban search techniques is available.4
 A more comprehensive glossary of SAR terms and acronyms can be found in the Land
Search and Rescue Addendum published by the National Search and Rescue Committee. This list
is a subset of the more complete glossary found in the National Search and Rescue Supplement
(NSS). In addition, a more complete discussion of SAR terms can be found from Selected Inland
Search Definitions which is an appendix within Sweep Width Estimation for Ground Search and
Rescue.5

SAR TEAM CAPABILITIES: SEARCH AND RESCUE

Wilderness SAR in the open desert southwest and in the densely forested wet-cold Appalachians
might seem very different, but there are many similarities. Wilderness SAR teams can and do
take advantage of mechanical devices such as helicopters, boats, four-wheel drive vehicles and
all-terrain vehicles (ATVs). See Chapter 28 for further discussion about mechanical vehicle use
in WEMS and wilderness SAR. But the primary transport mechanism for most SAR team
members on most operations is the human foot, usually encased in a wool sock (SAR team
members mostly, and appropriately, despising cotton socks*) and an appropriately sturdy hiking
or climbing boot. SAR team members are expected to be able to travel efficiently long distances
on foot.† The expectations for WEMS personnel may be lower, but SAR team members are
generally expected to be able to navigate from point A to point B with flair and élan, regardless
of terrain or weather, often using a map, occasionally a compass, but mostly disdaining their
GPSs (at least when others can see them). They are expected to be keen-eyed searchers, capable
team managers, expert communicators, and survival experts. Misquoting the inscription on the
New York Post Office: Neither snow nor rain nor heat nor gloom of night stays these SAR team
members from the swift completion of their appointed tasks.
Wilderness SAR teams vary widely in their size and capabilities. A few teams are just search
teams. . . they find lost people, but do not provide any first aid, medical care or rescue. Mostly
these are teams that field air-scenting or trailing dogs, though most teams that have such dogs
also provide at least first-aid-level care and do some rescue. Some teams provide a full range of
SAR services, including technical cave and mountain rescue. Some states offer certification of
team by certain minimum requirements, which provides some assurance of quality. Sometimes
this certification is by a state agency, sometimes it is by a statewide association of SAR teams. In
North America, the generally accepted highest level of wilderness SAR team competence is that
provided by the Mountain Rescue Association (MRA).

SEARCH RESOURCES, STRATEGY, AND TACTICS

SAR resources (things, people, or animals that can search: planes, trains,‡ and automobiles, as
well as horses, dogs, humans, helicopters, drones, and the like) can use different strategies. A
strategy can be carried out using different tactics, depending upon the task’s specific
requirements. The strategy of confinement ensures that the subject does not leave the search area
unbeknownst (it has happened). Attraction is a strategy for mobile responsive subjects who will
move toward a noise or light source. Investigation collects additional information or sightings
about the missing subject. Hasty searches follow well-defined linear features, a known route, or
go to specific spots where the subject might be located. Area searches cover larger areas with
either multiple resources or a single resource following a well-defined search pattern.
Most SAR tasks are designated to use one of these strategies, using resources such as human
ground searchers, dogs, mounted teams, ATVs, snowmobiles, or mountain bikes. Man-trackers
and tracking/trailing dogs try to follow the subject by visible tracks or scent. Man-trackers
sometimes learn the subject’s direction of travel, or document clues, or do cutting for sign
(described later). Aeronautical resources (low-flying light aircraft, helicopters, or drones) can
cover an area using different search patterns. They can do a hasty search by following a known
route, search specific linear features or likely crash sites (such as where the flight path crosses a
mountain range), or use electronic equipment to search for radio or radio-beacon signals.

Humans
There are various human being search tactics: techniques for looking (or sniffing) for a lost
person, or looking for clues to the lost person’s whereabouts. Some textbooks classify human
search tactics as Type I (emphasizes speed more than thoroughness), Type II (a balance of speed
and thoroughness), and Type III (emphasizes thoroughness more than speed). Most SAR people,
though, rely on the roughly equivalent terms hasty, sweep, and line (or saturation) for tasks.
Early in a search, especially when searching for a likely responsive subject, it makes sense to
use available resources for less-thorough but more widespread searching, using hasty and sweep
tasks. With a wide-spaced sweep task, searchers may be spaced far beyond their visual sweep
width for detecting an unresponsive subject and certainly for small clues. However, they likely
have much larger and overlapping sweep widths for hearing a responsive subject.
In the past, it was taught that repeated non-thorough (eg, sweep) tasks were more effective
than a single line/saturation task with the same amount of searchers and searcher effort. This was
based on a mathematical model that has since been shown to be incorrect.6
For an aircraft searching a segment, it therefore is best to do a single pass over the segment
with close track spacing instead of multiple passes over the segment with wide track spacing.
Applying this finding to ground search is a bit trickier, however. Close-spaced human-searcher
saturation or line search tasks are usually done by large teams that have high operational friction.
Operational friction consists of those things that suck up time and effort, or otherwise impede
operations, but do not contribute directly to the search effort.
Convoys move at the same speed as the slowest vehicle, and the more vehicles in a convoy,
the more likely you will have a slow vehicle. If a vehicle needs to stop for gas or some other
reason, the entire convoy needs to stop, and the more vehicles in a convoy, the more likely a
vehicle will need to stop. Even in this day of ubiquitous GPS apps on smartphones, dividing up a
convoy still seems to cause major complications and is best avoided.
Hiking groups move at the same speed as the slowest hiker, and the more hikers in a group,
the more likely you will have a slow hiker. If a hiker needs to stop to retie a boot, the entire
group must stop, as breaking up a hiking group is even worse than breaking up a convoy. And
since saturation/line search teams are basically large synchronized-hiking groups, this applies to
them as well. Large saturation/line search tasks have other sources of operational friction, such
as parts of the line drifting downhill, so that the leader must call a halt and move searchers back
and forth to re-dress the line.
The higher operational friction of line searches might mean that, unlike aircraft searches,
repeated sweep searches actually might be a more effective use of searchers compared with a line
search. Until someone does a comparative study, carefully not controlling for operational
friction, we won’t know for sure. Even if most search managers don’t believe that repeated
sweep searches are better than a line search, sometimes a repeated sweep is appropriate. If a
segment has already been searched by a sweep search, but a new clue makes it much more likely
that the subject is in that segment, it may be appropriate to get another sweep task into that area
quickly, as a sweep task is usually quicker to dispatch into the field than a line search task.
Trailing and air-scenting are tactics which work best if you have a long nose, pointy ears and
four feet, and we will discuss search dogs in the next section. If you’re a dog, you may consider
the human sense of smell laughable. But there are searches where the smell of fire or aviation
fuel led human searchers to a small-aircraft crash site, which leads to advice to human searchers
to use as many senses as you can to search for clues: vision (including checking out suspicious
clumps of brush, and from time to time turning around and looking with a different view, and
even looking up in trees), hearing (“JAKE, CAN YOU HEAR ME?! JAKE?!” [then stop and
listen intently]), and smell.
A hasty search task is often sent to search along a linear feature such as a trail or a stream.
Another type of search, used either after hasty search tasks or sometimes at the same time, is
searching an assigned area rather than a linear feature. This can be with an air-scenting dog, zig-
zagging through the area. It can also be with a team of humans in a line traversing the area,
sometimes called area search. When the humans are very widely spaced, we call this a sweep
search; when close-spaced, we call this line search or saturation search. Sometimes hasty search
and sweep search are combined; a linear feature can be searched with flankers out to either side
of the linear feature looking for clues as well as a responsive subject, though this slows down the
team and may delay them in finding a responsive subject along the trail.
Search resources (field teams) vary in their ability to find clues. An air-scenting dog and
handler can rapidly search an area and find, or exclude the possibility of finding, a human being
in that area. A sweep task with human searchers, though slower, is much more likely to find
clues, such as tracks that can be identified as the subject’s, or something left by the subject.
One of the authors once found what are arguably the two best clues of which we have heard,
both on the same task, off the Appalachian Trail in a ravine in Virginia’s Blue Ridge Mountains.
First, a plastic bag of clothes with the subject’s name on tapes sewn into each item. Second, after
man-tracking from that point (see below) and calling out the subject’s name, a response of “I’m
over here, dammit!”
Man-tracking (usually just shortened to tracking) is a technique that has long been used in
law enforcement. It probably started by using guides skilled at tracking wild game applying their
skills to track humans. Man-tracking was introduced to SAR teams in the 1970s by those such as
the late Ab Taylor of the U.S. Border Patrol. The Border Patrol uses man-tracking to locate
illegal immigrants, but Ab also put his skills to work to find lost children, and brought these
skills to the attention of SAR teams, developing a cadre of SAR tracking instructors.
Teaching searchers how to search for, identify, protect, and follow human tracks is now part
of the training of most wilderness SAR teams. Trained searchers are expected to be clue-
conscious: to know how to identify human tracks and appreciate their value as clues, especially
in untracked wild areas, and to protect them. One of the authors, searching such an untracked
area, found a track crossing perpendicular to his assigned hasty task, going from north to south.
This directed the search strategy to the area south of his assigned search task, where another team
quickly found the lost subject, a 92-year-old woman who had been mushroom-hunting and had
fallen and gotten her leg trapped between two rocks. She had been stranded there for days, but
luckily was right next to a small stream with water. This points out how a single track can serve
as a clue and result in a save.
 Searchers are sometimes tasked to cut for sign (also known as sign-cutting). This means to
search, either in circles around a clue, or perhaps perpendicular to the subject’s projected line of
travel, looking for tracks (“sign”).
Some SAR team members go on to advanced training in man-tracking, and may be
dispatched to a potential track to start tracking at that point, using the step-by-step method taught
by Ab Taylor and others. Man-trackers may start at the Point Last Seen (PLS), or if a good clue
establishes it, the Last Known Position (LKP), but often investigators have trampled the tracks
there. Scent-specific trailing-dog tasks are sometimes used from the PLS instead, though with
frustratingly low rates of success.

Dogs
Many animals have highly refined senses of smell, and could theoretically be used for searching
—in particular, pigs and buzzards seem to feature frequently in SAR humor—and horses used by
mounted teams have a keen sense of smell compared to humans, which adds to their baseline
usefulness as mounts for humans. But the animal most used for lost-person search is “man’s best
friend,” the dog. There are arguments about which breed of dog is best for SAR, but this is best
left for informal discussion (probably both lengthy and heated) with a group of knowledgeable
dog handlers, as there is no consensus even as to whether one breed is best, much less which
breed. Search dogs can be highly effective at finding those lost in a wild area.
As with the term search and rescue, the term dog team can be more than a bit confusing
when used in conversation, and we know of four separate meanings of the term. On the one paw,
a dog team can be a wilderness search organization, all of whom are dog handlers. On the other
paw, a dog team can also be a search organization, only some of who are dog handlers, although
this more commonly is called a wilderness SAR team with dogs. On the third paw, a dog team
can be a team sent out on a search task, consisting of a handler and dog working together, along
with one or a few other humans who are called walkers or flankers: SAR team members who
accompany the handler stay well back and often handle communications and some navigation.
The usual term for such a group heading out for a search or rescue is field team. But the teams
that are specifically tasked to use a dog, usually for an air-scenting or trailing task, are sometimes
informally called a dog team to distinguish them from the other, non-dog teams, which are called
just field teams.
On the fourth and final paw, we have a dog team of one human handler and one dog who
have trained together, tested together, and have been credentialed as competent in a specialty
such as air-scenting, trailing, or human remains detection (HRD). It takes lots of time and
dedication, on the part of both the dog and the handler, to become a competent and credentialed
dog team. There are quite a variety of credentialing agencies for such search dog teams, with
different testing standards; if you ask a dog handler about them, you will probably get a strong
response about which are of high quality and which are not. But, as a dog handler in the
Appalachian Search and Rescue Conference (ASRC) once famously observed: “If you get three
dog handlers together, about the only thing you’ll get two of them to agree on is that the third
one is wrong.”
Dogs have different training and capabilities. There are a variety of dog specialties, including
water search (searching from a boat), cadaver/human remains detection (HRD), collapsed-
structure search, avalanche search, and evidence search. The two most commonly used in
wilderness SAR are air-scenting and trailing.
First, let us describe how to do an air-scenting task. To make it easier to appreciate, we will
describe this from the dog’s view.
Your human handler and the other humans will usually follow a trail, a stream, or perhaps
steer a fairly straight course through the middle of an assigned search area (SAR teams often call
this a segment). You should stay ahead of the humans; stay close enough that you can hear them,
but being out of sight is OK, at least for brief periods. While they are struggling along behind
you (humans can be quite slow in the woods), you should run back and forth ahead of them,
sniffing carefully for the distinctive scent of a human, any human. As any competent dog knows,
individual animals (including humans) all have a slightly different scent, but animals have a
distinctive species-specific smell. It is said that foxes are particularly sharp and acidic, whereas
humans are warm and complex with overtones of oak and cedar, especially if the human has
been eating beef, and often a yeasty finish if the human has been eating bread or drinking beer,
but perhaps this is just one dog’s interpretation. This scent is created by small bits of skin, hair,
and evaporating skin oils that animals give off. This material floats downwind, spreading as it
goes, in a cone of scent. When you are air-scenting, keep your nose up and sniff periodically.
Ignore the scent of the humans with you, but keep sniffing for a different human.
When you are air-scenting, you are just sniffing for an unexpected human scent, any
unexpected human scent. As soon as you scent any human other than your team, check the wind
direction and remember it. When training your human, you should have worked out a standard
way to communicate this “alert”; whatever it is, run back to your human (for some reason, an
alert never happens when you are right next to your handler) and give your alert signal, whatever
it is. Once you are sure your human has paid attention and acknowledged your alert, it’s time to
head out and try to catch that scent again. Winds shift, so you will usually have to range back
and forth until you can smell it again. And sometimes, you won’t find it again; c’est la vie. Still,
even a single alert can be useful to those back at Base who are plotting these things on a map. If
you are lucky, you will get another noseful of that same scent, at which time your job is to follow
that scent upwind until you find the search subject. If the wind shifts, you may need to range
back and forth a bit more to pick it up. It is important to remember that old search-dog mantra:
humans are slow. While there is a certain competitive urge to get to the subject as fast as
possible, you may need to slow down a bit so your humans don’t get out of barking range.
When you find a search subject, you need to communicate this with your handler who, as
usual, is probably lagging far behind. Run back to your handler, give the signal that you have
taught your handler, get a response that you have been understood (“Show me!” seems to be
pretty standard) and then lead your handler back to the subject. This is called a refind.
With air-scenting, there is lots of scent in the air, at least when you get close. But for trailing,
you have got your nose down near the ground, trying to find some of that scent that has drifted
down onto the ground. That makes it harder, as there is less scent, and the older the trail the less
scent is left; sometimes they have you try to follow trails that are a couple of days old, which is
well-nigh impossible. What is worse is that you have to pick out the right person’s trail from
other people’s scent trails; unlike air-scenting, trailing is scent-specific. If you are lucky, your
handler will have a good scent article in a paper or plastic bag for you to check from time to
time. Ideally this is from someone who has been trained how to collect a good scent article
without contaminating it, but you will have to work with whatever you have got.
As discussed above, man-tracking is a well-trained human visually following someone’s
footprints or other signs of passage; do not confuse it with a dog’s trailing.*

Containment
When searching for a lost person in a wilderness area, searching may be complicated by the fact
that the subject may still be moving, resulting in an ever-expanding search area. Thus, we arrive
at the key concept of containment: knowing if the subject leaves the established search area.
There are many tactics that can help contain the search area. You could:

Post notes at trail intersections “this way out.”

Run string lines with flagging tape on them, and small signs saying “this way out.”
Put camp-ins (a couple of searchers camping out) at locations where a lost person might
reasonably end up, such as a major trail junction, or the main approach to a mountain climb.
A camp-in team may carry in a tent, sleeping bag, sleeping pads, a stove and food, and may
serve as a rest and resupply area for more mobile field teams.
Create a “track trap” in an area where a mobile subject might travel: sweep an area of mud,
dirt or dust flat, so it is ready to accept good tracks, and then send teams to check the track
trap on a regular basis.
Have searchers do slow patrols along roads around the area from a vehicle. Have searchers
similarly walk to patrol trails that bound the area. These tasks may be particularly useful to
get less-trained and less-fit searchers into the search effort.

However, patrolling or searching by vehicle is not nearly as sensitive for either clues or
subjects as foot-based searchers. Once upon a time, in a large wilderness area traversed by the
Appalachian Trail in southwestern Virginia, both foot searchers and trail-bike motorcycles
looked for the subject for many days. When finally found by the foot searchers after almost a
week, the subject commented, “the only time I was afraid for my life was once when I almost got
run over by a motorcycle.”

SEARCH THEORY AND STRATEGY

For many years, researchers have worked to get search management into a more scientific
framework. This has resulted in a fair amount of literature, and several computer programs
designed to assist search managers. Here we will review only the most prominent aspects. If you
are interested in more details you can consult the literature on this topic.5,7–9 In particular, a
rigorous but very readable introduction to search theory, prepared for the U.S. Coast Guard by
J.R. Frost, is available free online.10,†
The central equation of search theory is:

POS = POD × POA

POA is Probability of Area: the probability* that the subject is in that circumscribed area.
POD is Probability of Detection: how likely the search technique will find the subject if the
subject indeed is in that area. Multiply the two, and you get the POS or Probability of Success:
the probability that you will find the missing subject.
With this equation, we try to quantify, and then combine, two uncertainties. The first
uncertainty is probability that the subject is in a particular search area segment (Probability of
Area = POA). The second uncertainty is the probability that your search tactic will find the
subject if the subject is in the area searched (Probability of Detection = POD).
If you are 100% certain the subject is in the area (POA = 100%), and you search it with a
tactic that never misses a subject (100% POD), then you have 100% × 100% = 100% chance that
you will find the subject (100% POS). Note that the math is easier if you do it using probability
rather than percentage. A probability of 100% is the same as a probability of 1.0; in this case, 1.0
× 1.0 = 1.0.
If you are 50% certain (probability 0.5) that the subject is in the area (50% Probability of
Area), and search it with a tactic with a 50% Probability of Detection (probability 0.5), then
multiplying them together (0.5 × 0.5 = 0.25) gets you a 25% Probability of Success.
The goal of search theory is to find the subject in the shortest amount of time. The most
powerful SAR tactical decision aids calculate the probability of success rate (PSR), which is a
measure of how effectively you are using your available resources to find the subject. The aid
then tells you how to allocate your resources appropriately to maximize it.3

Defining the Search Area

The first step in planning the search is to plot an Initial Planning Point (IPP), using either the
PLS (point last seen, where the subject was last seen by a human observer) or the LKP (last
known position, a position established by a reliable clue). The next step is to define the overall
search area: What will I search, and where will I send some (or no) resources? Too small an area,
and you may miss the subject. Too large, and you may never be able to finish searching the area
with your available resources. Textbooks traditionally describe establishing the search area
through a four-step process of Theoretical, Statistical, Subjective, and Deductive.11 Actual
practice tends to involve your looking up the 95% distance the subject is likely to travel from the
IPP, based upon statistical models.12 Then, you reduce the search area where there are obvious
travel barriers (eg, an impassible river). Finally, you match the boundary of the search area to
features a field team could find on the ground.
We mentioned containment above, but there are many times when containment is not a major
factor for search planning. When a person has been missing for several days, the possible travel
distance makes the potential search area huge, usually orders of magnitude larger than could be
covered by available resources. In such cases, the actual search area is much smaller than this
theoretical area.
To aid us in deciding how large an area to search, and which areas within that we should
search first, we can use data on lost person behavior. Robert Koester, a long-time search manager
of the ASRC and one of this chapter’s authors, also authored a book called Lost Person Behavior
that provides this information, which is also available in a smartphone app.12 For example, if you
are searching for a lost hiker, you can consult Lost Person Behavior, which recommends
concentrating on trails, cutting for sign around decision points: points where the trail route is
unclear and a hiker might go astray. Cutting for sign means traveling carefully around the
decision point, searching intently for human tracks. If we look at the statistics in Lost Person
Behavior, we find that 50% of hikers are found within 1.9 miles (3 km) of the IPP, and 52% were
found downhill from the IPP. Thus, even if the subject cannot be contained, search efforts can be
focused on the most probable areas.

Probability of Area
Search theory rests on the premise that, while the location of the subject is unknown, some areas
are more likely to contain the subject than others. Much like looking for your lost keys, they are
more likely to be in some specific locations than others (coat pockets?) The actual probability for
each area ranges from near zero to approaching one. You can use three main methods to
determine the initial POA.
For decades, the traditional land SAR method has been the Mattson consensus method.13 This
is based on information from your investigations, and is a consensus of subject matter experts
you gather together, calculated mathematically. The Mattson consensus may also include
information from the other two methods.
The second method is a statistical method, also known as the stochastic approach. It takes
various models (or a single statistical model) of where people (or aircraft, or ships) tend to be
found, typically calculated from an IPP. Figures 30.10 to 30.14 provide examples of this
approach. Wherever the subject was last seen by a human (seeing them on live video or on a
time-stamped video recording counts) is the PLS. Wherever the subject can last be located (for
example, by a good clue) is the LKP. The point first chosen as the starting point of the search,
whether it is the PLS or an LKP, is the IPP. Segments of the search area are then assigned POA.
This is the model most commonly used to look for missing aircraft based upon track information.
As mentioned above, one of the authors once found, deep in a ravine, a plastic bag of clothes
with the subject’s name on name tapes sewed into each. The PLS was back, up on a ridge along
the Appalachian Trail. This clue reliably established a new LKP, and it refocused search efforts.
The final model is a particle motion or Markov model. This is the model used by the U.S.
Coast Guard; it considers how the subject may move due to wind and currents in the ocean.14 A
particle motion model creates a mathematical set of rules defining how a particle moves, and
essentially rolls the dice (introduces probability) for each discrete move. You then run a Monte
Carlo simulation on hundreds or thousands of particles. Then, using specified time parameters,
where the particles end up define the probable locations. This particle motion technique is
seldom used to predict the location of missing people on land.
Some computer programs allow you to combine these techniques to calculate one composite
POA for each of your search area planning regions or segments.

Segmenting the Search Area

When planning area searches (air-scenting, sweep or line/saturation tasks), search managers
generally segment (using the word segment as a verb) the area into small, searchable segments
(using the word segment now as a noun). A rule of thumb—actually the rule of two thumbs—
says that on a standard-scale USGS topographic map, the area covered by your two thumbprints
is about the right size for an air-scenting dog or human search task. A field team can usually
search such a segment in 4 to 6 hours, and can usually complete two tasks in a 12-hour shift.
Linear features may also be assigned a segment number for purposes of planning hasty search
tasks. Some method is then used to assign a POA to each segment, and you generally send teams
into the segments those with the highest POA first. Segmentation is an art taught to SAR
managers; the segments must not only be of a reasonably searchable size, but must have
boundaries that can be well seen on both the map and in the field (Figure 30.1).
More terminology: search area generally refers to the entire area currently being searched,
and searchable segment (using the word again as a noun) usually refers to a small portion of the
search area, assigned to a particular field team to search during a search task. Sometimes people
to refer to a small segment as a search area; refer to the context to figure out the usage.
There is one “segment,” or better, region that is not on the map, and is referred to by the
acronym ROW (Rest of World). Searching particularly high-probability locations in the ROW,
particularly nearby bars, is a part of some searches and has given rise to the common term
bastard search, though a much more politically correct term, especially if you are dealing with a
subject with dementia, is investigative search.

The Mattson Consensus

The original method for assigning land search POA is the Mattson Consensus Method, named
after the U.S. Air Force’s Robert J. Mattson, who taught this method at the joint U.S. Air Force
—U.S. Coast Guard National Search and Rescue School in the 1970s.13
The original, basic, pencil-and-paper method works as follows. First, choose a small number
of people who have some sort of qualifications to provide an educated guess as to where the
subject might be. (The guesses of psychics are usually classed as “uneducated” and not
included.) Things that might lead to an educated guess include:

specific knowledge about the search subject;

experience at running searches;
knowledge of the local terrain, including such things as popular hiking trails, good fishing
streams, or favorite hunting areas;
thorough knowledge of lost person behavior; or perhaps
training in using Geographic Information System (GIS) to, for example, predict travel times
on and off trails.

Next, divide the search area, not into searchable segments, but into planning regions, and
assign each region a letter. These regions may be larger (or smaller) than searchable segments, as
they are for assigning POA, not for creating specific tasks.
Then, using a pencil and paper (see Figure 30.2), make a list of the search region letters
down the left side of the paper, then a draw a grid next to this. The grid needs a horizontal row
for each planning region, plus an extra one for ROW.* It also needs a vertical column for each of
the people who will be contributing their thoughts; you can call them your Mattsoners. Add
another column at the far right for the averages.
Have each Mattsoner assign a POA to each region, including the ROW “region.” For a
traditional Mattson, each Mattsoner must be capable of some mental math: the total POA for all
regions, including the ROW, must add up to 100%. (This is why computer programs are so
popular for doing this.) Mattson recommended that all the Mattsoners use a separate sheet of
paper, and list their percentages privately. This avoids peer-pressure effects that might dilute the
wisdom of this particular crowd. Then, have someone enter the values in the grid illustrated in
Figure 30.2 and do the calculations.
Finally, it is a simple matter (at least if you are a computer) to average all the readings. You
use the averaged POA for each of the regions to direct your search strategy: search the regions
with the highest POA first. Given the results of the Mattson Consensus in Figure 30.2, and the
reality that at the time of this consensus there were just three field teams currently available,
those teams should be assigned to Regions A, B, and C. If the first set of planning regions
corresponds with the segments on the map in Figure 30.1, A=1, B=2, C=3 and so forth, then send
teams to segments 1, 2 and 3.
FIGURE 30.1. Segmenting a Search Area. Initial segments for a man who “. . .went up the holler to do a bit a huntin’ on Calf
Mountain.” Illustration by Keith Conover, MD, FACEP. Used with permission.

There are issues with the classical Mattson method. Mattsoners will sometimes give you a set
of probabilities that add up, not to 100%, but to 90% or 120%. Scaling these entries so they do
total to 100% is sometimes called “coherentizing” the entries. Or, Mattsoners assign probabilities
for a few of the more likely segments, then simply provide a similar low probability for all the
rest (cheating).
These are indicators of the cognitive friction of the process. Think of cognitive friction as
things that make a computer application “not user-friendly.” Cognitive friction is a term coined
by computer user-interaction guru Alan Cooper in his book The Inmates Are Running the
Asylum.15 He defines cognitive friction as “. . .the resistance encountered by human intellect
when it engages with a complex system of rules that change as the problem permutes.” Charles
Twardy, in an online blog post about the Mattson process, says “People are often incoherent:
their probabilities don’t add to 100%. We get an 18% gain in accuracy if we coherentize their
estimates. But we get a much bigger 30% gain in accuracy if we also assign more weight to
coherent estimates.”16 In simple terms, we rate the advice of people whose estimates add up to
100% over those whose don’t. He references a paper he coauthored to support this.17 Twardy
goes on to say “Our ‘decision aids’ might be hiding carelessness, incapacity, or neglect which we
would do better to recognize and ignore.”
FIGURE 30.2. Mattson Consensus. The numbers along the left, and the rows, refer to segments of the search area. The columns
have been filled out by participants in the Mattson Consensus; their names appear at the top. The numbers represent their
educated guess as to the POA (Probability of Area: the probability the subject is in the area). The far-right column averages the
percentage entered by the participants and is used to assign task priority. Illustration by Keith Conover, MD, FACEP. Used with
permission.
 Or, perhaps we do not need to invoke carelessness or neglect. This may simply indicate that
people who can overcome the (high) cognitive friction of the classic Mattson system provide
better estimates, and by providing a system with lower cognitive friction we can overcome this.
Twardy notes that Mattson variants with a lower cognitive friction tend to coherentize the
POA estimates. He cites two of these:

Proportional: allow people to put in whatever percentages they want, and don’t worry
about them totaling 100%. Scale them (usually using a computer) so that they now do total
100%.
O’Connor: instead of percentages, Mattsoners enter probabilities as follows, then they are
scaled to percentages adding up to 100%:
A - very likely in this segment
B
C - likely in this segment
D
E - even chance
F
G - unlikely in this segment
H
I - very unlikely in this segment

These two methods require a computer, or at least a calculator. But smartphones are
ubiquitous now, and not only are there smartphone calculators, there are also smartphone
spreadsheets, so it is hard to argue that the technology to carry out these calculations is not
readily available. And given these methods are easier to perform and less likely to result in error,
it is hard to argue for the traditional Mattson. With the Proportional method, it is common to
ignore the ROW “planning region”; you do not search it with searchers, you search it by
investigation. The Proportional variant is recommended in the literature.6
FIGURE 30.3. Trail-based POA. For each decision point along the trail, the field team estimates a probability, from 1 to 8, of
how likely it is that the subject would have left the trail at that point. The areas off either side of the trail are segmented into six
search areas (segments). By using the number of decision points leading into an area, and the relative probability that the subject
would leave the trail at each decision point, a trail-based probability of area (POA) can be estimated for each area. Illustration by
Martin Colwell. Used with permission.

Trail-Based Probability of Area

Trail-Based POA methods determine POA by non-Mattson methods. There are two meanings of
the term Trail-Based POA.
First, in the early phases of a search, it is common to send hasty teams along trails or streams
looking for a responsive subject, saving sweep searches of areas for later efforts. It is possible to
assign each trail a POA via a Mattson Consensus or some similar process. We should probably
call this Probability of Trail or Probability of Stream or perhaps Probability of Linear Feature.
Second, and a much more common usage, has been popularized by the writings and teaching
of Martin Colwell, of Lion’s Bay Search and Rescue in British Columbia. The key to this is
looking for decision points along a trail and assigning each a probability that the subject might
have left the trail at each (see Figure 30.3). This allows you to determine a POA for areas to
either side of the trail. Examples of decision points include:

misleading dead-end side trails,

overshoots off trail switchbacks,
minor trails that intersect the main trail,
 apparently easy shortcuts,
enticing “natural routes” that follow easier ground,
overused and “braided” trails,
visible or marked attractions off the main trail, such as springs, shelters, or viewpoints, and
“one-way” decision points, where the route forward leads onto a more-used trail or dirt
road, but the route back involves finding a nonobvious trail turning off from a well-worn
trail or dirt road.18

For popular trails, you may know these decision points ahead of time. If you are on a field
team doing a hasty search along a less well-known trail, you can keep an eye out for decision
points. Whenever you find one, you can perform a quick consensus of all team members to
establish how likely the subject might have left the trail at the decision point. Based on the
number and probability of each decision point leading off a trail into a search segment, Base can
use this to calculate a POA for that search segment. Martin Colwell has written this up in a
detailed paper available online.19

Statistical Method
Another alternative to a Mattson-style consensus is to use statistical data to determine the most
likely search segments; statistical data can also be shared with Mattsoners before performing a
consensus. If the subject is lost in an area where people get lost all the time, you might look first
in the segments where you have found lost people before. If not, you can use aggregated lost-
person behavior from many searches. Gather data from your Missing Person Questionnaire
(MPQ) and match as closely as you can with one of the profiles derived from many prior lost-
person searches. Here is a list of the profiles available in one of the authors’ published work
(Koester: Lost Person Behavior12) and the corresponding smartphone app (also Lost Person
Behavior):

Abduction
Aircraft
Angler
All-Terrain Vehicle (ATV)
Autistic
Car Camper
Caver
Child (Toddler) 1 to 3
Child (Preschool) 4 to 6
Child (School Age) 7 to 9
Child (Pre-Teenager) 10 to 12
Child (Adolescent/Youth) 13 to 15
Climber
Dementia
Despondent
Gatherer
Horseback Rider
Hunter
Mental Illness
 Intellectual Disability
Mountain Biker
Other
Runner
Skier-Alpine
Skier-Nordic
Snowboarder
Snowmobiler
Snowshoer
Substance Intoxication
Urban Entrapment
Vehicle
Water-Related
Worker

If the subject was riding a mountain bike, or was autistic, was a child, or was hunting, you
can select a corresponding profile and use the statistical data to help delineate the search area,
segment it, and assign priorities to the segments based on this information. For example, if you
are looking for a hunter in a temperate climate in the mountains, a quarter are found within 0.6
miles of the IPP, half are found within 1.3 miles of the IPP, 75% within 3 miles, and 95% within
10.7 miles. Seventy percent are lost, 22% are simply overdue, and illness and injury account for
only 3% (2% medical, 1% trauma). Additional statistical models are based upon direction of
travel (dispersion), elevation changes, track offset (distance away from linear features,
watersheds, mobility, find feature, and specific points). This allows you to focus your search
efforts in appropriate segments.

Geographic Information System

You can use a GIS to determine the overall search area and assign POAs to planning regions or
segments based on elevation, roads, and trails. Given known travel time formulas, your GIS can
plot how far the subject may have traveled in different directions. Thus, you can estimate travel
times from the IPP. In the early stages of a search, you may be able to search only a small area,
as the subject could only have traveled a relatively short distance. Given the elapsed time since
last seen, a GIS can easily plot on the map an estimate of travel times from the IPP. This will not
be a perfect circle, as the subject could have traveled faster along roads and trails. If there is a
network of roads and trails in the area, the GIS does a much better job of estimating travel times
than a human.

POD (Probability of Detection) and Sweep Width

For this theoretical framework to help search managers in the real world, we need a reliable way
to assess the POD for various search tactics. For searching at sea, where the environment is very
uniform, tables are available. But for wilderness SAR, with widely varying environments and
weather, POD values are just beginning to be known. The old traditional method—while
debriefing the Field Team Leader (FTL), ask for an estimated POD—is likely very inaccurate.
The most recent work in estimating wilderness search POD involves actually measuring
something called effective sweep width, which is essential to determining POD.5,9,20,21 Sweep
width is a measure of the detectability of a particular search object for a particular searcher
(sensor) in a particular environment. It can be considered a detection index. The detection index
will vary, not only in different types of terrain (desert, forests, meadows, alpine tundra, brush),
but along a search path, depending on how much brush there might be at a particular point.
Nonetheless, determining an average effective sweep width for a searcher (eg, air-scenting dog:
olfactory; human searchers: visual and auditory) in each environment (open forest, brush) gets us
a much more reliable estimate for the actual POD than the “FTL’s best guess” method. In a 2003
report to the Department of Homeland Security, search experts recommended research efforts to
determine sweep width values for land search.6
Wilderness SAR team members sometimes practice and assess themselves by having
someone leave clues in a practice area, then have a field team search the area to see how many of
the clues they can find. Under controlled conditions, a similar exercise can allow researchers to
determine effective sweep width, almost always shortened to sweep width in common speech.
“The effective sweep width may be thought of as the width of the swath where the number of
objects inside the swath that are not detected equals the number of objects that are detected
outside the swath.”9 This is illustrated in Figures 30.4 and 30.5. The advantages of sweep width
over other models of search detector range are that it is more easily manipulated mathematically
and can actually be determined by experiment. In fact, since the sweep width integrates the
actual environment, it can only be determined by experiment at this time.
FIGURE 30.4. Effective Sweep Width, Top View. This represents a search resource—for example a searcher, or a field team of
trained searchers—moving across a search area. The superimposed red curve represents the ability of the tactic to detect objects
(responsive or unresponsive subjects, or clues); the shape of the curve likely varies quite a bit depending on the search tactic and
the terrain and weather. The shape of the curve here is arbitrary. Detection is high directly in line with the team, but tails off on
either side. The effective sweep width (“sweep width”) is represented by the dashed lines. Illustration by Keith Conover, MD,
FACEP. Used with permission.

If you use a simulated body (a dressed human manikin) as the subject, the sweep width is for
an unresponsive subject and requires visual search; if you use a live person who is coached to
answer a searcher’s calls, the sweep width is for a responsive subject and uses an auditory
search. If you use a standard “clue” such as a quart milk carton painted orange, then the resulting
sweep width is for a clue of similar size and color.
Research efforts are now deriving actual sweep width numbers for human and canine
searchers in different terrain and vegetation.7,8 It is also possible now to use a much shorter field
experiment taking just a few minutes to obtain an estimate for the sweep width value for the
particular task area about to be searched.8 This allows (somewhat) evidence-based estimations
for the POD term of that central equation of ground search theory, POS = POA × POD.
If we know the area (segment) a team has covered without finding the subject, the effective
sweep width of their search technique in the given terrain, and the effort of the team, we can
calculate a revised POA for that segment: an opinion about how likely the subject is in the area,
revised downward based on the efforts of the search team.

FIGURE 30.5. Effective Sweep Width, Mathematical View. If we know the segment searched, the tactic used, and the sweep
width and spacing of the tactic, we can calculate the probability of detection (POD) for that segment. This can then be used to
modify the probability that the subject is in the area (POA). Illustration by Keith Conover, >MD, FACEP. Used with permission.

Shifting POA and Other Complications

Once a segment has been searched, it is less likely that the subject is in that segment, and your
attention will usually turn to other segments. You can quantify this through the process of
shifting POA: if you know the POD of a resource that has searched a segment, you can calculate
how much less likely the subject is in that segment, deriving a new POA for that segment. Then,
you (or more realistically, your computer) can calculate how much higher this makes the POA
for all the other segments. This allows you to direct subsequent tasks to the highest-probability
areas. It is also possible to calculate a cumulative probability of detection (cumulative POD) for
an area that has been searched multiple times. However, “no mathematical method can be
allowed to take the place of good judgment in the field. The mathematics in this Addendum
provides valuable decision aids, but cannot make decisions; mathematics only processes the
available data and may not account for important, operationally significant realities. On the other
hand, while pure intuition is easier to use, it is harder to justify later if success does not come
early and if is not as reliable in the long term. Use the mathematics as a guide, but not as the
complete answer.”3
For example: segment 5 was searched by an air-scenting dog who alerted twice when near
the border with segment 8, but then lost the scent. Was this the subject being scented, or perhaps
a hiker or hunter passing through segment 8? It certainly increases the POA for segment 8, but
by how much? And what if, at the same time—remember this is a dynamically changing
situation—a field team in segment 4 found a fresh gum wrapper of the type the subject was
known to be carrying?
This can get very complex, very quickly. However, the basic idea of the Mattson Consensus
—that many heads are better than one*—has been around for a long time, and its truth well
documented in the literature, as summarized in the popular book The Wisdom of Crowds.22
It is hard for our minds to mathematically quantify how various clues affect the search
strategy, or even to quantify the uncertainty of the effect it should have on search strategy.
Indeed, in the Mattson or similar consensus methods, Mattsoners are asked to quantify their
certainty/uncertainty about where the subject is for different search area segments; perhaps there
is also a way to quantify Mattsoners’ certainty or uncertainty about these estimates. This is a
great opportunity for those involved in the mathematical and computer science field of fuzzy
logic. And, since few, if any, search managers naturally think in terms of matrix algebra, this is
also a challenge to software engineers to develop a matrix calculation system that employs fuzzy
logic. It will also need an intuitive graphical user-interaction design that corresponds with human
mental models, allowing accurate entry of incoming information and meaningful presentation of
the results.

Limits to Search Theory

As with the physicist’s recipe for fried chicken (“First, assume a spherical chicken. . .”), there are
some issues in trying to apply search theory to actual searches. An underlying assumption of
much search theory (developed for maritime search) is that the POA is a circular normal
distribution (very much like the physicist’s spherical chicken). This is a somewhat reasonable
assumption for searching for a warship or a life raft from a patrol airplane if we ignore local
areas of mist or fog or sun reflection, or observer fatigue. But both mathematically and in real
life, wilderness lost-person search is much messier. Assumptions about probability distributions
must be extensively modified for varying elevation, terrain, vegetation, impassible barriers, easy
travel routes, and the like. This is why a combination of human input via a Mattson Consensus
and several different statistical models provide the best input to the search planner.
For determining sweep width and POD, it is easier to find a subject who is screaming “Over
here! I’m over here!” than to find a subject who is unconscious or dead. And searchers, at least
well-trained ones, search for clues as well as subjects. So, the POS = POA × POD equation is
complicated by the fact that different resources and tactics have different PODs for responsive
and unresponsive subjects, and we do not really calculate POD or POA for clues. A recent report
in the literature helps quantify the brief difference between visual and auditory searching.23
But these theoretical constructs, even if they cannot always be directly applied to search
operations, especially for wilderness SAR, nonetheless inform our decisions about how and
where to search, and are part of the training and mind-set of any effective search manager.
Going further into search theory can rapidly get both complicated and controversial and we
will remand those interested to take a course such as Managing the Lost Person Incident,
Managing Land Search Operations, Managing the Inland Search Function, Managing Search
Operations or the joint U.S. Air Force—U.S. Coast Guard Basic Inland SAR Course* or Inland
SAR Planning Course.†

SEARCH MANAGEMENT
The most basic SAR team capability is search. Even if someone comes out of the
woods/desert/mountains/cave and says “my buddy fell and broke his leg!,” finding the injured
person can still be taxing. Often the person coming out with the message is too
exhausted/dehydrated/cold/hot to serve as a guide to the injured person. And, even if physically
able to serve as a guide, his or her memory and navigation skills may not be up to the task.

Initial Operations and Reflex Tasks

In emergency medicine, we sometimes follow an internal-medicine-ish model: gather data,
formulate a diagnosis, then come up with a treatment plan. But sometimes, as with a Level I
trauma patient, we follow a trauma-surgical model: do a standard trauma exam and start a
standard resuscitation protocol all at the same time, to make sure important things get done
quickly.
The type of search management we have discussed thus far—gathering data, doing a Mattson
Consensus and the like—takes time, and is an internal medicine-type approach. But for the first
hours of a lost-person search, a trauma-surgery approach is better: A standard part of modern
search management is to get people out into the field as soon as possible. You do this by starting
reflex tasks: Basically, as soon as you have enough information to send a team into the field, you
do so.
In the future, we may want to dispatch a reflex task using an unmanned aerial vehicle (UAV,
also known as a drone) to survey the area. UAV information may identify areas that are best for
certain types of tasks. For large grassy areas or fields, a UAV’s camera, combined with humans
interpreting the still pictures or video, may provide a high POD much faster than a human or
even canine field team can. Given how quickly a UAV can get to and search an area, it may have
a far better PSR than a human field searcher.
For lost-person searches, SAR team members tend to arrive at Base not all at once but in
dribs and drabs. As soon as enough people arrive at Base to create field teams, even before you
have detailed information you get teams out to what seems like high-probability areas, almost
always as hasty tasks. These field teams may not have a complete briefing, but they can get more
information via cell phone or radio. You can re-task a team if you get new information and
decide that somewhere else has a higher POA. But by that time, you usually have enough people
to dispatch additional field teams to those areas.
This is one situation where remote support may help; when SAR team members first set up a
base and plug in the laptops and printers, remote support personnel have already generated some
reflex-task Task Assignment Forms (TAFs; more later on this) and maps that can be printed right
away.
The initial information you gather, which you should record on a MPQ (more on this later),
along with any other relevant data (such as location of the subject’s car, or any reported
sightings) helps you establish the two most important points in a search: the PLS and the LKP.
They are often but not always the same. You will choose one of the two, likely based on the
reliability of the reports, as the IPP. An ideal reflex task is to send a couple of clue-aware
searchers, or better yet credentialed man-trackers, to cut for sign around the IPP.
Initial searching can be a point search, for example, checking the area around where the
subject’s car was found. Small teams of searchers are also usually sent out to search along trails
and streams, as lots of lost people turn up along trails or streams. These are called hasty search
tasks, as you are instructed to move quickly, at least more quickly than a line of searchers
moving through the woods, trying more to locate a live subject than clues. If your field team is
assigned a hasty search task, you will likely be sent out with instructions to search a linear
feature, usually a trail or stream, and along with a Task Assignment Forms (TAF; more on that
later), your FTL gets a map with the linear feature highlighted, attached to the TAF.* It is
traditional, particularly in the eastern United States, but by no means universal, to letter Field
Teams by the international-standard ICAO-ITU (International Civil Aviation-International
Telecommunications Union) phonetic alphabet: Team Alfa, Team Bravo, Team Charlie. . . and
to number tasks. Team Alfa will probably be assigned Task 1, but once they are done with that,
they might be assigned over the radio to Task 8.
Dog teams are sometimes simply named after the name of the dog. Dog handlers strongly
favor this as it makes their job easier: they do not have to remember a team name. Purists object
on several points. First, this might end up causing confusion between two teams named Charlie
or Romeo or Sierra, though the likelihood of a dog named Foxtrot or Hotel seems remote. A
more salient point is that the ITU-ICAO phonetic alphabet is designed to be easy to hear and
understand when those communicating are under stress, or communications are less than clear,
and people only need to discern 26 separate words. That is not true of dog names: there are
many, and some may be hard to understand or to spell, which can lead to confusion.
A common teaching and memory tool for the initial phases of a search is the Bike Wheel
Model (see Figure 30.6; Table 30.1). In this analogy, the axle is the IPP. The hub is initial
search area right around the IPP. The rim is the rings that describe the 50% and 95% probability
areas. The spokes are linear features (roads, trails, powerlines, streams) leading from the hub out
toward the rim: ideal linear hasty search tasks. Reflectors are areas of special interest: attractions
such as mountain peaks, hazards such as places where it is hard to follow the trail, or simply
places where lost people seem to end up.

Ramping Up to a Big Search

Whether in the city or in the wilds, finding lost people is usually considered a law enforcement
function, so it is usually the local law enforcement agency—sheriff or police or park/forest
rangers—who handle the initial call and perform the initial investigation; sometimes, they will
perform some of the initial searching, too. But when an individual or a group is overdue after a
trip into the wilds, and as time goes on and more and more and more people and organizations
get involved in the search, finding them can get more complicated, and more complicated, and
more complicated, not in a linear but in an exponential fashion. Given the time pressure,
organizing the searchers can be a nearly overwhelming challenge, which is one reason the
Incident Command System (ICS) is essential for such large operations. ICS for WEMS and SAR
operations is described in more detail in Chapter 3. In addition to the organizational challenges,
the operation needs people expert at the specifics of search management to serve in Base, and
people expert at search tactics to serve in the field. This is often met by local wilderness SAR
teams, who supplement local law enforcement and generally work under their direction. Getting
such professional volunteers involved early allows local law enforcement to keep a grip on the
operation, especially as less-well-trained responders (fire, EMS, others) show up and need to be
managed by trained search managers in Base and led by trained leaders in the field.
Unless you find the person right away with hasty search tasks, a lost-person search becomes
a mystery, and to solve a mystery you must search for clues. While teams search for clues in the
field, many clues are found not in the field. There is a saying in medicine that 80% of the
diagnosis comes from the history, and only 20% from a physical exam and laboratory tests. The
same thing applies to lost-person search: The best and most clues come from gathering a history.
What’s the lost person’s name? Physical description? Fitness and medical conditions? Outdoor
experience? Clothing and gear? What was he or she doing: Hiking? Climbing? Hunting?
Fishing? Where was he or she going? When was he or she supposed to be back? Did he or she
mention alternate routes? Was he or she despondent?
While a search in the United States almost always runs under the ICS—and wilderness SAR
teams are expert at using the ICS and its forms—there are two additional forms that wilderness
SAR teams almost always use. One, the TAF, we will discuss later. The other, the MPQ, is used
to help gather this information. You can find an evidence-based MPQ in an appendix to Lost
Person Behavior.12 Law enforcement officers are generally very good at investigating missing
person situations, but when it comes to a person lost in the wilderness, sometimes SAR teams
find additional information helpful, and the MPQ is very helpful in preventing you having to go
back and say “there’s one more question I need to ask. . .”
FIGURE 30.6. Map of bike wheel model.

A large lost-person search operation will put hundreds of people in harm’s way. It will
juxtapose many different agencies and organizations, with different cultures, procedures, and
goals. Just to keep the people and agencies working together without bloodshed is a test of any
manager’s capabilities. Getting all of them to cooperate in doing an effective job is an ever-
bigger challenge. While similar in some ways to managing a large wildfire, lost-person search
has its own peculiarities. And this usually happens at a place with little or nothing in the way of
food, shelter, electricity or communications, which nonetheless becomes a place called Base. The
ICS calls the place where the Command Staff is the Incident Command Post (ICP), reserving the
term Base for a logistical center that may be at a different location.24 But for lost-person
searches, Base and the ICP are usually co-located. And, since they first evolved in the 1940s or
so (long before the ICS), wilderness SAR teams have used the term “Base” and this seems likely
to persist. On the radio, it is easier to say “Base, this is Team Alfa” instead of “Incident
Command Post, this is Team Alfa,” which tends to reinforce this usage.

Search Management Processes and Technology

The ICS was developed to deal with wildland fires, and then mandated for intergovernmental
incidents in which the U.S. Federal government is involved. Almost all non-Federal emergency
service agencies in the United States have adopted the ICS, with variable degrees of penetration.
While most EMS personnel have some familiarity with the ICS, it does not much affect their
day-to-day operations. But SAR personnel eat, drink, and sleep thinking about the ICS, because
they use it almost every time they respond to an operation. The ICS itself is designed to be an all-
risk* incident management system that can be applied to almost any incident, and in this it
succeeds, with the degree of success dependent on the participants’ knowledge of, and
compliance with, the ICS. However, some search managers find the ICS forms unsuitable for
large or even small lost-person searches. For example, the ICS Form 207 (table of organization)
for decades betrayed its roots in wildland fire by having a box for “Air Tanker/Fixed Wing
Coordinator.” The ICS forms have evolved to be more general-purpose and generally better, but
specialized forms for lost-person search, which predate the ICS, remain in use by many SAR
teams, though they too have evolved over the decades.

Table 30.1 Reflex Tasking Using the Bike Wheel Model

Reflex Tasking
Axle
1. Plot the Initial Planning Point (IPP) • Preserve
• Immediate locale search
• If a structure, search and re-search repeatedly
• Signcutters/trackers
• Tracking/trailing dogs
Rim
2. Determine subject category. • Establish containment.
3. Determine statistical ring. • Consider camp-ins, road/trail blocks, track traps, patrols,
4. Draw 50% and 95% rings. attraction, and string lines.
5. Reduce search area using subjective and deductive
reasoning.
6. Mark boundary on map.
Hub
7. Mark 25% ring if appropriate. • Canvass campgrounds, if appropriate.
• Thoroughly search from IPP to 25% when less than 0.2
miles/0.3 km.
Spokes
8. Draw travel routes: • Conduct hasty search of trails, roads, drainages, and other
a. Blue lines (water features, drainages) travel routes leading away from IPP.
b. Dashed lines (trails) • Emphasis at likely decision points.
c. Black/red lines (roads, man-made features)
d. Travel corridors (ridges, contours)
e. Corridor tasks, if appropriate
Reflector
9. Mark high probability/hazard areas • Send hasty teams to areas of high probability, high hazard,
10. Prioritize and deploy tasks using quick consensus method historic locations of finds.
© 2011 by dbS Productions. Adapted from Lost Person Behavior by Robert J Koester. Reproduced with permission.

In 1992, Conover (one of the authors) developed, as a draft for discussion within the
Pennsylvania Search and Rescue Council, a set of ICS-type forms specific for running a lost-
person search operation. These forms, including a non-ICS MPQ and non-ICS TAF, were
immediately adopted without discussion and are still used today in Pennsylvania for lost-person
searches, but may be freely used in other jurisdictions.†
A TAF, shown in Figure 30.7, is central to lost-person search management. Search managers
have tried a variety of means for tracking individual field teams, including the T-cards‡ used by
the wildland fire service, and various computer-based systems. But since the TAF was developed
by the ASRC in the mid-1970s,§ it has been enduringly popular for managing the many teams
and tasks required for a large lost-person search. Indeed, the ICS Form 204, which started as the
Division Assignment List, has slowly evolved to look more like a TAF and is now called
Assignment List.25
The ICS Plans Section (Plans) fills out the upper portions of the TAF’s front page, indicating
what they want done, and how they want it done. The Plans section then hands a pile of TAFs to
the ICS Operations Section (Ops), which then matches the tasks with the searchers (who), both
human and canine, and completes the middle sections as they dispatch teams into the field
(when). When teams arrive back in Base, or complete a task and report in via radio or cell phone,
the Ops Section works with the FTL to gather useful information from the team’s task. Ops then
files the completed TAFs where Plans can use the information from them to plan the strategy and
create the tasks (the top of the TAF) for the next operational period.
FIGURE 30.7. A, Generic task assignment form (TAF), first page. Upper portion completed by Plans Section, middle sections
completed by Operations Section. This TAF is specifically designed to be used either as a printed form filled out with pen or
pencil, or as a fillable PDF typed into on a computer. A PDF version of this form is available at http://www.conovers.org/ftp/ics-
TAF-2.0h.pdf; updated versions will also be posted at http://www.conovers.org/ftp/. Illustration by Keith Conover, MD, FACEP.
Used with permission. B, Back of generic TAF: debriefing. Completed when team returns to Base or reports completion of task
over radio or cell phone. Illustration by Keith Conover, MD, FACEP. Used with permission.

On small searches (which sometimes go on to become large searches), there may just be two
people at Base, one who is mostly on the radio and another who does most of the paperwork; in
this common scenario, there is not much differentiation into four standard ICS Sections. The
person who is doing most of the paperwork and dispatching the teams, as opposed to issuing
handheld radios and setting up and communicating using the Base radio, is mostly doing Plans
and Ops, and this position has gotten to be called Plops. Really. And Plops’ main job is to get the
TAFs done and to get teams into the field ASAP. There is always tension between field
personnel wanting to get into the field and Base personnel wanting to keep the paperwork
straight. Experienced field personnel, especially those who have spent some time in Base before,
recognize the critical importance of this paperwork, and will often help out for a bit until they go
into the field.
ICS in the WEMS and SAR environment is discussed in more detail in Chapter 3.

SAR Technology
Technology affects all our lives at an increasing pace, and lost-person search is no exception.
Pencil, paper, carbon paper, and the printing press sufficed to allow generations of search
managers to develop sophisticated operational doctrines and procedures that saved the lives of
innumerable people lost or injured in the backcountry, as evidenced by search management
courses, and tools such as the PSARC forms packet and the TAF. “NCR sets,” two- or three-part
pressure-sensitive forms, are in common use particularly for TAFs, but represent just a minor
improvement over carbon paper. Water-resistant two-part form paper for laser printing is now
available, another incremental advance.*
Photocopiers came into wide use in the 1970s. Combined with clear acetate grid overlays,
this allowed search managers to create gridded grayscale letter-size photocopies of USGS
topographic maps. Having the same gridded map for the field team and the search base allowed
much better communication of team and subject locations. For many years, a feature of searches
was digging through a large supply of USGS topographic quadrangle maps to find the right one,
then sending someone from Base, with an original USGS map and an acetate grid overlay, to a
distant location where there was a photocopier, to prepare more maps.† While this type of grid
system has mostly gone by the wayside, the acetate grid overlays are still sometimes pulled out
to photocopy a park or forest map with much more trail detail than available from the USGS
maps. Another use of this type of grid overlay is in cave search; given caves are three-
dimensional, cave maps often include not only a bird’s-eye (bat’s-eye?) top view, but also side
views of some cave passages, and even sketches showing how to find the entrance in a cliff. For
example, Allegheny Mountain Rescue Group, which is also a cave SAR team, has PDF and
printed cave maps with an extended ASRC grid added to the map, so you can use the grid
coordinates to refer to a specific point on the side view or entrance-cliff sketch on the map.
Technology continues to change. Now we have GPS units, smartphone GPS/map apps,
Universal Transverse Mercator (UTM) grids printed on USGS maps, and digital raster graphics
(DRG) versions of USGS maps that can be printed, sometimes even in color on water-resistant or
waterproof paper. The advent of laptop computers and portable printers has eliminated the need
for a large cache of printed maps, and the routine use of acetate grid overlays for photocopying
maps for field teams. (It does, however, makes having AC power or a generator at Base more
important than it used to be.) It has also, to a degree, eliminated the need for a large USGS
master map of the search, with clear acetate overlays with colored markings for each day’s
search efforts. Even the maps printed at Base are being threatened by maps that can be sent to a
GPS unit or a smartphone GPS app, but given the vicissitudes of electronic equipment, battery
life, and the small screens of GPS devices and smartphones, printed maps are still in demand.
Another significant advance was simply to have PDF versions of ICS and other forms that
could be filled out on a laptop, and saved as well as printed. Laptops and printers are also
threatening to replace much of the other paperwork of a large search operation.
Some of the earliest computer programs for SAR were to simplify the Mattson Consensus
and other computationally intensive jobs such as dealing with shifting POA. One of the earliest
such programs, in the 1970s, was CASIE‡ (Computer-Aided Search Exchange), a DOS program
which is now available in an updated Windows version.§
Another program that automates search planning and operations is Incident Commander
Pro,¶ which now integrates some GIS features. This software is known for its facility in dealing
with trail-based POA calculations.
SARtopo** is a free, online shared workspace with USGS topographic maps. Multiple people
can be looking at the same segmented map at the same time, and can associate data (usually
called metadata) with a line or polygonal area on the map that represents a task. From the
metadata for a hasty-search line or area segment on the map, SARtopo can generate a TAF-like
printout. It is relatively simple to use.
An aggressive map-based approach has been spearheaded by Dr. Donald Ferguson of West
Virginia University and the ASRC’s Mountaineer Area Rescue Group. It uses the GIS ArcGIS,
with specialized overlays, to prepare TAFs and maps. Called Integrated Geospatial Tools for
Search and Rescue (IGT4SAR),* it is a free template. It is one of the best-known GIS-based SAR
tools, so it is worth looking further at its capabilities.
ArcGIS is the best-known and most widely used GIS. It is a commercial product with a paid
subscription; discounts are available to nonprofits such as SAR teams. Given that governments
and agencies worldwide use it, ArcGIS is a mature product with more capabilities than SARtopo,
though it is complex and harder to learn than SARtopo.† When using IGT4SAR, you deal with
IGT4SAR more than the underlying ArcGIS, which makes the learning curve much easier.
IGT4SAR can combine statistical data, such as that provided in Lost Person Behavior, with
terrain and trail information to provide locale-specific probabilities, so you can assign POA to
segments with some assurance of using the best information available.
Since the IGT4SAR maps are based on a GIS, they can have more detail than USGS
topographic maps, such as updated trails; it is also possible to georeference (resize and align to
fit the underlying map), for example, an overlay of a Park map that has lots of detail about trails
and other features. The assigned task can be highlighted on the map electronically without the
old standby of a highlighter on photocopied maps.
IGT4SAR can also generate TAFs for teams with attached maps, and keep a file of them for
quick reference as needed. This replaces the standard Tasks Planned, Tasks in Field, and Tasks
Completed folders that have been a feature of large searches for decades.
IGT4SAR also can provide printed maps with more information than standard USGS
topographic maps, including updated trail information and communications coverage. Park and
forest maps, with details of trails and facilities not available on USGS maps, are increasingly
available in PDF or graphic formats. You can import one into IGT4SAR, georeference it, and
overlay it to correspond precisely with the underlying topographic map. You can then print it out
for field teams with standard map grids, serving as a supplement to a standard topographic map,
or as a semitransparent overlay on a topographic map.
Dedicated GPS units with Automated Position Reporting Systems are sometimes issued to
teams, which allows real-time tracking of teams in the field using IGT4SAR. Other teams have
used satellite tracking devices to track teams when an Internet connection is available.
Team members with a GPS or with smartphones and a GPS app such as BackCountry
Navigator for Android, or Gaia for the iPhone, can also record a track and add waypoints for
clues or other important points. When they return to Base, they can use the smartphone’s
Bluetooth (or another method for dedicated GPS units) to download their GPS tracks and
waypoints to a laptop computer where this gets associated with the record for that task in
IGT4SAR.
Having all this information in IGT4SAR means that search managers may easily access the
relevant data for a focused area. In the past, this meant dealing with many separate printed maps
and TAFs, and multiple operational periods’ individual clear acetate map overlays with
segments, coverage and other information scribbled on them in different colors of grease pencil
or marker.
A thesis providing an overview of the many uses of computer-based mapping for wilderness
SAR is available online.26 See also Figures 30.8 and 30.9.
The Department of Homeland Security Science & Technology Directorate First Responder
Group is working with one of the authors (Koester) to develop software named FIND.‡ FIND
integrates GIS-type mapping (with a new custom topographic map), search theory, and search
management. It is a turn-key solution and does not require any GIS-specific knowledge. FIND
integrates all lost-person behavior spatial models to display a combined heat map, a graphic
representation of the POA, where denser color or three-dimensional elevation corresponds to the
POA. This allows search managers to assign POA to segments using what all the scientific,
evidence-based models say about where the subject might be. It takes this one step further and
determines a PSR,§ perhaps the best measure of search effort, automatically.
If you do a Mattson Consensus, FIND will integrate it with the probabilities provided by the
other models. It will then suggest initial search tasks for first responders, and use search theory to
prioritize those tasks. As the search progresses, it will calculate PODs, shift the POA, and then
update the probability of success values; thus, you can allocate your resources optimally. From
an operations standpoint, it also tracks teams and tasks, using forms like the TAF. There are
several dashboards that provide quick views of essential information showing how the search is
progressing (Figure 30.10 to 30.14).
FIGURE 30.8. IGT4SAR Tactical Field Assignment Map. Produced by Integrated Geospatial Tools for Search and Rescue
(IGT4SAR), this map provides Field Teams information regarding the location and surroundings for assigned task. Combined
with a completed Task Assignment Form or ICS 204 form, this map should provide adequate information for the Field Team to
conduct its assigned task effectively and safely. Illustration by Don Ferguson, PhD of West Virginia University and the
Appalachian Search and Rescue Conference’s Mountaineer Area Rescue Group. Used with permission.

FIGURE 30.9. IGT4SAR Incident Action Plan Map. Produced by Integrated Geospatial Tools for Search and Rescue
(IGT4SAR), this map and text effectively communicate geographic feature relationships and incident management objectives on
an incident. This map is included in the ICS Incident Action Plan (IAP). Illustration by Don Ferguson, PhD of West Virginia
University and the Appalachian Search and Rescue Conference’s Mountaineer Area Rescue Group. Used with permission.

Remote Support
In the first two decades of the 21st century, we have developed technologies to allow people to
collaborate remotely. And in the past few years, these technologies have become widespread and
easier to use. Skype, Google Docs, Dropbox, and broadband on cell phones are well-known
examples. This infrastructure now allows people who are far apart (perhaps even on a different
continent) to work together for search management.
A truism for almost all lost-person searches is there are never enough trained-person-hours
available in Base. Most search managers are also field-capable, and there is pressure to send just
one more team out. And as a search ramps up in size, the number of Base personnel never seems
to ramp quite enough to meet the need. Planning tasks and generating the TAFs and maps for the
next operational period is one of the great time-sinks in Base, and doing it well takes even more
time.
 One way to meet this need for trained-person-hours in base is remote support. At its root,
this just means getting someone who is not at Base to help. Here is a simple example. You know
a retired park ranger who moved away from the area. But she has run multiple searches in this
same area and knows where people tend to be lost. You look in your cell phone, find her new
phone number, and give her a call for advice about which segments to search first. She answers,
and you put your cell phone in speaker mode so the rest of your incident staff can hear the
conversation. In a matter of minutes, her advice persuades your entire management team to
reorder your segment priorities.
There are two problems with using remote planning, even in this simplest form. First,
realizing that remote planning should be part of your procedures, and second, having a system
for identifying and contacting such knowledgeable individuals. But remote planning can go far
beyond this.

FIGURE 30.10. FIND Displacement Model Map. This and the following model maps show the model’s prediction for where
the subject is as a brown tint. The degree of tint corresponds with the probability density. The higher the probability, the darker
the tint. Based on statistics specific to the subject’s profile, such as in Lost Person Behavior, this map displays the probability
density, for horizontal distance traveled from the IPP, as the crow flies. The outer ring boundary encloses the area with a 95%
Probability of Area (POA). Each model is specific for subject category (eg, ecoregion domain, topology, and population density.
Illustration by Robert Koester. Used with permission.
 For a more technological example, you could be sitting at home in front of your computer in
your bathrobe. With IGT4SAR you can produce TAFs and maps, or with SARtopo you can
produce maps and TAF-like documents. You can then send them electronically, even with a low-
bandwidth Internet connection, and those at Base can print them.
We should make a careful distinction between remote planning and remote support. Planning
is likely the first technology-enabled remote support process for most SAR teams. But remote
support can be more than just planning tasks for the next operational shift, that is, more than
creating maps and TAFs. For example, remote support can also include analyzing UAV (drone)
data, either stills or video, to identify potential suspicious areas which field teams should check.
One of the challenges of remote support is to develop such resources; SAR team members
who have moved away are an obvious choice, but there may be other ways to develop such
trained people. Another challenge is to develop a system to activate remote resources when they
are needed.

DOWNED AIRCRAFT SEARCH

Wilderness SAR teams sometimes work with other organizations, such as the Civil Air Patrol, to
find downed aircraft. Downed aircraft search is very different than lost-person search:
containment’s impossible, and the search area is vast. Satellites and aircraft may detect a radio
signal from an Electronic Locator Transmitter (ELT), which has gone off when the airplane
crash-landed or when those aboard the aircraft triggered it. (Many such alerts turn out to be from
an aircraft in a hangar, when the ELT was accidentally triggered, but these are usually quickly
dealt with.) Clues such as radar, flight-plan information, or cellular forensics (cell phone tower
information) may also narrow down the search area.27
In such cases, vehicle-based teams may drive around the area, interviewing local people.
They ask about low-flying planes, or planes that sounded like they were having engine trouble,
or perhaps the smell of fuel, at about the time the plane was lost. They also sometimes take
handheld ELT locators, special directional radio receivers that may pick up a signal. If they pick
up a signal and are able to establish the direction, sometimes they can coordinate with other
teams to triangulate on an ELT signal to get a more precise location.
FIGURE 30.11. FIND Dispersion Model Map. Based on statistics specific to the subject’s profile, such as in Lost Person
Behavior, this map displays the probability density based on the angle between direction of travel and find location. Illustration
by Robert Koester. Used with permission.

Wilderness SAR teams are sometimes vectored in to a crash site by a low-flying aircraft or
helicopter that has seen a possible crash site from the air. But if the forest canopy is thick, or it is
not flying weather, field teams may need to search the area in a manner not much different than
that for a lost-person search. ELT locators are small enough to be carried and are sometimes
issued to field teams to use to close in on the crash site.

SEARCH AND RESCUE POLITICS AND REGIONAL

VARIATIONS
As is famously true of volunteer fire departments and EMS services, SAR turf is a big deal.* We
know that emergency services workers, paid or volunteer, need to be needed and need to be in
control and are action-oriented. These are important survival characteristics for emergency
services workers, but predictably they lead to interpersonal and interorganizational conflict in
emergency services organizations, particularly volunteer ones. If you search the Web, you can
find videos of EMS agencies fighting over patients. If you are getting involved in WEMS, you
are also getting involved in wilderness SAR, and being aware of such issues is critical to your
success. As former Speaker of the U.S. House of Representatives Tip O’Neill† famously
observed, “all politics is local,” and the same might be said of wilderness SAR. And so a careful
survey of the local SAR and EMS political landscape is important for anyone getting involved in
WEMS.
An understanding of the personalities and organizations and their conflicts and alliances is
critical, but it is also important to understand the official lines of authority and responsibility in
the area. The sociopolitical organization of wilderness SAR teams in the United States is
heterogeneous, not only due to local variation, but also in that it is very different in the East and
the West. The flatter central part of the continent has much less in the way of wilderness and thus
fewer wilderness SAR teams.

FIGURE 30.12. FIND Elevation Model Map. Based on statistics specific to the subject’s profile, such as in Lost Person
Behavior, this map displays the probability density based on the probability of the subject going uphill, downhill, or staying at the
same elevation. Illustration by Robert Koester. Used with permission.

In the western parts of the United States, each mountainous county tends to have a single
SAR team, usually volunteer, but under the direct control of the sheriff’s office. A deputy sheriff
is usually appointed to be in charge of the team. Some of the larger western teams also have
deputies who respond to SAR incidents on a regular basis, although in some of the larger
counties (for instance, Los Angeles) sheriff’s deputies are charged with SAR and provide the
primary response. Counties with large urban areas tend to have several wilderness SAR teams,
each with their own specialties, such as search dogs, high-mountain/alpine rescue, or four-wheel-
drive vehicles. These teams may also be under the direct control of the sheriff’s office as well.
In the eastern parts of the United States, counties are smaller, the mountains and wild areas
are also smaller, and even rural areas are much more highly populated than in the west. In the
East, given the higher rural population, the functions of eastern SAR teams are often carried out
by the many local fire departments and EMS agencies. But there are also SAR teams that
specialize in lost-person search management and wilderness rescue, usually covering a multi-
county region, and which provide a backup or sometimes primary response to wilderness SAR
situations.

FORCE PROTECTION
From a WEMS perspective, you should think about having 400 people out in the wilderness (or
at least a relatively wild area) searching: the opportunities for illness and injury are impressive.
Even for a small search or rescue, teams are sometimes in the field for a protracted time.*
The term force protection might suggest armed guards protecting against terrorist or criminal
attacks. A more WEMS-oriented view considers it to include protection against illness and
injury, and treatment of minor illnesses and injuries. The goal is to keep team members
operational by providing simple medical interventions, often oral medications, that are generally
outside the standard scope of practice of a street EMT or paramedic. The target of this type of
force protection is not the search subject or rescue victim, but the team members themselves.
FIGURE 30.13. FIND Track Offset Model Map. Based on statistics specific to the subject’s profile, such as in Lost Person
Behavior, this map displays the probability density based on the probability of the subject’s likely distance from a linear feature
(road, trail, stream, or infrastructure). Illustration by Robert Koester. Used with permission.

Back in the day, the standard of care was to dispatch an unused funeral hearse to bring the
patient to a hospital emergency room, literally a single large room with many cots in it. With the
rise of EMTs and paramedics and well-equipped ambulances, it was said that the goal of EMS is
to bring the hospital to the patient, but this stopped at the roadhead. Indeed, for many decades,
Pennsylvania’s EMS law extended only to care in or near an ambulance. We now might say,
consistent with this tradition, that the goal of WEMS is to bring the hospital (or many of its
resources) all the way to the patient, even if far from the road. If we continue in this vein, then
you can think of force protection, not only as bringing part of the hospital’s ED along with the
team, but also as bringing the urgent care center along with the team.
We know from many studies that ankle injuries are very common in the backcountry, and
there is no reason that SAR team members will be spared from this. If the EMS personnel on
field teams are trained to apply the Ottawa Ankle Criteria, then they can determine in the field
whether a team member needs X-rays or not. And if the team member does not need X-rays, then
an urgent evacuation is not needed, and the ankle can be taped and the member can either
continue with the task or walk out if necessary. If necessary, another team could bring an air
stirrup type ankle brace to aid in self evacuation, though this requires the preplanning to keep
such braces at Base. Another example would be for teams to carry agents to control minor
medical conditions such as diarrhea that could impair a member’s ability to carry out SAR tasks
(imagine if it is a cave rescue). Some of this material has crept into WEMT and Tactical
Paramedic training: dealing with sprained ankles, blisters, and minor lacerations.
If it is a nice late spring or early fall day, environmental concerns for your searchers may be
minimal. But during high summer or deep winter, force protection may also mean monitoring
heat, humidity, cold, and weather and their effects on field teams. Arranging and staffing
rest/rehab areas, with appropriate rehab for searchers, is another force-protection consideration.
Force protection could include screening searchers heading to the rehab area for medical needs,
and even more importantly screening searchers coming out of the rehab area for return to duty.
These tasks sometime involve complex medical decision-making, and represent an important
force-protection role for EMS personnel at Base.

FIGURE 30.14. FIND Watershed Model Map. Based on statistics specific to the subject’s profile, such as in Lost Person
Behavior, this map displays the probability density based on the probability of the subject’s being found in the same, adjacent, or
beyond the adjacent watershed. Illustration by Robert Koester. Used with permission.
 Force protection may also involve public health aspects at the team level between operations.
This might involve screening team members for medical conditions that might cause problems in
the field, and personal physical fitness evaluations, such as screening members for, supervising
training for and testing members to the standard fire-service work capacity test28:

Arduous: 3-mile level hike with 45-lb pack in 45 minutes

Moderate: 2-mile level hike with 25-lb pack in 30 minutes
Light: 1-mile level hike in 16 minutes.

While this work-capacity test of aerobic and walking fitness is designed for wildland
firefighters, it has been adopted, as-is or slightly modified, in many other disciplines. Some SAR
teams have adopted alternative tests involving actual wildland trails with rough footing and
elevation change.

RESCUE
Providing medical care during technical rescue, and during cave rescues, is covered in Chapters
24, 25, and 29.
But most wilderness rescues are not technical and not in a cave. Most wilderness rescue
involves carrying a litter over terrain that varies from easy to difficult. In SAR we tend to talk of
evacuation (“evac”), which is getting the patient from the incident site to the roadhead, whereas
transportation is from the roadhead to the hospital. We generally categorize evacs as follows:

Nontechnical Evacs: when ropes and technical rope-rescue hardware are not needed.
Semi-Technical Evacs: when the terrain is steep enough to require a belay (safety rope) for
the litter, but not for the litter bearers, though litter bearers may be clipped into the litter for
additional security and to make the evacuation more efficient.
Technical Rescue: when specialized vertical rescue techniques are needed, such as
lowering a litter down a cliff, or raising it up a cliff. If it is not a cliff, but it is steep enough
to need the same techniques, it is still technical rescue.

Most wilderness rescues are nontechnical evacs. A sizable minority are semi-tech evacs. A
small fraction are true technical rescues. The distribution depends quite a lot where you are; for
instance, in the Boundary Waters Canoe Area Wilderness, which includes the highest peak in
Minnesota, Eagle Mountain (701 m [2,301 ft]), technical rescues are unlikely, while in Rocky
Mountain National Park, where the road elevations vary between 2,350 m (about 7,800 ft) and
3,713 m (12,183 ft), technical rescues are more likely. Nonetheless, even in very rugged
mountains, there tends to be plenty of what is often called “humping the litter down a trail.”
Learning how to conduct nontechnical and semitechnical evacuations is beyond the scope of
this chapter. However, for those wishing to learn, a free text on the topic is available online.29
There are a few things about nontechnical and semi-tech evacs specific to WEMS that you
should know. First, position on the litter team. On level or fairly level ground, it is standard to
have six litter bearers. And regardless of which direction you are headed, the usual standard is to
have the litter handler in the front left (the “driver’s seat,” at least in the United States) be the
litter captain. The litter captain gives instructions to the rest of the litter. If the litter must back
up, then whoever’s now in the front left is the litter captain. If it is a semi-tech evac, then the
litter captain is also the one who communicates, on behalf of the entire litter team, with the
rope/belay team.
There are good arguments that the top medical person on the team—referred to here as the
medic—should not help carry the litter, but should just walk along with the litter all the time, as
litter bearers get fatigued and rotate out of carrying the litter. That means the medic can continue
to stay with the litter. This does not always work. Sometimes there is just no way to stay right
with the litter without helping to carry it, especially in narrow cave passages or along a narrow
trail. And, for that matter, there may not be enough litter bearers to spare the medic from having
to help hump the litter. If the medic has to be on the litter, then the medic should be the one and
only person who talks to the patient. Having six people chattering with the patient is confusing
for the litter team and the medic, not to mention distressing unprofessional behavior from the
patient’s perspective.
Another standard, though not as standard as the litter captain, is that the litter bearer in the
front right is the speaker. If the patient does not have much in the way of medical problems, let
us just say a badly sprained ankle, then there is not much need for the medic to talk with the
patient all that much. But it is still unprofessional to have everyone on the litter team chatting
with the patient. So that person in “the shotgun seat,” the front right, should be the speaker and
the only one to be chatting with the patient unless the patient initiates a conversation with one of
the other litter bearers.
One other issue with evacuations, even nontechnical ones, is of keeping medical records.
This is discussed in more detail in Chapter 31. A detailed discussion of the issues around a field
medical record, and a recommended record form, has been published by the ASRC.* The major
conclusions were that electronic systems are not yet reliable, flexible, and hardy enough to
replace paper, that water-resistant paper is a must, and two-part forms on water-resistant paper so
that a copy can easily be handed off to during a transfer to another EMS service. Other
considerations include:

Small: Fits in a cargo pocket, big shirt pocket, or parka pocket.

Big: big enough to reasonably write on.
Light.
Durable.
Works in rain and snow.
Should have mnemonics with it, either on the forms themselves or on a separate page, to
help remind us how to do good medical charting.
Should follow principles of good form design and good information design, as expressed in
Forms for People30 and the work of Yale’s Edward Tufte.31–35
Suitable for adding additional reference pages for not only medical reference material, but
also generic SAR references.

References
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3. National Search and Rescue Committee (U.S.). Land Search and Rescue Addendum to the National Search and Rescue
Supplement to the International Aeronautical and Maritime Search and Rescue Manual. Charlottesville, VA: dbS
Productions; 2012.
4. Young CS, Wehbring J. Urban Search: Managing Missing Person Searches in the Urban Environment. Charlottesville,
 VA: dbS Productions; 2007.
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at http://sartechnology.ca/sartechnology/ST_TrailPOA.htm. Accessed August 19, 2017.
20. Koopman BO. A theoretical basis for method of search and screening. DTIC Document; 1946.
21. Koopman BO. Search and Screening: General Principles with Historical Applications. New York, NY: Pergamon Press;
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22. Surowiecki J. The Wisdom of Crowds: Why the many are Smarter than the few and How Collective Wisdom Shapes
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subjects in New Zealand mountainous terrain; 2013:1. Available at: www journalofsar org. Accessed July 1, 2017.
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dbS Productions; 2014.
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Accessed August 19, 2017.
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USDA Forest Service, Technology and Development Center; 1998.
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*http://www.mngeo.state.mn.us/committee/emprep/download/USNG/2011_1118_Published_Land_SAR_Addendum_1.0.pdf.
†The international standards-setting organization American Society of Testing and Materials International (ASTM)’s Committee
F-32 on Search and Rescue uses the term land search and rescue extensively; however, this term is not commonly used in the
broader search and rescue community.
‡For example, New York State has state wilderness areas in the Adirondack and Catskill mountains.
*Unlike wool, cotton retains water against the foot, making the foot colder in cold environments, also keeping the foot damp and
making blisters more likely. Cotton under the sole of your foot mats down and becomes hard, but wool socks retain their
cushioning effect on the sole.
†Experienced members who serve in the field also quickly learn to appreciate the particular competencies of those who stay at
base and keep the operation running. And there are those who, in this increasingly Internet-connected world, stay at home in their
pajamas and help with remote support, which is discussed later.
‡Although trains are not usually considered search resources, some wild areas are traversed only by train tracks, so interviewing
the crew of trains passing through might be helpful.
*Some dogs are trained to sniff individual tracks to follow a subject, and this is sometimes called canine tracking, but trailing is a
more common method for dogs to follow a subject.
†http://www.navcen.uscg.gov/pdf/theory_of_search.pdf; note that this paper uses probability of containment (POC) for what is
more commonly called probability of area (POA); POA is the terminology adopted in this chapter. Note also that in this
document equations 2.4 and 2.91 are missing some minus signs; equation 2.4 should read “POCafter = POCbefore × (1 − POD) and
equation 2.91 should read PODc = 1 − (1 − 0.6)(1 − 0.7) = −0.88.
*Purists insist we call this conditional probability but probability is good enough for everyday use.
*Some question whether we really need to include the ROW, but it is traditional.
*The earliest we could find this phrase in English was in an 1811 edition of The Examiner, but it probably predates this; the
concept dates back at least as far as Aristotle.
*http://www.forcecom.uscg.mil/Our-Organization/FORCECOM-UNITS/TraCen-Yorktown/Training/Maritime-Search-
Rescue/Inland-SAR/BISC-Course/
†http://www.forcecom.uscg.mil/Our-Organization/FORCECOM-UNITS/TraCen-Yorktown/Training/Maritime-Search-
Rescue/Inland-SAR/Inland-Course/
*No specialty is complete unless it is rife with three letter acronyms (TLAs).
*In simple terms, that means it works for a forest fire, a lost person search, or a visit by the Pope or the Queen of England.
†http://conovers.org/ftp/PSARC-Archive/PSARCForms/sarfrm10.pdf
‡T-shaped cards that can be inserted in slots on a large rack for easy viewing and manipulation.
§http://archive.asrc.net/ASRC-Operations/ASRC-Operations-Manual/1976-09-00-ASRC-Operations-Manual-V.pdf.
*http://www.riteintherain.com, 2-part Carbonless Copier Paper
†A system for doing this is described in http://archive.asrc.net/ASRC-Operations/1982-12-02-ASRC-Grid.pdf. A set of graphic
formats of the grid overlay may be found in http://archive.asrc.net/ASRC-Operations/2015-11-06-ASRC-Grid.zip.
‡http://math.arizona.edu/˜dsl/casie/whatis.htm.
§http://www.wcasie.com/.
¶http://sartechnology.ca/sartechnology/ST_ProgramOverview.htm.
*http://sarsoft.org/, https://sartopo.com/.
*https://github.com/dferguso/MapSAR_Ex which also has a PDF available that explains the capabilities of IGT4SAR in much
more detail than presented here; several video tutorials are posted on YouTube as well.
†Alternatives to ArcGIS, including free and open-source options, are available, but none that we know of provide powerful tools
designed for lost-person search.
‡https://www.dhs.gov/science-and-technology/news/2016/09/01/snapshot-find-offers-simple-guidance-lost-person-searches.
§PSR is officially defined as the instantaneous rate of change in POS for adding one more increment of effort (one more
searcher) to a search segment. Another way to understand this is the probability of locating the subject per unit time. The
equation is PSR = W × V × Pden. It factors in the detectability of the subject W (sweep width), the velocity of the searcher V,
and the missing subject’s probability of area density for the search area of interest Pden.
*As far as we can tell from online searching, this term and the term turf war developed in the 1970s to describe the wars between
urban youth gangs over which blocks they controlled. But it seems to us this term was in current use by volunteer fire
departments even back then, so perhaps street gangs stole the term from the fire service.
†December 9, 1912 to January 5, 1994; Speaker 1977-1987.
*https://www.fs.fed.us/fire/safety/wct/pdf03512805dpi300.pdf and http://www.conovers.org/ftp/SAR-Evacs.pdf
*http://archive.asrc.net/ASRC-Medical/2016-01-17-ASRC-Patient-Record-Form-1.0.pdf.
INTRODUCTION
The alpine environment offers outdoor and snow enthusiasts almost limitless opportunities for
recreation and sport. With those opportunities comes equally limitless opportunities for injury
and illness. While the medical and traumatic processes are similar to those encountered in other
urban and wilderness environments, ice, snow, and cold temperatures offer unique challenges in
patient assessment, care, rescue, and transport. From a wilderness emergency medical services
(WEMS) perspective, these environments can be generally divided into those in which WEMS is
provided by ski patrols and those in which WEMS is provided by mountain rescue teams.
Granting that there is significant potential for overlap between these groups, nonetheless the
unique challenges faced in each of these environments make this division useful for planning and
training purposes.
Although widely used, the term “ski patroller” has no specific definition in terms of training
and scope of practice. Starting as small groups of skiers dedicated to safety at a few resorts,
alpine ski patrols are now essentially ubiquitous throughout the ski resort industry. The practice
of a ski patroller is influenced by regulatory, administrative, and environmental influences. As
frontline WEMS providers in a wide variety of practice settings, ski patrollers are vital links
between the general public and front country EMS systems. While the illnesses and injuries they
care for match those seen in other WEMS environments, there are significant differences in
transport, rescue, and evacuation techniques used by ski patrollers versus other WEMS
disciplines.
Also note that in terms of training and scope of practice we use an expanded definition of
“physician medical oversight” in this chapter. We use it here to represent the requisite oversight
any EMS system must have for non-clinicians. Consistent with most state laws, published
consensus of wilderness medicine and EMS educators, regulators, and clinicians, and with the
National EMS Scope of Practice Model, physician medical oversight and collaboration must be
present in the organizational structure.19,33 However, a physician may defer certain portions of
that medical oversight to other qualified clinicians (like APRNs or PAs). Throughout this
chapter, “physician medical oversight” also includes such arrangements with collaborative
providers who reinforce and supplement that required physician oversight.
Defining the role of a mountain rescue unit (MRU) is a unique challenge that may present as
much variability as the terrain in which these groups operate. With the formation of the
Mountain Rescue Association (MRA) in 1959 (see Chapter 1), many MRUs have pursued
technical accreditation validating their unique skillset in technical terrain. This association of
professional rescuers, comprised of volunteer and paid resources, typically performs its work
within the National Incident Management System (NIMS; see Chapter 3) where they have the
opportunity to share in the role of patient care with other WEMS personnel.

SKI PATROL–SERVICED ENVIRONMENTS

While the term “ski patrol” often brings to mind images of lodges and lift-serviced terrain, ski
patrols in fact provide WEMS care in a number of terrain types and across many snow sport
disciplines. The vast majority of ski patrolling is carried out in lift-serviced terrain but patrollers
also operate in Nordic (cross-country) and backcountry environments. Organized ski patrols
evolved in large part from the advocacy efforts of the National Ski Patrol (NSP), a training,
education, and consulting member-based organization established in 1938 to consolidate and
standardize ski patrol practice.1 The newly formed NSP played a significant role in the
development of the U.S. Army’s 10th Mountain Division; consequently, when its veterans
returned into the civilian ski and alpine community immediately following World War II, ski
resorts embraced them and took on greater responsibility in providing emergency medical care to
sick and injured outdoor enthusiasts.2 See Chapter 1 for further discussion of this history.
The exact incidence of injuries and deaths in ski areas in the United States is unknown. The
National Ski Areas Association, an U.S. industry trade group, estimates 2.5 injuries per 1,000
skier days with 40 catastrophic injuries and 50 fatalities per year.3 However, this number is felt
by some to underrepresent the scope of the problem.3 Regardless, considering that a large resort
may be visited by several thousand skiers per day on busy days, it is clear that ski patrols provide
an important service to ski area patrons on a daily basis.
A ski patroller’s practice is shaped by a number of regulatory, managerial, and
environmental factors. It is the combination of these various factors that create the medical and
geographic scope of practice of a ski patroller. The following overview should help the reader to
understand the general principles but before practicing at a specific site, any patroller must
understand local regulations and practice.
State regulators take a number of approaches to ski patrols. These may include no regulation,
in which case managerial and environmental factors primarily define the patrollers’ scope of
practice. Other states have rules that define a minimum training requirement for medical
providers at ski area operations. Since most states codify American National Standards Institute
Standard B77.1 “Ski Chair Lift Safety” into law and the U.S. Forest Service requires compliance
with the most current version of ANSI B77.1 for any lifts operated on National Forest Lands, this
standard sets a minimum for essentially all ski areas in the United States.4 ANSI B77.1-2011
states, “One or more persons must be trained to provide first aid/emergency care at the BLS level
including cardiopulmonary resuscitation (CPR). Basic Life Support is defined as medically
accepted non-invasive procedures used to sustain life”.5
Beyond ANSI B77.1, there are few states that specifically regulate ski patrols. Maryland has
recognized the NSP’s OEC Technician certification as an EMS licensure level if the patroller is
also affiliated with the local fire department, formally embracing ski patrols within the EMS
system. Nevada has used a hybrid approach to insert EMS licensees into the ski patrols. Other
states such as Idaho6 and Maine7 explicitly exempt ski patrols from EMS System oversight. The
Maine Code Title 32: Professions and Occupations, Chapter 2-B: Maine Emergency Medical
Services Act of 1982 §82. Requirements for License, subsection 2 License Not Required defines
those not requiring medical licensure:
E. A person serving as an industrial nurse or safety officer, a school or youth camp nurse, a life guard, a member of a ski
patrol, a nurse or technician in a hospital or a physician’s office, or other similar occupation in which the person provides on-
site emergency treatment at a single facility to the patrons or employees of that facility.

As the only reference to Ski Patrols in Title 32, this places ski patrols outside of regulation of the
Maine Office of EMS. Idaho goes so far as to define the medical care delivered at ski resorts by
ski patrollers with OEC Technician certification as completely first aid, exempting it from other
regulated practices of medicine and from the need for further license or medical oversight.17
Unless specifically excluded by state law, ski patrols do appear to meet all criteria in the
published definition of EMS.8
Since there is limited statutory regulation of ski patrols, often the decisions regarding
training and certification requirements for patrollers and patrollers’ scope of practice are made by
the ski area management. When there are state regulations requiring a certain level of training or
licensure, then the ski area must at a minimum abide by those rules. Otherwise, management has
a number of options including requiring basic first aid and CPR training only, accepting other
health care licenses (eg, RN, MD, DO, PA)9 or emergency medical technician (EMT)
certifications that have additional training in ski rescue,1 requiring another standardized
certification, or some combination thereof. For many ski area operators, this decision is made
based on insurance requirements. Insurance companies recognize the NSP’s Outdoor Emergency
Care (OEC) training program and certification as valid training and therefore many ski areas
elect to require OEC certification.9 While OEC is typically not required by insurers and an area
could choose to accept another brand of WEMS certification, it is commonly used due to its wide
recognition and acceptance.
Many patrols have patrollers that hold additional EMS or medical licensure and patrols may
elect to formally take advantage of the scopes of practice of those licensed EMS providers. This
is typically done in one of three ways:

1. The ski area contracts with a medical director for the patrol who defines a scope of practice
and protocols for patrollers with various EMS licenses. In states in which patrols are
unregulated, this essentially becomes a form of delegated practice.
2. Patrollers with EMS licenses affiliate with the primary EMS agency that responds to the
resort. When such a patroller encounters a patient with medical needs that exceed his scope
of practice as a patroller, the patroller “switches” to being an EMS provider for the
responding service and therefore falls under all EMS rules and regulations, including
 documentation standards and medical oversight.
3. The ski patrol registers with the state as a licensed EMS agency and all patrollers are
required to hold some level of EMS license and affiliate with the EMS agency.

The environment of practice also influences the scope of practice of the ski patroller. At the
broadest level, this class of winter sports can be divided into lift-serviced downhill (aka alpine),
Nordic (aka cross-country, on established and typically groomed trail systems), and backcountry
(off-piste, non–lift-serviced touring without formally established/groomed trail systems and
alpine/downhill riding). The types of equipment and styles used in these disciplines vary
tremendously (see Figure 31.1 and Table 31.1). The three disciplines have different implications
for ski patrollers as WEMS providers. Patrollers may work in alpine resorts with typical
transport times from the scene to the aid room of under 15 minutes, a situation akin to an urban
EMS system. In these cases, patrollers need a scope of practice that allows them to address ABC
life threats (Airway, Breathing, and Circulation) but do not necessarily need a broader scope of
practice. By the same token, many larger alpine resorts may have trails from which transport to
the aid room may take over 45 minutes. Similarly, Nordic ski resorts will often have prolonged
transport times since trails may lead miles from the lodge and aid room. In these situations,
practice is akin to rural EMS in that beyond immediate life threats, patrollers may be forced to
deal with the natural history of the disease process as it evolves over periods of an hour or more.
Therefore, a more extensive scope of practice may be necessary to adequately meet the needs of
patients. Finally, for Nordic patrols with a backcountry responsibility or dedicated backcountry
ski patrols, the scope of responsibility (and therefore the scope of practice) is similar to that of a
WEMS search and rescue (SAR) team. Response to an incident may be prolonged and treatment
and transport may be extended to hours or even days.

Table 31.1 List (not exhaustive but covers the major classes of equipment) of Commonly
Used Snow Sports (skiing and boarding) Equipment
Discipline Description
Alpine Two skis with fixed heel bindings and rigid boots. Typically used in lift-serviced
downhill terrain
Telemark Two skis with free heel bindings, boots range from moderate stiffness to rigid. Typically
used in downhill disciplines
Nordic Two skis with free heel bindings, boots are soft to moderately stiff. Used for cross-
country (skating or classic techniques) or backcountry touring
Alpine terrain/AT/Randonee Two skis with bindings designed to fix the heel in place during descent but to be free
heel and pivot at the toe for ascent and touring. Boots vary in stiffness and modern boots
typically designed to be able to double as mountaineering boots. Used in backcountry
touring and non–lift-serviced descents, this configuration is also popular with many lift-
serviced terrain ski patrollers due to the ability to climb hills and efficiently traverse flat
areas
Monoski Single wider ski with two fixed heel bindings oriented with the pelvis facing downhill
and the feet fixed side by side
Snowboard including split boards Wide board with fixed bindings set with a leading foot and a trailing foot. The setting of
the bindings rotates the pelvis to an orientation more parallel to the angle of the descent
than with skis. Typically used in lift-serviced terrain, but split boards designed to break
in half are used in Nordic style for touring and ascent in backcountry pursuits, and
backcountry snowboarders may carry their boards in a pack using short “approach skis”
or snowshoes to reach descents
FIGURE 31.1. Different Snow Sports Disciplines Require Different Equipment. From left to right, alpine skis, telemark skis,
Nordic (cross-country) skis, alpine terrain (AT or randonee), and a snowboard. Courtesy of Jonnathan Busko.

National Ski Patrol Outdoor Emergency Care Technician Training

Since the majority of active ski patrollers in the United States are trained through the NSP’s OEC
Technician class, it is important to understand the scope of this training so that one can define the
skill set and scope of practice of ski patrollers who practice based on this certification. Broadly
speaking, the OEC Technician training exceeds that of the Emergency Medical Responder
(EMR) but does not include all of the elements of an EMT curriculum.10 Additionally, there is a
heavy emphasis in the OEC Technician curriculum on cold environment and winter sports
emergencies, for obvious reasons. The National Highway Traffic Safety Administration
(NHTSA) National Emergency Medical Services Education Standards for EMR include airway
management (manual maneuvers, suctioning, application of supplemental oxygen, use of pocket
masks, oropharyngeal airways, and bag-valve-mask ventilation), acquisition of vital signs
manually, manual CPR and use of an automated external defibrillator, assistance of normal
childbirth, manual stabilization of the cervical spine or extremity injuries (but not the use of
splints), hemorrhage control including use of a tourniquet, emergency moves, and eye irrigation.
The OEC Technician curriculum adds to those skills the following11: moving, lifting, and
transporting patients, use of nasopharyngeal airways, assisting with a metered dose inhaler,
administration of an auto-injector, stabilization of impaled objects, splinting of injured joints and
extremities, reduction of a posterior sternoclavicular dislocation, traction splinting, spinal cord
protection (SCP) including SCP techniques and use of adjunctive splints, helmet removal,
stabilization of ocular impalements, management of open chest wounds, stabilization of pelvic
injuries, patient restraint, documentation, and administration of nerve agent antidotes.
It should be clear from this scope of practice that ski patrollers do not practice “first aid” in
the generally used sense of the term by the American Red Cross,12 Occupational Health And
Safety Administration,13 or ANSI.14 Rather, ski patrollers have a sophisticated medical practice
involving complex decision making with the risk of causing harm if errors are made.

Ski Patrol Medical Direction and Oversight

From the discussion thus far, it is clear that ski patrols are an integral component of EMS
systems of care. The NSP in particular has made this a center point of the current (5th edition)
Outdoor Emergency Care Technician certification, asserting that ongoing medical oversight, the
hallmark of EMS practice of medicine, is also “the hallmark of quality health care and is the best
method of ensuring that the treatment rendered by ski patrollers meets or exceeds both
customers’ expectations and the national education standards for emergency medical
personnel”12 (medical oversight in WEMS operations is discussed in further detail in Chapter 4).
NSP’s magazine, Ski Patrol Magazine, has also published assertions that “nationwide, ski patrols
are known as an integral part of the EMS system.”15
Despite this affirmation from the largest member organization for ski patrollers, many patrols
position themselves as outside of not just the EMS system but of medicine itself. While
reasonable arguments can be made about whether current state EMS structures can adequately
accommodate the specific skill set and scope of practice of the OEC Technician,9 it is difficult to
argue against using the traditional medical quality assurance tools of oversight, review, and
credentialing to assure that the public is receiving the highest quality care from ski patrollers. As
identified in the Institute of Medicine (IOM) report “To Err is Human,” it is expected that health
care providers, even when well intentioned, have the potential to cause medical errors.16 Yet,
when an error occurs, there should be a process to review the error, and develop training
programs to correct the error. The process of patient care review falls within the purview of
indirect medical oversight (see Chapter 4 for a more complete discussion of indirect medical
oversight). This process should be clinician-led and should be about education and improvement
of patient care. The focus should be on the patient and the system and not on the provider. For
these reasons, among others, all ski patrols should aspire to have medical oversight from a
licensed clinician-level provider.9,17,18
With the understanding that EMS is a practice of medicine, as discussed previously in this
text, ski patrollers have a defined scope of practice that is established by four pillars—education,
certification of the education, licensure, and credentialing.19 Ideally, in order to be allowed to
provide care to the public at a level above first aid, the patroller needs to be recognized by the
state EMS regulatory authority through licensure, and credentialed by a local EMS medical
director. Ski patrollers that do not have an established scope of practice, as established by the
four pillars described above that necessarily include physician oversight for non-clinicians, risk
practicing medicine without a license. If an appropriate regulatory structure can be put into place
that is sensitive to the specific contextual practice of ski patrols, is driven by patrollers and ski
patrol medical directors with an EMS background, and does not produce excessively
burdensome fees for participation or requirements for compliance, recognition from and
oversight by a state’s EMS regulatory authority carries many potential benefits to ski patrol.
These may include civil and criminal liability protection, access to grants and special funding,
and a professional track for career development. For this reason, we support intelligent,
thoughtful, and effective integration of ski patrols into state regulatory structures, specifically
under EMS. That being said, even in states such as Idaho and Maine that exempt patrollers from
EMS regulatory oversight, participation in the field of medicine itself ethically mandates
participation in quality assurance and oversight practices.
It is important to note that while few patrols may have a formal arrangement for medical
direction, there are many mechanisms for participating in a quality management system. For
example, in the 13 active NSP-affiliated alpine patrols in Maine, medical oversight is achieved in
several through the following mechanisms: formal medical director contracts, designation of
medical director duties as part of patroller responsibilities (with physician-specific liability
coverage provided), and as NSP “Medical Associates,” a designation for physicians who provide
professional medical expertise to the education and oversight of the patrols. In the case of the
patrol with the formally contracted medical director, this contract is with a physician to provide
EMS-style oversight, protocols, and medical control. That ski area’s management pursued such
an arrangement and therefore patrollers at that patrol use protocols that mirror the Maine EMS
protocols with additional training that affords them an operationally specific scope of practice
including the use of blind insertion airway devices, assisted and primary medication
administration, and evidence-based guidelines for orthopedic injury management and
disposition. Although unusual, this arrangement is consistent with recently published consensus
guidelines for WEMS development.33

A DAY IN THE LIFE OF A SKI PATROLLER

Ski area operations in the United States vary greatly based on geographic zones, resort size, and
target markets. For example, whereas most major ski resorts in the intermountain west have to
contend with environmental hazards such as avalanches, areas in the mid-west and east coast are
more likely to contend with ice storms. Furthermore, major ski resorts, regardless of location,
often receive most of their business from local season pass holders and people who travel to the
resort from out of state for vacation, while patrons of smaller local ski hills such as are often
found in the mid-west and east coast are almost exclusively locals out for day trips. Finally,
whereas large ski resorts in the intermountain west and New England are typically staffed with
paid full-time patrollers or a combination of volunteers and paid patrollers, smaller hills are often
staffed with volunteer patrollers.
By examining a patroller’s typical day managing a variety of types of patient care issues, the
reader should be able to understand the challenges and importance of ski patrollers serving as
wilderness providers within the emergency care system and integrating with traditional EMS and
emergency care providers. Note that while these vignettes focus primarily on patrollers working
in an alpine environment on lift-serviced terrain, the principles apply to Nordic and backcountry
patrols as well.

Preparing for the Day—Equipment

A ski patroller’s day typically begins with checking to make sure that all equipment is assembled
and in working order. As is the case for most WEMS providers, the ski patroller has to carry
equipment for initial patient stabilization on their back while skiing to the patient, unless a
snowmobile is used or equipment is hauled on a sled or toboggan (both of which may allow for
marginally more equipment deployment). Patrollers vary in the preferred method to carry
medical equipment. Some prefer fanny packs, some prefer to carry equipment in a specially
designed vest, and some prefer to carry all of their equipment in a backpack (Figure 31.2).
Table 31.2 lists typical supplies carried by a patroller, although this list may be modified based
on area and environmental considerations. Regardless, the patroller needs to be able to provide
initial emergency stabilization and shelter in place with the patient while waiting for backup
resources using equipment carried with them during a duty day on the hill. Before setting out on
the hill the patroller should check through their personal medical gear, making sure it is all in
working order and assembled in their pack.
FIGURE 31.2. Ski Patrollers Use a Variety of Wearable Systems to Transport Medical Supplies and Personal Gear.
Pictured here are a load-bearing patrol vest, a backpack, and a fanny pack. Selection is based on personal preference, area
policies, and the amount and types of gear a patroller must carry in the specific operational environment. Courtesy of Kathryn
Busko.

Table 31.2 Typical Equipment Carried by a Ski Patroller. Note that all patrollers need
reliable communications as well
Discipline Equipment
Alpine Lift Serviced Suggested:
2–4 pairs disposable nonlatex gloves, malleable aluminum splint, 4 cravats, 6–10 4×4
gauze pads, two 2-inch gauze wraps, Kling, or self-adhering wrap, tube of cake frosting
or instant glucose (will require rewarming to flow), 3-inch roller bandage, two
abdominal pads, two 30 gallon or larger trash bags, bivy bag, or Bothy bag for
emergency shelter, pocket mask or face shield, roll of 1 inch adhesive tape, mixed band
aids, 1 pair trauma shears, 1 commercial windlass style tourniquet, fine-tipped
permanent marker, 1 pencil, Rite-In-Rain or similar waterproof notecards, multitool,
three 1-quart sized sandwich bags, pediatric and adult size oral airways, flashlight with
spare batteries (preferably lithium or similarly cold-resistant), space blanket or similar
radiant heat reflective wrap.
Optional:
Stethoscope, blood pressure cuff, hemostats, small pipe cutter, topical antibiotic
ointment, sunblock, personal over-the-counter medications, any medications allowed by
protocol (eg, aspirin), low reading digital thermometer, fingertip pulse oximeter, 50 ft of
550 paracord, self-evacuation equipment if allowed by ski area, any technical rescue
equipment needed to access patients and mitigate further fall risk, avalanche safety if
indicated (shovel, probe, transceiver), 2 ski straps.
Nordic on established trail systems Suggested:
2–4 pairs disposable nonlatex gloves, malleable aluminum splint, 4 cravats, 6–10 4×4
gauze pads, two 2 inch gauze wraps, Kling, or self-adhering wrap, tube of cake frosting
or instant glucose (will require rewarming to flow), 3-inch roller bandage, 2 abdominal
pads, two 30 gallon or larger trash bags, bivy bag, or Bothy bag for emergency shelter,
pocket mask or face shield, roll of 1 inch adhesive tape, mixed band aids, 1 pair trauma
shears, 1 commercial windlass style tourniquet, fine-tipped permanent marker, 1 pencil,
Rite-In-Rain or similar waterproof notecards, multitool, three 1-quart sized sandwich
bags, flashlight with spare batteries (preferably lithium or similarly cold-resistant), space
blanket or similar radiant heat reflective wrap, low reading digital thermometer,
Kendrick Traction Device, or supplies to improvise a femur splint with a ski pole.
Optional:
Stethoscope, blood pressure cuff, hemostats, 1 L water bottle (collapsible style is most
convenient), topical antibiotic ointment, sunblock, personal over-the-counter
medications, any medications allowed by protocol (eg, aspirin), fingertip pulse oximeter,
50 ft of 550 paracord, two fire-starters, lightweight poncho, wire saw, lightweight
inflatable or foam roll mat to provide thermal protection from conductive heat loss,
candle, compact stove (gas, fuel tablet, or twig burning type), lightweight pan to melt ice
for water, ultralight rescue sled, survival type candle or collapsible candle lantern,
whistle, navigation tools (map and compass), charcoal vest, 2 ski straps
Backcountry As for Nordic on established trail system with the following modifications:
Suggested:
Navigation supplies (map and compass, consider GPS), fire starting supplies, consider a
larger survival shelter (eg, a Bothy 8 instead of a Bothy 4), any technical rescue gear
needed for the environment, avalanche safety (probe, shovel, transceiver), any
evacuation gear needed (eg, ultralight sled, Bauman Bag, Model 350 sled, etc.).

Adapted from McNamara EC, Johe DH, Endly DA. National Ski Patrol’s Outdoor Emergency Care. 5th ed. Pearson, 2012.

Once on the hill patrollers often check to make sure toboggans (Figure 31.3) are in working
order. Toboggans are used in the patrolling industry to safely transport injured or sick skiers out
of the environment. Toboggans can also be used to transport heavier equipment to the patient’s
side that may be useful on the hill, but not able to be carried by the patroller—for example,
heavy splints, backboards, oxygen, and blankets. Different styles of toboggans may be used
depending on the environment being patrolled (Figure 31.4).
Strategically placed on the hill, many ski patrols will have caches of medical supplies or
limited stocked first aid “huts” or “shacks.” These first aid huts provide a safe location for
patrollers to care for the public out of the elements, are a place for on-duty patrollers to sit duty
shifts, and provide on-hill storage of heavier medical gear.
Finally, most ski patrols have a large first aid station at the ski resort base. This location will
typically have beds for patient care, storage of medical supplies, base communications, and easy
access for traditional EMS handoff. Some resorts have clinician-level providers or contract with
EMS services to staff EMS providers at these first aid stations. In other cases, the aid room is
proximate to a privately run medical clinic, often staffed by orthopedic clinicians. These clinics
may work with the patrol to assist in stabilization of critically ill patients or to accept the patient
“in transfer” from the ski patrol to provide care at a more comprehensive level.
At the beginning of the day the patroller needs to check to make sure equipment in all
locations is stocked, in working order, and ready for deployment for patient care. Yet, one must
consider what equipment should be stocked in these various locations—on the patroller, in the
toboggan, on the hill, and in the base first aid station. Considerations for equipment include
expected patient encounter and expected delivery of level of care.
FIGURE 31.3. The Toboggan is the “Ambulance” of the Ski Patroller, Used for Transporting Equipment to and Patients
from the Scene. Pictured here, from left to right, are an unloaded toboggan, a toboggan with a resuscitation bag, and a toboggan
with a resuscitation bag and quick splints. This patrol uses retired EMS litter mattresses to perform spinal cord protection
techniques. The mattress conforms to the patient’s spine and eliminates pressure points. Courtesy of Hermon Mountain Ski
Patrol.

The equipment stocked is based on the scope of practice of the ski patrollers. Some supplies,
such as oxygen and injectable normal saline require physician authorization to purchase. One of
the major benefits of ski patrol medical direction is that the medical director can prescribe and
facilitate purchase of these supplies. The equipment that is stocked by the ski patrol and carried
by the patroller should be approved by a medical oversight clinician and assembled in
accordance with plans for integration of care with the rest of the emergency response system.
FIGURE 31.4. The Cascade Rescue two-piece carbon fiber/titanium model 350 weighs 24 lb and is suitable for lift-serviced and
backcountry terrain. Courtesy of Geoffrey Ferguson.

Lift Evacuation and Technical Rescue

Although low and high angle rescue are covered in Chapter 25, it is important to note that alpine
ski patrols in lift-serviced terrain have a unique responsibility to perform lift evacuation.
Evacuation techniques vary widely depending on the types of lifts being evacuated and the type
of terrain into which the riders are being evacuated. Generally speaking, evacuation techniques
are divided into either ground-based evacuation techniques or aerial evacuation techniques. The
choice of techniques will depend on a number of factors including type of lift (eg, chair versus
gondola), height of the lift, and whether or not the lift can be accessed by ground and riders
safely lowered and evacuated from the terrain under the lift.
Ground-based lift evacuation is essentially single rope technique (SRT, derived from cave
rescue); that is, there is a main rope but no belay. The rope is pulled over the cable, a patroller
attaches the rope to a lowering device on one end, and riders are lowered to the ground using a
strop, evacuation seat, or diaper seat (Figure 31.5). Once evacuated to ground, riders must be
able to safely navigate the slope they have been lowered onto (remember that a lift that carries
beginner skiers may traverse expert terrain). If the chairlift riders are too scared or too young to
safely participate in the evacuation, a patroller may need to ascend to the chair using techniques
similar to caving SRT or be hauled up to the chair.
FIGURE 31.5. Patrollers working with mutual aid firefighters to evacuate riders from a lift during a training exercise. Courtesy
of Jonnathan Busko.

In cases where the lift cannot be accessed by ground or there are gondola cars that require
riders to be lowered from the cars, aerial evacuation may be necessary. This requires the use of a
cable riding device that a rescue technician uses to travel to the chairs or car and initiate cable-
based rescue (Figure 31.6A and B). In certain situations, helicopter-based rescuer insertion and
rider extraction may be necessary.
Patrollers for both “in-bounds” resorts and backcountry patrols may be required to perform
low and high angle rescue. A steep and deep slope that is skiable on an individual basis may
require snow or ice anchors and lowering techniques to safely extract an injured skier. Patrollers
must make a decision about how much additional rope rescue gear to carry versus having a
dedicated toboggan or other transport mechanism to move the gear. If a patroller is expected to
be able to access and secure any potential rescue patient while awaiting additional gear, however,
she should at least carry enough equipment to do so on the most technical slopes in her response
area.

FIGURE 31.6. A, The ZipRescue Trolley is used by a patroller to ride the ski lift cable so the rescuer can access chairs or
gondolas without having to traverse the ground below. B, Many gondolas are too far from the ground to use ground-based
evacuation techniques. Riding the cable allows evacuation to be initiated directly from the gondola. Courtesy of ZipRescue.

Depending on the size of the resort, preferences of management, and number of patrollers on
the hill at any given time, ski patrollers may also be expected to self-evacuate from a stalled ski
lift (Figure 31.7). As an unbelayed SRT, patroller self-evacuation techniques are similar to
firefighting bailout techniques with three major differences. First, most patrols do not fall under
National Fire Protection Association (NFPA) standards on rope rescue (the exception being
patrols at areas owned by governmental bodies or municipalities that are required to comply with
NFPA). Therefore, equipment can typically be lighter and more in-line with wilderness rescue
techniques. Secondly, as opposed to firefighting bailout systems that use ropes sized to allow
movement between a few floors but not necessarily to reach the ground, patrollers must be sure
they are carrying an adequate length of rope to reach the ground from the highest point from
which they might have to self-evacuate. Finally, while the rope used in a firefighter’s bailout can
be left on the structure, patrollers who self-evacuate must be able to pull down their rope so that
when the lift is restarted, the dangling rope will not drag and get caught or damage/derail the lift.

FIGURE 31.7. A patroller self-evacuates from a ski lift using a rope doubled over the hanger of the chair. While this
technique makes it easy to pull down the rope, the patroller must carry a rope that is twice the length of the longest possible self-
evacuation rappel. Courtesy of Jonnathan Busko.

Snowmobiles
Snowmobiles are commonly used in ski areas in a number of operational roles from courtesy
shuttles to equipment transport to snowmaking to patrolling. Although high liability equipment,
they are a convenient and at times critical tool for effective patrolling. This is particularly true in
resorts with remote trail systems and Nordic resorts where patients may need to be transported in
towable toboggans (Figure 31.8). Snowmobiles are also used to transport tired or injured
patients who do not necessarily need toboggan transport. See Chapter 28 for more details about
vehicles in WEMS operations.

Special Considerations for Nordic Ski Patrols on Established Trail Systems

Nordic ski patrollers who patrol established and groomed trails typically need to be as
parsimonious in their choice of gear as a SAR team member since they will be carrying this
equipment throughout their patrol, potentially many miles a day. Since trails are established,
equipment can be stored in caches. Depending on access to transport resources and distance to
the aid room or trailheads, Nordic patrollers may use specialized lightweight compact evacuation
sleds for transport (Figure 31.9A, B, and C). If there is an extended response time for the
transportation (eg, snowmobile with pull behind toboggan) to reach parts of the trail system, the
patroller should consider carrying a lightweight shelter (Figure 31.10). This will allow the
patroller to protect the patient from the elements and expose as much of the patient as is
necessary to perform an appropriate exam.

Special Considerations for Alpine and Nordic Backcountry Ski Patrols

Backcountry patrollers are essentially functioning as an organized WEMS/SAR unit. While the
general area of responsibility is defined, users may be anywhere in that area and there may not be
anyone else riding in that section of the area on the same day. Therefore, a patroller or small
team of patrollers need to have sufficient resources to locate patients, provide initial assessment
and stabilization, call for evacuation, provide stabilizing medical care that may be ongoing for
several hours, and provide protection from the elements with the equipment carried on their
backs. In addition to the considerations for Nordic patrols on established trail systems,
backcountry patrols must consider warmth, nutrition, specialized evacuation, and safety concerns
about avalanche and crevasses.

FIGURE 31.8. This toboggan has been modified with a yoke designed to allow it to be towed behind a snowmobile or, in this
case, a tracked ATV. Courtesy of Robert Bakker.
FIGURE 31.9. A, Taking up less space in a pack than a pair of gloves, B, The Brooks Range UltraLight Rescue Sled uses the
patient’s own skis to make a toboggan C, that can be used to transport an ill or injured skier. A, courtesy of Jonnathan Busko. B
and C, courtesy of Brooks Range Mountaineering.

Given the potential for prolonged response and evacuation times, backcountry patients are at
risk of developing secondary hypothermia before or after patroller arrival. Therefore, patrollers
must carry the equipment necessary to prevent further heat loss. Additionally, consideration
should be given to carrying equipment for techniques that allow active rewarming such as a
charcoal heat vest (Figure 31.11). Additionally, a way of producing high-calorie, warm drinks is
vital to support the nutritional, thermoregulatory, and morale needs of patients.
Evacuating patients from the backcountry can be a real challenge. As discussed for Nordic
patrols on established trail systems, use of ultralight or improvised evacuation sleds is a mainstay
of backcountry patrolling. However, vehicles such as snowmobiles, snow cats, tracked four-
wheel drive vehicles, utility task vehicles (UTVs), and helicopters may all be used to perform
backcountry evacuation (these vehicles are discussed further in Chapter 28). Proper planning,
such as establishing designated landing zones for helicopters, will markedly improve the
efficiency of vehicle-assisted evacuation (Figure 31.12). Some special points should be made
regarding the use of soft vertical lift litters such as the Bauman Bag.* Weighing only 10 to 15 lb,
soft litters may serve multiple functions for backcountry ski patrol patient evacuation. First, they
can serve as an improvised shelter for a patient and provide thermoregulatory protection during
an evacuation by mounting them on an ultralight or improvised sled. Second, when used in this
way, they serve as a secure way to perform low and mid-angle rescue. Finally, when a patient is
secured to an ultralight sled with a frame and then the sled is placed INSIDE the soft vertical lift
litter, it can be used as designed for vertical lifting operations including helicopter lift operations
without requiring a backboard (Figure 31.13). Regardless of the technique, effective
backcountry evacuation requires planning and having the proper equipment on hand at the time
of need. The use of soft vertical lift litters is covered in more detail in Chapters 24 and 28.

FIGURE 31.10. A Nordic patroller uses an ultralight Bothy Bag (the Bothy 4) to protect a patient from the elements during the
examination and while waiting for transport. Courtesy of Jonnathan Busko.
FIGURE 31.11. The charcoal vest will actively rewarm a hypothermic patient in the wilderness setting, potentially converting an
evacuation into a ski-out. Courtesy of Jonnathan Busko.

Patient Care Response

Minimally Injured
Working as a ski patroller at a mid-west local’s ski hill, you are staffing the first aid room at base
operations. Your fellow patrollers transport a 13-year-old snow boarder to the first aid room with
a wrist injury. The boarder went over a box in the terrain park and landed poorly on his wrist. He
has a classic dinner fork injury that demonstrates an obvious fracture. He has no other injuries
and his pain is fairly well controlled with the splinting that the patrollers performed on the hill.
The boarder’s parents come to the patrol room and tell you they do not want an ambulance
called. They will plan to take him to their orthopedic physician the next day. They do ask you if
you have any acetaminophen to treat his pain.

FIGURE 31.12. LifeFlight of Maine Lands on the Scene of a Skier Evacuation from Tuckerman’s Ravine. Knowing in
advance where and under what conditions helicopter evacuation is available makes these types of evacuations much faster and
safer. Courtesy of LifeFlight of Maine.
FIGURE 31.13. By placing a patient packaged on an ultralight evacuation sled inside the Bauman bag, the patient can be
vertically evacuated and a backboard is not needed. Courtesy of Jonnathan Busko.

Moderately Injured
Having completed the NSP OEC course and becoming certified as an OEC Technician, you are
patrolling at a local hill on the west coast 2 hours’ drive from your home where you work as an
emergency physician. Although you are licensed to practice medicine in the state where the hill
is located, you have been told by ski area management that you are not allowed to tell patrons at
the hill that you are a physician as you are only a patroller while on duty.
It’s a beautiful sunny day. While skiing on duty, you see someone take a bad fall in a mogul
field. You ski to the person and ask if they need help. The person says they are fine and attempts
to ski away. Not getting far the skier stops and sits on the ground clutching her abdomen.
Accepting your help, you find the person has pain on palpation in her left upper quadrant. She
tells you she just needs some help to get to the bottom of the hill and she’ll stop skiing and go
home. You are concerned that she may have a splenic injury. Knowing that the evidence
suggests patients seem to more closely follow the recommendations of physicians than non-
physician EMS providers regarding need for hospital-based evaluation and care,20 you want to
tell her that your opinion as a physician is that she really needs to go to the hospital.

Major Injury
You respond from the top patrol shack at a destination ski resort in the intermountain west for a
report of someone unconscious. When you get on scene, bystanders report that they saw an
advanced level skier skiing through the trees. It seems that the skier must have misjudged the
distance between two trees as he slammed his shoulder and head into a tree. You arrive on scene
to find the patient unconscious. He was wearing a helmet that is cracked.

Medical Emergency
Working as a patroller at an east coast ski resort you respond to the base cafeteria for a report of
a patient not feeling well. You arrive to find a mid-50s male patient sitting in a chair. You assess
that he looks pale and diaphoretic. The patient states that he is short of breath and is having chest
pains. You are concerned that he may be having an acute myocardial infarction. You put him on
oxygen, give him aspirin, and call to base for an ambulance. The patroller working at base calls
911 to activate the local EMS system.

Discussion of Cases and Their Significance

The four scenarios above highlight a number of issues with regard to the interface between ski
patrollers and traditional EMS. Most importantly, these scenarios all highlight that ski patrolling
is indeed a practice of medicine. All four of these scenarios involve complex medical situations
that have the potential for a poor outcome if decisions are not made correctly. Even the
minimally injured patient with a probable wrist fracture has the potential for a poor outcome if
the patrollers splint incorrectly.
The scenario with the probable wrist fracture identifies a common situation with ski
patrolling medicine. Quite frequently, patrollers release the skiing public without formal
arrangement for continuing care, or without requesting the patient sign a refusal of care
following an official/evidence-based patient refusal protocol even when the patient is clearly
refusing offered and indicated medical care. Indeed, it is not atypical that patrollers initiate
refusal of care by suggesting to the patient or family that it is best to proceed to definitive care on
their own without formal transport by traditional EMS services. Although there may seem to be
little risk in refusal of care for a simple problem such as a wrist injury, it is possible that the
snow boarder also has another more critical injury missed by the patroller. Indeed, a meta-
analysis by Brown et al.21 demonstrates that even seasoned EMS providers risk missing injuries
or illness that need emergent medical care. Integration of the ski patrollers into the EMS system
with a formal patient care refusal policy, which allows for real-time physician consultation for
high-risk refusals, would minimize the risk of patient refusal.22 Refusals initiated by ski patrollers
likely carry even more risk.
This question of the disposition of minimally ill and injured patients is a critical one for ski
patrols. In some ways, ski patrols are analogous to industrial infirmaries and camp medical
services. That is, they are serving a limited population with a variety of complaints that are
highly variable in acuity and severity. In other ways, they are similar to special events (Chapter
9). They serve an important role in not overwhelming local EMS and hospital resources.
However, the OEC Technician is not qualified to triage patients to make decisions regarding
transfer to other health care resources versus discharge. A review of Outdoor Emergency Care,
5th Edition reveals that there is no training of any sort for the OEC Technician to make these
decisions. In fact, as opposed to treating and transporting a patient, the decision not to treat a
patient is one of the most difficult in medicine and requires high-level decision making supported
by deep knowledge and experience bases. Medical oversight is critically important to develop
evidence-based, algorithmic approaches to this type of decision making and to perform the
necessary quality assurance to guarantee that patient safety is not compromised.
 One example of the necessity and value of medical oversight is in the application of SCP
techniques. Despite “spinal clearance” protocols in effect since the WEMS environment since the
mid-1990s and the subsequent validation of the NEXUS (National Emergency X-Radiography
Utilization Study) criteria and Canadian C-Spine Rules in the out-of-hospital environment, many
patrols have policies that require all patients placed in SCP to be transported by EMS for hospital
clearance. This creates a dilemma for the patroller on the hill who initially encounters a patient.
It can be very challenging to appropriately assess a patient’s potential for spine injury on a ski
slope, in the cold, through several layers of clothing. So if there is a mechanism to suggest a
possible spinal injury, deciding to perform SCP so the patient can be transported to the aid room
for a good physical assessment would mandate the patient be transported to the hospital
regardless of the findings on the physical exam and complete history. An evidence-based spinal
assessment protocol that can be applied in the aid room would allow for nonselective SCP
techniques to be applied on the hill if any question of risk exists while allowing patrollers in the
controlled environment of the aid room to assess the actual necessity of SCP. Such an approach
improves patient care on the hill and in the aid room but requires oversight to assure it is carried
out rigorously, consistently, and appropriately. Similar evidence-based joint injury assessment
protocols (Table 31.3) can enable an OEC Technician to safely and appropriately manage and
discharge some patients but, again, require rigorous oversight to safely implement.

Table 31.3 A Ski Patrol Protocol for Evaluation, Treatment, and Disposition of Patients
with Isolated Knee Injuries
Evaluation of Knee Injuries
On the Hill/In the Aid Room
1. Did the patient have blunt trauma or a fall as the mechanism of injury?
a. If no, apply ace wrap to restrict movement and refer to an emergency department, walk in care, or primary care provider
for follow-up in the next few days
b. If yes, then
2. Is the patient older than 12 and younger than 50?
a. If no, then immobilize the affected leg and refer to an emergency department or walk in care for evaluation and possible
x-rays
b. If yes, then
3. Is the patient able to walk 4 weight-bearing steps?
a. If no, then immobilize the affected leg and refer to an emergency department or walk in care for evaluation and possible
x-rays
b. If yes then
4. Apply an ace wrap to the knee to restrict movement and refer the patient for emergency department, walk in care, or primary
care provider follow-up in the next few days.
Note: This particular protocol applies the externally validated “Pittsburgh Knee Rules.”23,24

Regarding the role of the physician patroller, physicians who elect to patrol should carry
medical malpractice insurance consistent with the physician’s scope of practice, not that of an
OEC Technician. The idea that a physician is able to be “only a patroller” lacks an understanding
of how physicians practice and juries think. The value of advanced medical training is much
more than the ability to perform procedures; it is importantly the ability to assess that a patient
may actually be sick. Juries do not accept the assertion that a physician practicing in an austere
environment is somehow no longer a physician. They expect physicians to practice within the
limits of their scope of practice based on available resources and organizational credentialing.
Physicians who patrol should have professional liability insurance to cover malpractice coverage
for their patrolling activities, as the physician is likely to be held to the standard of reasonable
and prudent physician, not a reasonable and prudent OEC Technician. Integration of the
physician into the patrol in a formal role of medical director or associate medical director, with
established liability coverage, would minimize the physician’s liability exposure and improve
overall patient care.
Finally, perhaps the situations that best demonstrate the importance of integrating ski
patrolling with traditional EMS are major traumatic and medical emergencies. These scenarios
highlight the importance of transfer of care in a timely manner, appropriate utilization of air
medical resources when needed, and interface between ski area operations and traditional EMS
dispatch. Ski patrols should be able to call directly into traditional EMS dispatching as a fourth-
party caller using a tool such as the SEND protocol developed by the National Academy for
Emergency Dispatch.25 Perhaps even more expeditious, the ski patrol may even be able to
develop mutual aid protocols. These more advanced mobilization techniques for interface with
traditional EMS necessitate a formal structure that mirrors traditional EMS. Further details
regarding the interface between WEMS teams like ski patrols and traditional EMS providers are
provided in Chapter 6.

The End of the Day

Typically not the favorite activity of any health care provider, patient care charting is
nevertheless an important part of the patient care process. Patient care charting provides a formal
means to transfer patient information from one health care provider to the next. It also provides a
method to document the actions of the patrollers for future education and quality improvement
activities. Finally, patient care charting is the means to provide legal protection to the patroller.
While many ski patrollers complete a chart after the encounter with the patient, the chart
typically completed is the National Ski Areas Association’s Accident Report which is primarily
designed for the purpose of ski area risk management. This document is primarily an accident
investigation and documentation tool and as such bears little resemblance to a formal patient care
chart. While any formal patient chart designed to capture meaningful medical data is useful
(Figure 31.14), integration into the traditional EMS system with patient charting in an electronic
charting format that can be uploaded to a state database would allow the patrol to share data in a
format that can be immediately utilized for patient care at the receiving facility, allow the
responding EMS services to better integrate operations with the ski patrol, and be analyzed by
the ski patrol medical director for future educational activities and research.
FIGURE 31.14. The Hermon Mountain Ski Patrol Patient Care Record (PCR). This PCR is completed in addition to the
NSAA Accident Report. If the patient is transferred by EMS, the PCR is copied and sent with the patient. Courtesy of Jonnathan
Busko.
MOUNTAIN RESCUE UNIT–SERVICED AREAS
Within the mountain rescue community, the MRA stands out as an accrediting organization
setting a benchmark of training and technical scope of practice. Its influence is shared
internationally with the ICAR (International Commission for Alpine Rescue). Together, these
two organizations share knowledge and exploration of techniques, and make recommendations
establishing standards of practice. In addition, both of these organizations investigate and
systematically address standards for mountain medical care with literature review and consensus
recommendations, similar to topics covered in Wilderness Medical Society Practice Guidelines
(see Box 24.2 in Chapter 24).26–28 Nevertheless, it is frequently the case that local agencies
responsible for the management of mountain rescue do not recognize the accreditation or
guidelines for care. Indeed, there are many teams that provide very adequate medical care in the
mountains that are not associated or accredited by the MRA. This may be, in part, due to the fact
that their context of mountain rescue has limited geographic parameters (eg, no glaciated
mountains) that makes formal accreditation and recognition by the MRA less feasible.
Historically, one of the least represented areas in the United States for MRA-affiliated teams has
been the American southeast. However, this has recently changed, with the Knoxville Volunteer
Emergency Rescue Squad becoming an ex officio team, and with the foundation of the
Appalachian Mountain Rescue Team (based in Asheville and Morganton, NC), which aspires to
become the first fully accredited southeastern MRA team.29,30
Comprised of mostly volunteer members, these mountain rescue teams, whether accredited
or not, possess a diverse background of human resources who serve in patient care activities.
Typically, MRUs are required by their respective states to meet a minimum standard of EMR.
Note that in this text, in Chapter 25, we also advocate this as a minimum medical standard for
mountain rescue teams. However, it is quite often that members will have completed additional
training such as Advanced Wilderness Life Support, Wilderness Emergency Medical Responder
(WEMR), or Wilderness EMT (WEMT) (more details about such trainings are described further
in Chapter 2). Additionally, while most mountain rescue teams are volunteer organizations,
many members come from professional vocations of medicine that may include nurses, PAs, and
physicians. As mentioned above, it is quite common that limitations in the scope and depth of
practice are put in place regarding the care given to patients in the field by MRU members.
Establishing a common approach to patient care often falls within team-operating policies and
protocols or is governed by a team-based medical committee—with additional input provided by
a physician medical director and other physicians, PAs, or APRNs who may be affiliated with
the team.
While the scope of training, accreditation, and context of rescue environments may be quite
varied both within the United States and abroad, the singular most influential aspect of medical
care provided by a mountain rescue team lies in its relation to the incident command system
(ICS) structure. Throughout the United States, for example, mountain SAR teams may fall under
the oversight of different agencies when employed in the field. This has implications both at the
state and local levels as many teams are often called across state lines. It is common for the
county sheriff to provide ICS structure for mountain rescues. However, it is not infrequent that
the state police (eg, Vermont), fish and game department (eg, New Hampshire), or the National
Park Service are involved with event oversight. Preparing to work within various environments
of ICS oversight is similar to maintaining a familiarity with various climbing routes, weather
patterns, and changing trends in technical rescue in that the maintenance of skill requirements,
training, and continued building of relationships within ever changing agencies is required. ICS
implementation and unique characteristics in the WEMS setting are discussed in further detail in
Chapter 3.

Medical Oversight in Mountain Rescue

With regard to mountaineering rescue in the United States, many rescues are performed by
volunteer teams that, like ski patrols, may provide emergency medical care that exceeds basic
first aid, without medical oversight. This situation becomes even more complex when a
mountaineering rescue occurs on a mountain adjacent to a ski resort. In the case where medical
oversight is both available and employed, the jurisdiction of oversight and scope of integration
into an ICS structure is affected by the regional variations of both county and state
implementation.

A DAY IN THE LIFE OF A MOUNTAIN RESCUE UNIT

MEMBER

Preparing for the Day—Equipment

Prior to heading into the field, members of MRUs are well served to geographically cache
resources in proximity to their typical region of response. Additionally, maintaining multiple
mobile units capable of response permits increasing resources when needed or bringing required
resources to rescue events located outside a typical coverage area. A portion of these resources
can be maintained by individual unit members allowing for hasty responses and “reach and treat”
strategies to be employed.
Continuous review of rescue statistics is essential for determining the proper allocation of
resources. While the American Alpine Club publishes Accidents in North American Climbing
(formerly known as Accidents in North American Mountaineering), which documents many
injuries nationwide, internal review of specifically required equipment and event logistics should
be maintained by the specific rescue unit.
That said, the context of the mountain rescue requires that rescue gear include tools for both
medical care and extrication from the vertical environment. The latter is often affected by
seasonal changes and terrain specifics. For example, while operating in the alpine environment, it
may be necessary to build anchors from ice, snow, or rock substrate. Along that discussion,
patient transport may include vertical raises, lowers, or wheeled transportation mediums. More
details regarding such high and low angle features of rescue are available in Chapter 25.
Consideration of environment forces must also be made so as to mitigate environmental factors
that may complicate patient care (eg, rain, snow, heat). Management of extremes of cold and heat
is covered in Chapters 13 and 14, respectively.
During the rescue, the ability to provide continual medical care to the patient may dictate
certain considerations in patient transport as well. Often, this requires placement of the rescuer
above, below, or next to a litter in motion where continued care and patient assessment can be
coordinated. All of these elements must be considered prior to entering the field with whatever
data can be gathered from a predeparture briefing. Placement of multiple caches of gear in
strategic locations may help provide additional resources as the dynamics of a rescue unfold.

Patient Care Response

Minimally Injured
As part of your Mountain SAR “Ready Team” program, you are participating in a Saturday
patrol on the high mountain when a small party of climbers quickly approaches you heading
downhill. They announce that there is a pair of climbers at the base of the 2nd pitch—the leader
slipped out of a chimney crack. After ascending to the pair, you recognize that other than being
mentally shaken, there is only one injured person who states that his foot slipped and loaded his
hand in the crack. He has an obvious deformity of his ring finger and partial degloving at his
middle finger. At this point, there is no significant bleeding. It is early spring. You work with the
uninjured climber to lower his partner to the snowfield below. The finger injuries are dressed,
splinted in position, and they walk off the snowfield to the trailhead, telling you they will head
directly to the local emergency department (ED).

Moderately Injured
It is an amazing late spring day on the high mountain. A recent snow has left a pillow of snow on
the mountain. While digging avalanche test pits for your Mountain SAR Team, you look up to
watch the summit traffic where a ski mountaineer has just charged off the summit headwall. He
inadvertently catches a ski at a hidden bergschrund and face plants down the 60-degree slope. He
cartwheels down fifty yards and lands near your position. His pack filled with crampons, ice
tools, and gear is scattered about the snowfield. You recently converted your prior WFR to a
WEMR and are excited to put your recently renewed skills to use. You call in the fall on your
radio to resources stationed at the lower mountain. Upon reaching the injured climber, he is alert,
oriented, and with stable vital signs. Secondary survey and physical exam make you suspicious
he has suffered a shoulder dislocation on his dominant extremity. The distal neuromuscular exam
is intact. Additionally, he complains of pain just above the cuff of his right climbing boot where
there is swelling, possible deformity, and tenderness to palpation. It is late in the afternoon and
he is unable to bear weight on the injured leg. Covering him with extra layers and fabricating a
splint from resources in your climbing pack, the patient asks you for some pain medication while
you await the anticipated 1 to 2 hour arrival of additional resources.

Major Injury
It is just before dawn on a late spring Saturday morning. Climbing season is in full swing and
you are arriving to the cache to pick up gear for your shift on the Mountain Rescue Team Ready
Squad. After completing beacon checks with your teammates, you head to the ski patrol office to
plead for a free lift to the lower parts of the upper mountain. Sipping on coffee and trading
stories, your radios come to life. A climber has called 911 from high on the mountain. His
partner has fallen on the descent to the snowfield below. The initial report is that he has suffered
a cracked helmet and is short of breath. Your climbing mountain rescue team is mobilized with
the assistance of the lower mountain ski patrol units. Resources are brought to the patient where
he is indeed found to have a cracked helmet and he is tachypneic. He is responsive with equal
pupils. He complains of dyspnea and a headache but denies neck pain. His vitals are otherwise
stable. Considering Canadian C-Spine rules, the possibility of a pneumothorax, and a closed head
injury, you must negotiate the appropriate evacuation method to further definitive medical care.
Maintaining continued assessments, reducing motion to the cervical spine, and vacuum mattress
splinting on the litter, your team negotiates the moderate slope angle terrain until you reach low
angle terrain where the local EMS team has been dispatched with a snowcat. The patient is then
brought to the ski lodge on the low mountain where an ambulance transports him to the nearest
ED.

Multiple Casualty
It is a clear midsummer afternoon and your team has just completed a day of navigation training
and changing of the batteries at the USGS high mountain fumarole monitors. As you are
prepping to enjoy a nice run down the mountain corn snow, you hear screaming above you as
you turn to see the upper cornice release. A climbing party was short roped to each other and fell
onto another four-person party below. As the climbers and snow continue to fall, two of the
subjects become partially buried by the late summer snow. There are now six injured people, two
of which are buried. You and your teammates begin to assess, triage, and decide on a course of
action. Dispatch is notified, whereby the rest of the mountain SAR team and an EMS unit are
mobilized from town 1 hour away. The ski patrol at the base of the mountain readies the
snowcats for transport with two patrollers skinning up hill to your location. Communications
with the Incident Command Sheriff Deputy puts the National Guard helicopter on alert for
evacuation. As triage and prioritization of patients is continued, a helicopter LZ is prepped in the
snow with Gatorade bottles. Bystanders and other climbers on the mountain converge to the
scene. Under your leadership, ropes, technical climbing, and extrication gear are procured to help
facilitate a hasty response team while your trained rescue colleagues approach the scene from
below.

Discussion of Cases and Their Significance

In the scenarios above, decisions are being made in the practice of the WEMS care spectrum that
demand evaluation of injuries in the context of the vertical environment. In many cases, the
correct course of action dictates prompt removal from the rock and alpine environment. In other
situations, stabilization or improvisation of care must be employed prior to extrication. The ICS
structure and team protocols will often dictate what level of care may be employed by rescue
team members despite their level of training. Operating within these parameters allows for a
clean risk management system, but may limit the depth of care being administered. This dictates
a thoughtful team strategy toward its medical protocols, insurance, and the role of the
supervising physician medical director and PAs or APRNs associated with the team.
Additionally, these considerations must be developed in collaboration with the technical
demands of rescue.
The ability to work in this setting with evolving conditions, patient status, and available
technical resources is essential for an effective MRU to accomplish its mission. This requires
continuous training and rehearsal of both the medical and technical aspects of care. For this
reason, wilderness and climbing medicine course work provides an excellent path to facilitate
continued education, and bring together what is often a group of diverse medical providers under
a similar plan of action. As mentioned earlier, the accrediting bodies of mountain rescue help to
bring greater clarity to the employment of resources in accomplishing a rescue mission; however,
greater integration and collaboration within ICS structures would be helpful. Team physicians
and other clinicians able to deliver more definitive care should work toward helping to establish
appropriate protocols both at the team level and in state/county relationships.

The End of the Day

It is often discussed in front country medicine and hospital-based transitions of care that effective
communication is essential to minimize medical error and maintain continuity of care. This is
most certainly true of WEMS as well. In fact, Chapter 6 is totally dedicated to this topic. In an
era of growing electronic medical record technologies that do not yet communicate between
different agencies, the WEMS provider is perhaps left with an even greater challenge to
document and transition care for the patient. Nevertheless, such documentation is required both
for completeness of care and for medical-legal protection. Even in the case of volunteer agencies
working with Good Samaritan instincts, effective documentation will facilitate continued
improvement in technical rescue and medical protocols for the responding agency. If properly
executed, it will also address other components of the rescue for process improvement such as
ICS structure management, hazard mitigation, and communication gaps.
Effective documentation can be accomplished in real time during technical rescue by many
methods. Simply executed, a “write-in-the-rain” pen/paper may be all that is necessary to
document history and physical findings along with treatment, responses, and continued care until
an appropriate handoff/transition of care can be performed. Other technologies showing promise
include the integration of smartphones where live dictation can be accomplished “hands-free.”
This can also be executed via radio to a SAR base provider who documents patient findings from
radio discussion. Care must be given in this circumstance to the protection of private health
information over open radio channels. Finally, for the more tech-savvy rescuer, there are a host
of smartphone-based apps allowing for a point-and-click style of documentation. All of these
serve to help develop a final synopsis of the day once the team and patient have been removed
from the field.

Force Preservation
It is not uncommon that a rescue in process can take a turn for the worse—a patient’s condition
can continue to deteriorate in the vertical environment. While this is the focus of continued
integration within the multiple disciplines of WEMS, another component of the rescue demands
discussion here. The challenges of a rescue often present a growing threat to rescue team safety
that could be compromised in the line of duty. It may simply be the exposure effects of alpine
environment, long-standing work contributing to fatigue or dehydration, or perhaps a more
drastic scenario.
A hasty response team may reach the subject with enough mental and physical reserve to
mount the initial rescue response but prolonged exposure or delay in additional resources
arriving may impede their abilities and safety. The technical demands of the vertical environment
require continued cognitive focus to ensure rescue and team member safety. Even when the
utmost attention to detail is given along with ample resource allotment for the goals of a mission,
things can and do go wrong where rescue team member safety becomes a concern. In the mass
casualty event described in the scenarios above, consider adding to the scenario that the arriving
rescue helicopter crashes into the mountain with rescue team members and a patient aboard.
Other examples of hazardous concern include additional avalanche risk, declining weather
conditions, rock and icefall, anchor failure, and depletion of hasty resources.
While this is not an exhaustive list of possibilities, it certainly paints the picture accurately
that there is inherent risk, often outside of measured control, by which rescuers are finding
themselves in compromised circumstances. In such a case, heightened integration of local
resources with training and mutual aid is of great importance. While challenging to incorporate
multiple types WEMS providers within one functional team structure, a multidisciplinary model
has been demonstrated to be possible and deserves further discussion.
Finally, whether working in a single agency or multiple discipline ICS structure, rescue
teams would do well to take notice of the inherent and perceived risk prior to entering the field.
In front country medicine, this is often accomplished as a “time-out” whose components are well
documented by the World Health Organization. Multiple rescue teams have advanced the search
and rescue green-amber-red (SAR-GAR) project across the United States as an effective tool to
identify and mitigate risk prior to entering the field.31 In some cases, it has changed the goal or
the possibility of rescue attempts being initiated.32 Noting the inherent risk of the work
environment, SAR teams should be prepared to provide force protection and care for team
members who fall sick or injured in the line of duty.

SUMMARY
Operational WEMS in snow, alpine, glaciated, and crevasse terrain poses unique challenges.
Organized ski patrols operate in a number of environments from lift-serviced frontside terrain to
backcountry Nordic and alpine wilderness. While the specific medical care provided is similar to
that of other WEMS disciplines, there are unique aspects including treatment and transport
options. Mountain rescue teams operating in these environments need to have a combination of
skiing, climbing, and mountaineering skills as well as basic and advanced medical skills to
stabilize and care for patients in challenging terrain.
Ski patrols deliver sophisticated care in a unique environment. Identified by the NSP as
integral components in EMS, ski patrols must hold themselves to the same standards as their
EMS colleagues to assure high-quality patient care is delivered consistently. The same is true of
MRUs. As identified by the National Association of EMS Physicians and NASEMSO, WEMS
programs managing patients in these operational environments require physician oversight and
integration into the emergency care system just as much as their traditional EMS counterparts, if
not more so.9,17–19,33
There is no doubt that integration of a ski patrol or MRU into a traditional EMS structure
may be challenging. There are always concerns regarding cost, placing additional training and
financial burdens on volunteers, and a perception that trying to fit WEMS into traditional EMS
structures is a “Round Peg-Square Hole” paradox. However, Maryland’s success with integration
not just of ski patrols but WEMS in general into the statewide protocols certainly demonstrates a
viable model for successful integration. Additionally, arguments that “there isn’t a need as things
have always gone well in the past” miss the point that in fact things have not always gone well
and have either been ignored or, more dangerously, not recognized. Resistance to integration is
often due to operational inertia resulting in a culture of resistance to change. All the operational
and logistical constraints to integration can and should be managed by a strong leadership team
with physician oversight. By focusing the conversation on the patient population, and reflecting
on the multiple possible scenarios of patient encounters (some of which are outlined in this
chapter), it becomes quite obvious that it is in the best interest of the patient population for
integration to occur.
References
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3. Injury statistics. Available at: http://www.snowsportsafety.org/injury-statistics/. Accessed January 4, 2017.
4. Fletcher J. NSAA Ski Lift safety fact sheet. Available at:
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http://www.nasemso.org/councils/medicaldirectors/documents/definition-of-ems-2012.Pdf. Accessed September 8, 2016.
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Accessed December 16, 2016.
13. US National Archives and Records Administration (2011). Code of federal regulations. Title 29. Occupational Health and
Safety Standards. Sec. 1910.151
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Washington, DC: ANSI; 2015.
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http://steepmanagement.com/recent-news/where-is-ski-patrol-headed/. Accessed December 16, 2016.
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practice of wilderness EMS providers: A joint project developed by wilderness EMS educators, medical directors, and
regulators using a Delphi approach. Prehosp Emerg Care. 2017;28:1-9.
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Department of Transportation, National Highway Traffic Safety Administration; 2007.
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Med. 2001;8(7):725.
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Emergency Care. 2009;13:516-527.
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medical-control physician assertiveness on transport rate. Acad Emerg Med. 1998;5:4-8.
23. Seaberg DC, Jackson R. Clinical decision rule for knee radiographs. Am J Emerg Med. 1994;12(5):541-543
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acute, high-risk knee injuries. Ann Emerg Med. 1998;32:8-13.
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Prehosp Disaster Med. 1999;14:93-96.
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http://wms.org/research/default.asp?t=pg. Accessed December 16, 2016.
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http://wms.org/magazine/1191/Practice_Guidelines. Accessed December 16, 2016.
29. Mountain Rescue Association. Mountain rescue association teams: appalachian region. Available at: http://mra.org/all-
teams/appalachian-region/. Accessed December 16, 2016.
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http://www.appalachianmountainrescue.org/index.php. Accessed December 16, 2016.
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DC: US Department of the Interior, National Park Service; 2014:11-12.
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*http://www.rescuegear.com/products/rainy-day-equipment-baumanbag
Note: Locators followed by ‘b’, ‘f’, ‘t’ denotes boxes, figures and tables respectively.

A
abdominal pain/illnesses, 404–406
abdominal/pelvic trauma, 384–386
Acetazolamide, for altitude illness, 278, 281
acute mountain sickness, 273–274, 277–278
advanced practice registered nurses (APRNs), 25–26
agitation, aggression, and violence, 424–427
assessment, 425
clinical features, 425
epidemiology and etiology, 424–425
evacuation recommendations, 427
treatment and disposition, 425–427
airway, WEMS equipment and, 141–142
all-terrain ambulances, 505
all-terrain trailer, 505
all-terrain vehicles, 504
altitude illnesses, management of, 271–285
acclimatization, 271
clinical management, 273–285
definitions, 271–272
epidemiology, 272–273
equipment, summary of, 284–285
portable fabric hyperbaric chamber, 284
pulse oximeter, 284
extreme altitude, 271–272
Golden Rules, 279
high altitude, 271
rescue, considerations for, 285
treatment of illness, 282b
identification, 273–276
acute mountain sickness, 273–274, 277–278
high altitude cerebral edema, 274, 277–278
high altitude flatus expulsion, 276
high altitude headache, 275
high altitude pharyngitis and bronchitis, 276
high altitude pulmonary edema, 274–275, 278–279
high altitude retinopathy, 275
high altitude syncope, 275
high altitude visual problems, 275
neurologic conditions, 275
periodic breathing, 276
peripheral edema, 276
sleep disturbance, 276
introduction, 271
medications, 278t
 prevention, 276–280
gradual ascent, 276–277
of HAPE, 278–279
of high altitude illness, 279
pharmacologic, 277–278
rescue, special considerations for, 285
scope, 272
treatment and disposition, 280–284, 282b
of AMS and HACE, 280–284
of HAPE, 282–284
unacclimatized rescuers, 279–280
very high altitude, 271
WEMS providers, screening of, 280
angina pectoris, 394
animal bites, management of, 333–343
nonvenomous
clinical management, 334–337
definitions, 333
epidemiology, 333–334
equipment, summary of, 337
identification, 334–335
introduction, 333
prevention, 334
scope of discussion, 333
selection of animal habits, 336–337
treatment and disposition, 335–336
venomous
atractaspidinae, 340–341
clinical management, 337–343
crotalin snakes, 338–339
definition, 337
elapid snakes, 339–340
epidemiology, 337–338
equipment, summary of, 343
identification, 338
introduction, 337
prevention, 341
reptiles, 338
scope of discussion, 337
treatment and disposition, 341–342
ankle fracture/dislocation, 390f
antacids, for altitude illness, 278
antioxidants, for altitude illness, 278
anxiety, 415–418
assessment, 416
clinical features, 415–416
epidemiology and causes, 415
evacuation, 418
treatment, 416–418
aortic dissection, 394
APRNs, 25–26
asthma, 396
atractaspidinae, 340–341

B
bacteria, 350
bad air, cave and, 521–522
barotrauma, diving injuries, 302–306
 dental, 305
ear, 304–305
gastrointestinal, 306
lung, 305–306
sinus, 304
skin, 304
behavioral emergencies, management of, 413–428
agitation, aggression, and violence, 424–427
assessment, 425
clinical features, 425
epidemiology and etiology, 424–425
evacuation recommendations, 427
treatment and disposition, 425–427
anxiety, 415–418
assessment, 416
clinical features, 415–416
epidemiology and causes, 415
evacuation, 418
medical causes of, 415t
treatment, 416–418
bipolar and psychotic disorders, 419–421
assessment, 420
clinical features, 419–420
epidemiology and etiology, 419
evacuation, 421
treatment and disposition, 420–421
clinical management, 415–427
definitions, 413–415
depression, 418–419
assessment, 418–419
clinical presentation, 418
epidemiology and etiology, 418
evacuation recommendations, 419
treatment and disposition, 419
equipment, summary of, 428
introduction, 413
medication toolkit, 428t
mental health medications and withdrawal, 417t
prevention of, 427–428
sleep disorders, 421–422
assessment, 422
clinical features, 421–422
epidemiology and etiology, 421
evacuation recommendations, 422
treatment and disposition, 422
substance use, 422–424
assessment, 423–424
clinical features, 423
epidemiology and epidemiology, 422–423
evacuation and recommendations, 424
treatment and disposition, 424
symptoms of withdrawal, 424t
beta-agonists, for altitude illness, 283
bipolar and psychotic disorders, 419–421
assessment, 420
clinical features, 419–420
epidemiology and etiology, 419
evacuation, 421
 treatment and disposition, 420–421
Blood Stopper, 142
burns, trauma and, 378–380
burrito (hypothermia wrap), 247

C
calcium channel blockers, for altitude illness, 278
cardiopulmonary arrest, 395
caregiver interfaces, transitions of care and, 126–128
communication and, 126–128
tenuous nature, 126
WEMS provider, impact of, 128
care providers, WEMS systems, 43–44
emergency medical dispatchers, 43
lifeguards, 43
ParkMedics, 44
ski patrollers, 44
wilderness EMRs, 43–44
wilderness EMTs, 43–44
wilderness first aiders, 43
wilderness first responders, 43
categories, selection, and organization, WEMS equipment and, 140
causality, concept of, 164
cave diving emergencies, diving injuries, 310–311
cave rescue, 519–527
bad air, 521–522
cold, 519
collapsed, 522
confused, 521
dark, 519
definition, 519
delicate, 522
dirty and muddy, 520
enclosed, 520
environment care, 519–522
equipment, summary of, 527
flooded, 522
implications for practice levels, 527
introduction, 519
medical considerations, 526
navigation and communications, 524–526
psychologically stressful, 522
remote, 521
scope of discussion, 519
specifics, 526
teams and organizations, 522–524
technical considerations, 526
vertical, 520–521
wet, 519–520
central nervous system infections, clinical management of, 366–367
cerebral vascular accident (CVA or “stroke”), 400
cervical spine motion restriction, 498
chest trauma, 382–384
chilblain, 251–252
clinical management, 252
definition, 251
disposition, 252
identification, 251–252
chronic obstructive pulmonary disease (COPD), 397
civil liability, 113–116
cold cave, 519
cold injuries, management of, 241–254
chilblain, 251–252
clinical management, 252
definition, 251
disposition, 252
identification, 251–252
epidemiology, 243
equipment, summary of, 253
frostbite, 249–251
clinical management, 250–251
definition, 249
disposition, 251
identification, 249–250
homeostatic physiology, principles of, 241–243
hypothermia, 245–249
clinical management, 246–249
definition, 245
disposition, 249
identification, 245–246
introduction, 241
prevention, 243–245
clothing, 243–244
food, 243
footwear, 244
skin protection, 244–245
scope, 241
thermoregulation, principles of, 241–243
trench foot, 252–253
clinical management, 252–253
definition, 252
disposition, 253
identification, 252
collapsed cave, 522
communication
high and low angle rescue, 466–468
WEM and, 183
wilderness survival, 237–238
confounding, 172
confused cave, 521
congestive heart failure (CHF), 394
criminal liability, 119
crotalin snakes, 338–339
cystitis, 359

D
dark cave, 519
decompression illness, diving injuries, 306–308
DCS type 1, 307
DCS type 2, 307–308
dehydration, 258–259, 261
basic life support/advanced life support/clinician, 267
levels of care, 266
thirst, 263
urine concentration, 262–263
 weight, 263
delicate, cave and, 522
demobilization, 94
dental barotrauma, 305
depression, 418–419
assessment, 418–419
clinical presentation, 418
epidemiology and etiology, 418
evacuation recommendations, 419
treatment and disposition, 419
detailed handovers, 126
Dexamethasone, for altitude illness, 278, 281, 283
diabetes, 401–403
equipment, summary of, 402–403
identification, 401–402
prevention, 402
treatment and disposition, 402
dirty and muddy cave, 520
diuretics, for altitude illness, 278, 281, 283
Dive Medicine Technician (DMT), 73
diving injuries, management of, 301–315
barotrauma, 302–306
dental, 305
ear, 304–305
gastrointestinal, 306
lung, 305–306
sinus, 304
skin, 304
cave diving emergencies, 310–311
clinical management, 302–314
decompression illness, 306–308
DCS type 1, 307
DCS type 2, 307–308
definition, 301
epidemiology, 302
equipment, summary of, 311–314, 312b
hazardous marine life, 309
hypoxic blackout, 309
immersion pulmonary edema, 308–309
introduction, 301
nitrogen narcosis, 309
oxygen toxicity, 309
scope of discussion, 301–302
training, 314
DMT, 73
documentation, WEM and, 183–184
downed aircraft search, 553–554
drowning, 289–298
ages above 55, 294
ages 5 to 10, 293
ages 10 to 55, 294
ages younger than six, 292–293
clinical management, 290–298
defined, 289
epidemiology, 289–290
equipment, summary of, 298
identification, 290–292
minimally symptomatic grade, 291
 moderately symptomatic grade, 291–292
severely symptomatic patient, 292
introduction, 289
prevention, 292–293
scope of discussion, 289
in submerged vehicles, 296–298
treatment and disposition, 294–296
vehicles, drowning in, 296–298
advanced life support, 297
basic life support, 297
clinician, 297–298
first aid, 296–297
drugs administration in wilderness environment, 209–218
donation of drugs, 218
drug information, 209
drug storage and stability, 209–215, 215t, 216t
recommendations, 211
expiration of drugs, 215–218
major routes of administration, 206t
medication use, effect of, 209
principle of medication, 211t
Rights of Medication Administration, 209

E
ear barotrauma, 304–305
ectopic pregnancy, 407–408
elapid snakes, 339–340
emergency medical responder (EMR), 66–67
EMR, 66–67
EMS, 22
defined, 22, 27
relationship between WM and WEMS, 23–28
EMS fellowship, 76–78
EMS provider
defined, 120
models of WEMS interaction, traditional, 131
scope of practice, traditional, 128–131
advanced emergency medical technician, 129–130
emergency medical responder, 129
emergency medical technician, 129
paramedic, 130–131, 130b
traditional, defined, 126
enclosed cave, 520
epididymitis, 409
equipment, WEMS, 139–157
discussion of
airway, 141–142
categories, selection, and organization, 140
personal protection equipment, 140
wounds, 142–145
introduction, 139
nonessential essentials, 153–156
orthopedics, 145–153
10 essentials, 150–153
medications, 146–148
survival equipment, 150
tools, 148–150
practice levels, implications for, 156–157
evidence-based medicine (EBP), 13–14
WEMS research and, 159–160
exercise-associated hyponatremia, 259, 263
basic life support/advanced life support/clinician, 267
dehydration vs. hyponatremia, 263
levels of care, 267
exercise-associated muscle cramps, 257–258, 261
levels of care, 264
exertional heat stroke, 258, 261–262
advance life support/clinician, 266
basic life support, 266
levels of care, 266
extreme altitude, 271–272

F
federal liability, 116
Federal Tort Claims Act (FTCA), 116
female genitourinary complaints, 406–408
equipment, summary of, 408
identification, 406–408
prevention, 408
treatment and disposition, 408
field medical kits, rescue and, 478
finger dislocation reduction, 387f
flooded cave, 522
FLOP, 86f
freefall swimmer deployment, 514
frostbite, 249–251
clinical management, 250–251
definition, 249
disposition, 251
identification, 249–250
FTCA, 116

G
gastrointestinal barotrauma, 306
gastrointestinal infections, clinical management of, 364–366
genitourinary infections, clinical management of, 359–361
Good Samaritan Laws, 121–122
GRADE, 177
Grading of Recommendations Assessment, Development and Evaluation (GRADE), 177
grey literature, 176

H
handover, defined, 125
hazardous marine life, diving injuries, 309
head, face, neck, and spinal trauma, 380–382
headaches, 399
heat exhaustion, 258, 261
levels of care, 264–266
heat illnesses, management of, 255–267
clinical management, 261–267
definitions, 255–256
dehydration, 258–259, 261
basic life support/advanced life support/clinician, 267
levels of care, 266
thirst, 263
 urine concentration, 262–263
weight, 263
epidemiology, 260–261
equipment, summary of, 267
portable blood analyzer, 267
temperature measurement, 267
exercise-associated hyponatremia, 259, 263
basic life support/advanced life support/clinician, 267
dehydration vs. hyponatremia, 263
levels of care, 267
exercise-associated muscle cramps, 257–258, 261
levels of care, 264
exertional heat stroke, 258, 261–262
advance life support/clinician, 266
basic life support, 266
levels of care, 266
heat exhaustion, 258, 261
levels of care, 264–266
heat syncope, 258
levels of care, 264
hydration, 256–257
identification, 261
introduction, 255
physiology of human, 256
predisposing factors, 259–260
prevention, 263–264
treatment approaches, 265t
heat prostration. See heat exhaustion
heat syncope, 258
levels of care, 264
helicopter rescue, 503–517
assets, WEMS, 507–508
definition, 505–507
implications for practice levels, 516–517
advanced life support, 517
basic life support, 516–517
clinician, 517
first aid, 516
introduction, 503
medical integration, 515–516
operations, 506–507
prevalence, 507–508
scope of discussion, 503–504
technical discussion, 509–514
helicopter types, 511
mission types, 511–514
onboard communication, 511
performance, 510–511
personal protective equipment, 510
preflight briefing, 511
regulations, 510
safety, 510
training and education, 509
types, 511
use, regulation, and risk, 506
helminths, 351–352
hemorrhage and shock, trauma and, 373–376
high altitude, 271
 headache, 275
pharyngitis and bronchitis, 276
rescue, considerations for, 285
retinopathy, 275
syncope, 275
visual problems, 275
high altitude cerebral edema (HACE), 274, 277–278
high altitude flatus expulsion (HAFE), 276
high altitude pulmonary edema (HAPE), 274–275, 278–279
high and low angle rescue, 459–479
advances and updates, medical practice, 479
communication, 466–468
common commands and clarity, 467
technology in, 468
types of, 467
user group terminology, 468
definition, 459–460
environmental teams, 461–462
environment care, 460–461
epidemiology, 462–464
equipment, summary of, 478
field medical kits, 478
implications for practice levels, 476–478
advanced life support, 477–478
basic life support, 477
clinician, 478
first aid, 476–477
introduction, 459
medical integration, 474–476
medical terminologies, 478–479
planning and preparation, 465–466
prevalence, 460–462
risk assessment and mitigation, 466
scope of discussion, 460
technical discussion, 468–474
gear competencies, 469–471
personal competencies, 471–473
rescue competencies, 473–474
vertical environment, patients in, 464–465
hoist operations, 512–513
dangers of, 513–514
human immune system, definition and description of, 352–353
hydration, 256–257
hyperglycemia, 401
hypoglycemia, 401
hypothermia, 245–249
clinical management, 246–249
definition, 245
disposition, 249
hypoxic blackout, diving injuries, 309

I
IC PLuS, 86f
ICS, 83
Forms, 92t
immersion foot. See trench foot
immersion pulmonary edema, diving injuries, 308–309
improvised pelvic splints, 385f
incident command, wilderness EMS, 83–99
chain of command, 89
defined, 83
further education of, 97–99
incident complexity, 87
incident duration, 87–89
introduction, 83–85
management by objectives, 89–90
managing in the field, 90–94
conclusion, plan for, 94
determination of incident commander, 90
documentation, 91–92
establishing command, 90
facilities location, 93–94
personnel, account for, 92–93
priorities and objectives, establishing, 94
role, importance of, 90
safety and supervision, ensuring, 94
scene size up, 90–91
practice levels, implications for, 95–97
advanced life support, 96
basic life support, 95–96
clinician, 96–97
first aid, 95
scalability and flexibility, 86–87
span of control, 87, 88f
standardization, 85–86
terminologies, 85–86
unity of command, 89
incident command system (ICS)
benefits of, 84f
features for EMS incidents, 83–85
infectious diseases, WEMS, 347–353, 355–368
bacteria, 350
central nervous system infections, clinical management of, 366–367
equipment, summary of, 367
identification, 366
treatment and disposition, 367
definitions, 347–349, 355
epidemiology, 356
gastrointestinal infections, clinical management of, 364–366
equipment, summary of, 366
identification, 364–365
treatment and disposition, 365–366
genitourinary infections, clinical management of, 359–361
equipment, summary of, 361
identification, 359–360
treatment and disposition, 360–361
helminths, 351–352
human immune system, definition and description of, 352–353
introduction, 347, 355
mycoses, 350–351
pathogens, description of, 347–349
prevention of transmission, 368
prions, 349
protozoa, 351
pulmonary infections, clinical management of, 356–359
equipment, summary of, 359
 identification, 356–357
treatment and disposition, 357–359
scope of discussion, 355–356
sepsis, clinical management of, 367–368
identification, 367
treatment and disposition, 367–368
skin and soft tissues, clinical management of, 361–363
equipment, summary of, 363–364
identification, 361–362
treatment and disposition, 362–363
virus, 349–350
wilderness manifestations of, 353–354
information bias, 172
inguinal hernias, 408
instructor training, WEMS education and, 78–79
in-water resuscitation, 498

K
knots, 440, 471
knowledge translation (KT), 164

L
liability, WEMS and, 113–119
civil liability, 113–116
anatomy of civil law suit, 113–114
legal relationships, impact of, 115
ordinary negligence, 115–116
criminal, 119
federal liability, 116
Federal Tort Claims Act, 116
Section 1983, 116
protection, 119–122
EMS-specific protections, 119–120
Good Samaritan Laws, 121–122
sovereign immunity statutes, 122
volunteer protection statutes, 120–121
stale and local civil, 117–119
abandonment, 117–118
administrative liability, 118–119
battery, 118
negligence, 117
and substance management, 119
lightning injuries, 317–330. See also severe storms
body systems and potential injuries, 327t
clinical management, 319–326
definition, 317–318
emergency supply kit, 328t
epidemiology, 318–319
equipment, summary of, 326
family emergency plan, 328t
feathering lesions, 321
high-risk indicators, 327t
identification, 321–322
introduction, 317
linear burns, 321
prevention, 322–325
punctuate burns, 321
 scope of discussion, 318
severe storms, 327–330
thermal injury, 321
tornado, 329t
treatment and disposition, 325–326
advanced life support, 326
basic life support, 325–326
clinician, 326
first aid, 325
types of, 321
literature reviews, description of, 166
litters, 473
lung barotrauma, 305–306

M
magnesium, for altitude illness, 278
male genitourinary complaints, 408–410
equipment, summary of, 409–410
identification, 408–409
prevention, 409
treatment and disposition, 409
Mattson Consensus Method, 536–539
medical advisors, 24–25
medical conditions, management of, 393–410
abdominal pain/illnesses, 404–406
equipment, summary of, 406
identification, 405
prevention, 405
treatment and disposition, 405
allergic reaction/anaphylaxis, 403–405
equipment, summary of, 404
identification, 403
prevention, 403
treatment and disposition, 403–404
cardiac/chest pain, 394–396
equipment, summary of, 396
identification, 394–395
prevention, 395
treatment and discussion, 395–396
clinical management, 394–410
definition, 393
diabetes, 401–403
equipment, summary of, 402–403
identification, 401–402
prevention, 402
treatment and disposition, 402
epidemiology, 393–394
female genitourinary complaints, 406–408
equipment, summary of, 408
identification, 407–408
prevention, 408
treatment and disposition, 408
introduction, 393
male genitourinary complaints, 408–410
equipment, summary of, 409–410
identification, 408–409
prevention, 409
treatment and disposition, 409
 neurologic conditions, 399–401
equipment, summary of, 401
identification, 399–400
prevention, 400
treatment and disposition, 400–401
respiratory/shortness of breath, 396–399
equipment, summary of, 399
identification, 396–398
prevention, 398–399
treatment and discussion, 399
scope of discussion, 393
medical considerations, WEMS, 111–123
introduction, 111–112
liability, 113–119
civil liability, 113–116
criminal, 119
federal liability, 116
stale and local civil, 117–119
and substance management, 119
liability protection, 119–122
EMS-specific protections, 119–120
Good Samaritan Laws, 121–122
sovereign immunity statutes, 122
volunteer protection statutes, 120–121
reasonable person standard of care, 112–113
U.S. legal system, overview of, 112
medical consult template, 105t
medical directors, 24–25
medical oversight, WEMS, 101–108
direct, 104
incident commander, 107–108, 108f
indirect, 103–104
introduction, 101
in operational EMS programs, 101–103
organization structure, 107–108, 108f
practice levels, implications of, 104–107
advance life support providers, 106–107
basic life support providers, 105–106
clinician, 107
first aid, 105
scopes of practice, 104–105
medical staffing, WEM and, 184–185
medical subspecialty, 51–52
medroxyprogesterone, for altitude illness, 278
meta-analysis, 167
minimal handovers, 126
mixed-methods research, 169
mountaineering rescue, 576–579. See also ski patrol
introduction, 562
life of mountain rescue unit member, 576–579
completion, 578
force preservation, 578–579
patient care response, 577–578
preparation, 576–577
medical oversight, 576
serviced areas, 576
mycoses, 350–351
myocardial infarctions, 394
N
Naproxen, for altitude illness, 278
National Incident Management System (NIMS), 83
navigation, basics of, 235–237
neurologic conditions, 399–401
equipment, summary of, 401
identification, 399–400
prevention, 400
treatment and disposition, 400–401
Nifedipine, for altitude illness, 278
NIMS, 83
nitrogen narcosis, diving injuries, 309
nonphysician clinicians, 25–26
nonvenomous animal bites. See under animal bites, management of

O
OEC, 71–72
off-road vehicles rescue
all-terrain ambulances, 505
all-terrain trailer, 505
all-terrain vehicles, 504
legality of, 505
prevalence, 507
definition, 504–505
introduction, 503
medical integration, 514–515
prevalence, 507–508
scope of discussion, 503–504
technical discussion, 508–509
utility task vehicles, 504
legality of, 505
prevalence, 505
WEMS response vehicles, 505
open water rescue, 495–501
cervical spine motion restriction, 498
definition, 495
equipment, summary of, 499–501
medical equipment, 500–501
rescue equipment, 499–500
implications for practice levels, 498–499
advanced life support, 499
basic life support, 499
clinician, 499
first aid, 498–499
introduction, 495
medical integration, 498
in-water resuscitation, 498
prevalence, 496
scope of discussion, 495
technical discussion, 496–498
advanced procedures, 497–498
basic procedures, 496–497
orthopedics, WEMS equipment and, 145–153
10 essentials, 150–153
medications, 146–148
survival equipment, 150
tools, 148–150
orthopedic trauma, 386–390
outdoor emergency care (OEC), 71–72
out-of-hospital communication, 126–128
ovarian torsion, 407
oxygen toxicity, diving injuries, 309

P
pain management, and technical rescue interface, 451
paraphimosis, 409
PAs, 25–26
pathogens, description of, 347–349
patient abandonment, defined, 136
patient safety, transitions of care and, 131–137
advanced life support, 136
basic life support, 132–136
clinician, 136–137
first aid providers, 132
pelvic inflammatory disease (PID), 407
pernio. See chilblain
personal protection equipment, 140
PFA. See psychological first aid (PFA)
pharmacology, WEMS, 203–224
basis of, 203–209
drug administration, route of, 205
drug formulation, 206t
geriatrics, 208
pediatrics, 207–208
pharmacodynamics, 207
pharmacokinetic processes, 203–205
pregnancy/labor and delivery/nursing, 208
renal impairment, 209
commonly used drugs, 219–223
implications for practice levels, 222–223
medical kit preparation, 219–223
drugs administration in wilderness environment, 209–218
donation of drugs, 218
drug information, 209
drug storage and stability, 209–215, 215t
effect of environmental conditions, 215t, 216t
expiration of drugs, 215–218
expose of drugs, during transport, environment conditions, 214t
major routes of administration, 206t
medication use, effect of, 209
principle of medication, 211t
Rights of Medication Administration, 209
phimosis, 409
phosphodiesterase inhibitors
for altitude illness, 278
placement of personnel, WEM and, 184–185
pneumonia, 397
portable fabric hyperbaric chamber, 284
prions, 349
priori analysis, 163
protozoa, 351
psychological first aid (PFA), 189–201. See also stress injuries
principles for, 194–197
pulmonary embolism (PE), 397
pulmonary infections, clinical management of, 356–359
pulse oximeter, 284
purpura, 359
pyelonephritis, 359, 406

Q
qualitative research, principles of, 168
study designs, 168
vs. quantitative research, 168–169
quantitative research, principles of, 164–168
case reports and case series, 166
quantitative data, 167–168
randomized controlled trial, 164–165
systematic review and meta-analysis, 166–167
vs. qualitative research, 168–169
Quigley’s traction, 390f

R
rappel devices, 470
rappelling, 473
rappel operations, 511–512
dangers of, 513–514
remote cave, 521
rescue. See also technical rescue interface
high and low angle. See high and low angle rescue
litters, 473
open water, 495–501
swiftwater, 481–493
rescue gear organization, 440, 444
rescue group structure, 438
rescue system fundamentals, 438
research, WEMS, 159–178
characteristics of, 159–176
engagement of, 177–178
evidence-based medicine, 159–160
challenges, 160
contribution, 160
health services and, 161
interpretation of, 169–175
conclusion and practice, 174–175
critical appraisal, final thoughts on, 175
researchers, role of, 170–171
trust, conclusion and, 171–174
introduction, 159
knowledge translation, 177
literature, searching of, 175–177
articles, getting of, 176–177
review question and research databases, formulation of, 175–176
scouring references, 176
mixed-methods research, 169
surveys, 169
qualitative research, principles of, 168
study designs, 168
vs. quantitative research, 168–169
quantitative research, principles of, 164–168
case reports and case series, 166
observational studies, 165–166
quantitative data, 167–168
 randomized controlled trial, 164–165
systematic review and meta-analysis, 166–167
vs. qualitative research, 168–169
rigorous study, 161
importance of, 162
steps in conducting, 162–164
conclusion to action, 164
ideas, 162–163
methods to results, 163
question to methods, 163
results to conclusion, 163–164
types of, 160–161
resource deficiency, 51
respiratory/shortness of breath, 396–399
equipment, summary of, 399
identification, 396–398
prevention, 398–399
treatment and discussion, 399
Rights of Medication Administration, 209
rigorous study, WEMS research and, 161
rule of nines, 380f
rule of threes, 231

S
SAR. See also search and rescue
operations, helicopter rescue and, 514
scopes of practice, 104–105
search and rescue, 529–558
definition, 530
downed aircraft search, 553–554
force protection, 555–557
introduction, 529
management, 543–553
big search, ramping up to, 544–545
initial operations and reflex tasks, 543–544
processes and technology, 545–551
remote support, 551–553
politics and regional variations, 554–555
resources, strategy and tactics, 531–534
containment, 534
dogs, 533–534
humans, 531–533
team capabilities, 531
terminology, 529–531
theory and strategy, 534–543
complications, 542–543
geographic information system, 540
limitations, 543
Mattson Consensus Method, 536–539
probability of area, 535–536, 542–543
probability of detection and sweep width, 540–542
search area, defining, 535
segmenting, search area, 536
statistical method, 539–540
Trail-Based Probability of Area Method, 539
wilderness rescue, 557–558
selection bias, 172
semesters, 72
sepsis, clinical management of, 367–368
severe storms, 327–330. See also lightning injuries
sexually transmitted infections (STIs), 407
short-haul operations, 513
dangers of, 513–514
shoulder reduction methods, 388f
sinus barotrauma, 304
skin and soft tissues, clinical management of, 361–363
skin barotrauma, 304
ski patrol, 561–576. See also mountaineering rescue
life of ski patroller, 565–576
lift evacuation and technical rescue, 567–569
medical direction and oversight, 564–565
National Ski Patrol Outdoor Emergency Care Technician Training, 564
patient care response, 571–574
preparation, 565–571
serviced environments, 562–563
snowmobiles, 569
special considerations, 569–571
sleep disorders, 421–422
assessment, 422
clinical features, 421–422
epidemiology and etiology, 421
evacuation recommendations, 422
treatment and disposition, 422
soft tissue trauma, 376–378
sovereign immunity statutes, 122
spironolactone, for altitude illness, 278
spontaneous pneumothorax, 398
stable angina, 394
stale and local civil liability, 117–119
STEP procedure, 514
stress injuries, 189–201
current language of, 192–193
description, 190
formation, 192
introduction, 189–190
signs and symptoms, 190–192
treatment of, 192–198
acute behavioral exacerbations, principles for, 193–194
advanced life support, 197–198
basic life support, 197
clinician, 198
first aid, 197
PFA, principles for, 194–197
in WEMS responder, 198–201
mindfulness of personnel, importance of, 199–201
prevention and treatment, 199
substance management, liability, 119
substance use, 422–424
assessment, 423–424
clinical features, 423
epidemiology, 422–423
evacuation and recommendations, 424
treatment and disposition, 424
suit squeeze. See skin barotrauma
sump diving, 310. See also cave diving emergencies, diving injuries
survivalism and personal safety, WEMS systems, 45–46
survival psychology. See wilderness survival, lost person behavior and
suspension syndrome, 453–454
swiftwater rescue, 481–493
definition, 481
equipment, summary of, 491–493
implications for practice levels, 490–491
advanced life support, 491
basic life support, 491
clinician, 491
first aid, 490–491
introduction, 481
medical integration, 490
prevalence, 481–484
resources of the river, using, 493
scope of discussion, 481
skills, 484
technical discussion, 484–490
equipment recovery, 489–490
river communications, 485–486
swiftwater incident command systems, 486–487
swiftwater rescue philosophy, 484–485
techniques, 487–489

T
technical rescue interface, 433–456
definition, 433
documentation and quality improvement, 436–437
equipment, summary of, 456
implications for practice levels, 454–456
introduction, 433
medical integration, 444–454
airway considerations, 449–450
basic patient packaging, principles of, 449
other considerations, 451–452
pain management, 451
prolonged field care, 454
real care, 450
spinal injuries and spinal cord protection, 452–453
suspension syndrome, 453–454
WEMS, training for, 454
principles, 433–436
commercial devices, 440
knots, 440
rescue gear organization, 440, 444
rescue group structure, 438
rescue system fundamentals, 438
technical rescue systems, 438–444
webbing, 439–440
tension pneumothorax, 398
testicular torsion, 409
tornado, 329t
tourniquet conversion, 376f
traditional literature reviews, 166
Trail-Based Probability of Area Method, 539
transient ischemic attack (TIA), 400
transitions of care
caregiver interfaces and, 126–128
communication and, 126–128
 tenuous nature, 126
WEMS provider, impact of, 128
patient safety and, 131–137
advanced life support, 136
basic life support, 132–136
clinician, 136–137
first aid providers, 132
trauma, management of, 371–391
clinical management, 372–391
conditions, 373–390
abdominal/pelvic trauma, 384–386
burns, 378–380
chest trauma, 382–384
head, face, neck, and spinal trauma, 380–382
hemorrhage and shock, 373–376
orthopedic trauma, 386–390
soft tissue trauma, 376–378
epidemiology, 371–372
incidence, 371–372
mechanism of injury, 372
equipment, summary of, 390–391
identification, 372–373
introduction, 371
prevention, 372
scope of discussion, 371
trench foot, 252–253
clinical management, 252–253
definition, 252
disposition, 253
identification, 252
triangulation, 237
tuboovarian abscess (TOA), 407

U
unmanned aerial vehicle, 543
unstable angina, 394
urinary tract infections (UTIs), 407
U.S. legal system, 112
utility task vehicles, 504

V
venomous animal bites. See under animal bites, management of
verbal communication tools, 133t
vertical cave, 520–521
victim, defined, 6–7
virus, 349–350
volunteer protection statutes, 120–121

W
WAFA, 65–66
WCP, 74
webbing, 439–440
WEMS. See wilderness EMS
WEMS responder, stress injuries and, 198–201
WEMS systems, 21–52
care, hierarchical categories of, 44–45
care providers, 43–44
 emergency medical dispatchers, 43
lifeguards, 43
ParkMedics, 44
ski patrollers, 44
wilderness EMRs, 43–44
wilderness EMTs, 43–44
wilderness first aiders, 43
wilderness first responders, 43
challenges, 47–51
accreditation, 50–51
fund, insufficient, 48–49
no-rescue areas, defining, 51
politics, 49
providers, shortages of, 47–48
of regulation, 50–51
of standardization, 50–51
definition of terms, 21–23
EMS, 22
wilderness, 21–22
wilderness EMS, 23
wilderness medicine, 21–22
examples, 46–47
future of, 51–52
evidence-based medicine evolutions, 52
implementation science, 52
medical subspecialty, 51–52
rural intersections, 51
technology, 51
history, 28–42
early modern era, 35–36
golden era, 35–42
premodern era, 35
timeline of, 28, 29f–34f, 35
introduction, 21
regulation and accreditation, 26–28
survivalism and personal safety, 45–46
WEMT, 68–71
wet cave, 519–520
WFA, 64–65
WFR, 67–68
whitewater rescue. See swiftwater rescue
wilderness, defined, 21–22
wilderness advanced first aid (WAFA), 65–66
wilderness APRNs, 44
Wilderness Command Physician (WCP), 74
wilderness EMS
behavioral emergencies. See behavioral emergencies, management of
definition, 23
definition of, 1–3
education. See wilderness EMS education
equipment. See equipment, WEMS
helicopter rescue. See helicopter rescue
incident command. See incident command, wilderness EMS
infectious diseases. See infectious diseases, WEMS
introduction, 1–3
medical conditions. See medical conditions, management of
medical considerations, 111–123. See also medical considerations, WEMS
medical oversight. See medical oversight, WEMS
 off-road vehicles rescue. See off-road vehicles rescue
pharmacology. See pharmacology, WEMS
relationship between EM and WEMS, 23–28
research. See research, WEMS
systems. See WEMS systems
terminology, precision and accuracy in, 5t
trauma. See trauma, management of
word matter, importance of, 4–9
wilderness EMS education, 61–79
implications for practice levels, 63–78
advanced life support, 73–74
basic life support, 66–73
clinician, 74–78
emergency medical responder, 66–67
first aid, 64–66
wilderness first responder, 67–68
instructor training, 78–79
introduction, 61
in present-day, 61–63
wilderness EMT (WEMT), 68–71
wilderness event medicine, 179–187
communication, 183
defined, 179
documentation, 183–184
equipment, 185
implication of practice levels, 185–187
advanced life support, 187
basic life support, 185
clinician, 187
first aid, 185
introduction, 179–180
logical considerations, 180–182
integration plan, 181–182
removal of unsafe participants, 181
standards of care and operational standards, 180–181
medical problems, epidemiology of, 180
medical staffing, 184–185
orientation, 182–183
placement of personnel, 184–185
wilderness first aid (WFA), 64–65
wilderness first responder (WFR), 67–68
wilderness medicine, defined, 21–22
Wilderness Medicine Education Collaborative (WMEC), 64
wilderness paramedics, 44
wilderness PAs, 44
wilderness physicians, 44
Wilderness StarGuard (WSG), 43, 72
wilderness survival, lost person behavior and, 229–238
analysing, 230
communication, 237–238
general wilderness gear, 231–234
backpacks, 233
clothing and footwear, 231–233
essential nonmedical equipment, 233–234
sleeping bag and pad, 233
introduction, 229
navigation basics, 235–237
pre-planning, 234–235
 prevention, 230–235
risk assessment and mitigation, 234–235
rule of threes, 231
stress response, 229–230
survival priorities, 231
survivor characteristics, 230
travel considerations, 238
WM, relationship between EMS and WEMS, 23–28
WMEC, 64
wounds, WEMS equipment and, 142–145
WSG, 72