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Risk Management & First Aid
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    This year took me by surprise, as I know it did for many of my colleagues and it was all about water. First came Hurricane Irene and then Tropical Storm Lee. Each September the Outdoor Action Program at Princeton University sends out over 1,000 students (800 freshmen and over 200 trip leaders) on our six-day outdoor orientation program. This year we had 95 trip groups out. This is the single largest program in the country; that is no one else sends out as many people at once as we do. In this post, for my friends and colleagues, I want to share my Lessons Learned, some old, some new about relocating over 1,000 students from a weather calamity in hopes that it is beneficial for your program..

    In order to handle the logistics and the need for emergency response, I've built an extensive backend logistical structure (See Running Mega Programs 1 and Mega Programs 2 and Mega Programs 3 for more information). For each busload of students in the field we have at least one Support Team stationed nearby. This is a pair of students in a minivan staying in a motel near the trip area. They provide transports for minor medical issues, drop off water for groups in dry periods and resupply groups with equipment. Trip groups carry satellite or cell phones (depending on their location) to call out in the event of an emergency and they turn on their phones at 12:00 PM and 6:00 PM so that we can contact them if there is an issue. On campus we have a fully operational Command Center with a group of over a dozen volunteers who staff banks off phones, laptops, a large TV monitor hooked to a laptop, access to online trip routes, and participant lists and map boards of each area. This structure has served us well over may years.

    This year was something different altogether. September is hurricane season so with our trips stretching from Virginia up to Vermont I am always tracking storms developing out in the Atlantic because of the potential for impacting our trips. So when Hurricane Irene approached the east coast at the end of August, I was on alert even though it was scheduled to hit New Jersey on Sunday, August 28 and our trips didn't leave until Sunday, September 4. Well Irene did hit and caused a shutdown of a number of our pre-trip training events since air and train transportation was significantly disrupted on the east coast for several days. Sunday brought tropical storm force winds and heavy rain to New Jersey leading to major power outages and significant flooding. It had already been an incredible wet summer in the east so the ground was already saturated before Hurricane Irene hit.

    That's my First Lesson Learned--it's not just the big weather event like the hurricane, it's also the rest of the weather context that's been in play for the previous weeks or months. As you look ahead to your program planning, keep an eye on the meta-weather picture over the last month or more. Has it been an exceptional wet period? Has a drought been in place for months or longer? These longer time scale weather events can play a big role. In New Jersey, for example, the ground saturation was so bad with the wet summer that when Irene hit large trees were toppled over from the roots from a combination of super-saturated soil that could no longer support the root system and high winds that simply pushed the trees over. Earlier this summer a sixteen-year-old died on another organization's summer wilderness program in the Wind River Range when a dead tree toppled as students were hanging a bear bag. Certainly in the past I wouldn't have thought to warn my leaders about trees simply toppling over from saturated soil, but with this mega-saturation event, it was a real possibility - Second Lesson Learned - mega-weather events bring up new safety risks that may be outside of our normal "risk radar." While flooded streams and dangerous river crossings were in my mind all the time, I now add toppling trees to the list.

    While Hurricane Irene cleared out of New Jersey on Monday, August 29 much of the state was in transportation gridlock until Tuesday, August 30. Downed trees and powerlines, flooded roads, closed airports brought transportation to a near standstill. As Monday wore on I began reviewing our status and checking the storm's impact on the various trip areas we were sending trips to. As I watched the news about how badly Vermont had been hit by the storm and the incredibly flooding and road damage I started thinking about our busload of students heading up there and began tracking down road closure information. Third Lesson Learned - the National 511 System. The Department of Transportation has a national 511 information system set up to provide realtime traffic information including road closures.  Each state's Department of Transportation manages and implements their own online system. Start with You can then drill down by state and it will link you to the State 511 Website. So I looked at Vermont and saw Rt. 9, one of our major trail access roads to the Appalachian Trail - closed due to flooding damage. I also used a free Website By default it is city-based but you can pick a nearby city and then scroll the map to see road closures and problems.

    Emails from colleagues in college outdoor programs like John Abbott at the University of Vermont and contacts with the Green Mountain rangers brought the bad news, the Green Mountain National Forest in Vermont was closed with a $10,000 fine for entering. So five trips cancelled on Monday, August 28. The news went from bad to worse. Flooding and catastrophic road damage in the Catskills resulted in the closure of the entire Catskills Park - 12 trips gone. Major flooding on the Delaware River washed away most of the riverside campgrounds. The National Park Service closed the Delaware River Corridor and all trails in the Delaware Water Gap National Recreation area - 13 trips gone. The Housatonic River in Connecticut flooded washing out sections of the Appalachian Trail in the southern part of the state (5 trips gone). Seven Lakes Drive in Harriman State Park in New York had was damaged by flooding, the park was accessible from the northern entrance but officials decided to close the park - 5 more trips gone. All told we lost 40 trip routes in about 48 hours and had to replan trips to new locations in just 5 days. [For the record what I was dealing with was an inconvenience as compared to the personal tragedy, loss of life and property that victims of these storms had to endure.]

    Fourth Lesson Learned - after a major weather event or national disaster, local officials have to allocate their resources sparingly. When they are stressed to the max just rescuing people from their homes, probably the last thing they want to add in is having to do Search & Rescue efforts on college outdoor orientation programs (or any other organized group) in the backcountry. So park closures can be due to major road closures in the area as well as damage to the park itself.

    Fifth Lesson Learned - have more trips in your back pocket than you need. Earlier in the summer we had been scouting an area we used about 10 years ago. During the summer we decided that the 8 routes weren't as good as the ones we had on the books so we didn't use it. We ended up bringing this area and other old trip areas back online. There were pluses and minuses to this approach. I had some familiarity with these areas but in the extremely short time span we had to bring these areas online, there wasn't time to fully develop emergency site plans (so later we had to do it on the fly).

    After all this trip reshuffling the weather cleared, all our freshmen arrived and our trips departed campus on Sunday, September 4, a beautiful sunny day. Once they all got dropped off by bus on Sunday, I took my first small sigh of the week. They are on the trail. So now I and the Command Center staff needed to stay attentive and handle whatever came our way over the next five days. I continued to watch the weather carefully. Sixth Lesson Learned - have a good online weather site/service. I've been using Accuweather Premium for years. It costs $80/year and some might say why pay when you can get it for free. Well, great radar, good 15 day forecasts and the ability to save 10 trip regions to quickly see weather in that area is worth it for me. I'm also tracking things on my iPad and Lightning Finder is a great app to keep realtime track of cloud to ground lightning strikes. I was watching what was happening in the field and that helped me make decision.

    I had heard about Tropical Storm Lee down in the Gulf but I didn't pay it too much attention since it was hitting Texas and Louisiana, way too far away for me on Saturday, September 2. Well, Lee had other plans. looking at radar on Sunday night I began to see a huge swath of rain heading north and east into the Mid-Atlantic and New England like a freight train that wasn't stopping. I knew the ground was already super-saturated so flash floods popped into my head.

    Seventh Lesson Learned - you've got communication out, how's your communication in? As I said, all our groups carry sat or cell phones and we have a time to have your phone on. Part of this is to be able to communicate to our groups in a natural or national emergency or if there is some family emergency for one of the students (which we've had like a death in the family). I also have implemented a database system for automatically sending text messages out to all those phones. [It combines a database of all the phone numbers in Microsoft Access, along with some easy database programming and a third party software program called Total Access Emailer which does email merges from an Access Database.] This whole thing can be sent up to send out text messages which is what I did on Sunday night. I texted that there was significant rain coming and that people needed to be aware of potential flooding and check their weather radios for local details (all the groups carry a NOAA Weather Radio). One problem, that text went out on Sunday night, but phones didn't go on until noon on Monday. So from here on in our groups will turn on their phones first thing in the morning as well as noon and six to see if there is a text. By the way, lots of times a text message will go through when a voice call won't so having text message capability IN and OUT is key.

    Here's what I was looking at on the radar. Scary looking isn't it. The first image is the storm track. The second shows the rainfall totals. It rained so much they had to restart the color shading at green.


    Rain started slowly on Monday and was forecast to come down 4-6 inches a day for 3 days. On Monday the flash flood watches and warning started popping up for Tuesday. I looked at the pattern and made a big decision, bring people out. At first that started with Pennsylvania and Maryland tow areas right in the "eye" of Lee, then I expanded it to include Virginia and then Connecticut and Massachusetts as the storm move north and east. I sent a text telling groups that we were going to pick them up and relocate them, basically a precautionary evac. Eighth Lesson Learned - have an Evac Location for each day of the trip. If you have to pull everyone out of an area, it's a huge transportation issue. You want to have a spot on each days trip route where you know you can easily pick people up. If conditions are not dangerous, it's better for people to hike/paddle/bike whatever to those locations rather than have them pop out randomly on the trail someplace. Keep in mind that the leaders are the one experiencing the actual field conditions so they need to make the decision about whether your planned Evac point is viable, or will they have to cross three flood-swollen creeks to get there. I had Evac locations for all of our longstanding trips, but not for many of the ones we just replanned, so we did it on the fly for those areas.

    Ninth Lesson Learned - Have an intermediate 'Rallying Point' I've known this one for a long time so it wasn't as much a new lesson for me, more of an 'I told you so.' For the areas that we've been using regularly for the past ten years we have identified in each region a relocation/evacuation rallying point--a state park with camping, an outdoor education center with cabins, etc. Someplace where we could move groups as an intermediate site in case of a major weather event. I had these lined up for our longstanding routes, but didn't get those worked out for the 40 replacement routes. Why is this important? You'll see. Many of the places that our trips go are 5 or more hours from New Jersey. Something I've known for years is that bus drivers are limited by Department of Transportation regulations from driving more than 10 straight hours. So a number of our bus driver who dropped groups off on Sunday, had to stay in a motel Sunday night since they couldn't drive back the same day. Well, that also meant that in order to pick up all our waterlogged groups they could not drive from New Jersey, pick the groups up and get back to New Jersey on the same day. That meant we had to relocate 1,000 people to an intermediate site and then bring them back the next day. That's the reason for knowing where these "rally points" are ahead of time. For example, in Shenandoah National Park, we moved everyone to Big Meadows Campground in the park. So do the research and have these locations tagged ahead of time. Talk to the camps, state parks, rangers, etc. and ask them if the could handle 50 people or however many in an emergency evac. Then you just have to activate this emergency relocation plan.

    So we got our people out to their intermediate sites. It was a challenge because I had 22 buses reserved for Friday, the day the trips were supposed to return and suddenly I called our bus company and asked for 22 buses on Wednesday. Tenth Lesson Learned - have a great relationship with your transportation provider - build it ahead of time. We have a really good relationship with our bus company Coach USA. Because they are in the business of keeping their buses on the road, they didn't have 22 buses and drivers. Just 9 they could give us with 24 hours notice (remember the 10 hour driver rule?). So I took the nine buses and worked out a way to have them drive out, pick up all the groups and ferry them to the closest state park, motel, etc. and then go back and get another load and got it all done in under the 10-hour driver limit. Being able to talk directly to Zarco the bus dispatcher was key.

    Eleventh Lesson Learned - have good transportation software. There are lots of products out there - online like Google Maps or software products like Microsoft Streets and Trips (which I use). None are perfect, especially when you are dealing with buses since consumer software ignores things like bridge weights and overpass heights, but they are better than nothing. Since I already had all my original bus drop-off points saved out in Microsoft Streets it was a fairly quick job to run directions for the drivers to go from Evac pickup locations 1, 2 and 3 to the motel and then back to locations 4, 5 and 6. It saved me hours of time trying to communicate with the bus dispatcher when I could just email him a PDF of the bus pickups. There are software products built for commercial trucking fleets that do know things like bridges and overpasses and route trucks (and buses) around them. Next year I'll sign up for a 30 day free trial of PC*Miler|Web and see how that works for bus directions.

    So we got over 1,000 people relocated to intermediate motels and campsites (no don't ask me about how much this all cost). We got a second wave of buses out to join the 9 buses and we got everyone back to campus, dry and happy on Wednesday and Thursday. I have so many people to thanks for pulling this off and getting everyone back safety. The tremendous student leaders who used great judgment to keep things under control. Our Support Teams in the field who did an epic job of picking up groups and getting them to buses. To the superb Command Center Team who stayed on the phones for 16+ hours a day working all the pickups. To all the administrators and staff at Princeton who figured out how to feed people when then got back to campus and came up with fun activities for our groups to do so they could continue to function in their small groups until the scheduled end of the program. Twelfth Lesson Learned - develop your campus network ahead of time. So when BIG things happen you have the relationships built to get the help you need. Thirty years of being at Princeton means that I have a great set of colleagues who I could call on and they all came to my aid. Thirteenth Lesson Learned - what is your campus emergency response plan and how does your trip fit into that? Like many campuses Princeton has an Emergency Response Team (ERT) to deal with some major campus calamity, a dorm fire, school shooting etc. Know what that plan is and talk to those people to know when, if your program is dealing with a major event, that event hits the threshold to initiate the college's ERT. They can get things done that you can't simply by virtue of their being activated and having mega resources at their disposal. Last Lesson Learned - have a great staff team - Leaders, Command Center and Support. It makes all the difference.

    I don't want to make it sound like these trips were terrible. On the contrary, while my week was terrible, the students bonding incredibly well. They had enough challenges to bring them together, not so much that it broke them apart. Making the decision to start to pull the trips out, knowing that it could not be all done in 24 hours, meant that we did get them out before conditions got really bad. Like I said the leaders did a great job and when I saw all the students in the main campus auditorium on Thursday night they were totally pumped about their experience. As I've said, it was the best possible outcome from a bad situation. We successfully achieved the goals of our outdoor orientation program.

    And I finally got some sleep. Here are  my Lessons Learned. Pop yours in the Comments Section or contact me about submitting a Blog entry.

    1. First Lesson Learned--it's not just the big weather event like the hurricane, it's also the rest of the weather context.
    2. Second Lesson Learned - mega-weather events bring up new safety risks.
    3. Third Lesson Learned - the National 511 System.
    4. Fourth Lesson Learned - after a major weather event or national disaster, local officials have to allocate their resources sparingly.
    5. Fifth Lesson Learned - have more trips in your back pocket than you need.
    6. Sixth Lesson Learned - have good weather software
    7. Seventh Lesson Learned - you've got communication out, how's your communication in?
    8. Eighth Lesson Learned - have an Evac Location for each day of the trip.
    9. Ninth Lesson Learned - have an intermediate 'Rallying Point'
    10. Tenth Lesson Learned - have a great relationship with your transportation provider - build it ahead of time.
    11. Eleventh Lesson Learned - have good transportation software.
    12. Twelfth Lesson Learned - develop your campus network ahead of time.
    13. Thirteenth Lesson Learned - what is your campus emergency response plan and how does your trip fit into that?
    14. Final Lesson Learned - have a great staff team - Leaders, Command Center and Support

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    by Paul Auerbach, M.D.

    Once of the major recent advances in trauma care has been the evolution of topical substances that can be applied to wounds in order to limit or stop hemorrhage (bleeding). This is very important in wilderness medicine, because uncontrolled bleeding is a leading cause of death from injuries. When the bleeding site can be approached in such a manner as to stop the bleeding, then something very valuable may possibly be done for the patient. 

    In article entitled “Comparison of Celox-A, ChitoFlex, WoundStat, and Combat Gauze Hemostatic Agents Versus Standard Gauze Dressing in Control of Hemorrhage in a Swine Model of Penetrating Trauma,” Lanny Littlejohn, MD and colleagues used an animal model of a complex groin injury with a small penetrating wound, followed by completely cutting the femoral artery and vein, to determine whether there was any benefit to one or another hemostatic (stops bleeding) agent in comparison to each other and to standard gauze dressing. To cut to the chase (no pun intended), the results showed that no difference was found among the agents with respect to initial cessation of bleeding, rebleeding, and survival. In this study, WoundStat was inferior with respect to initial cessation of bleeding and survival when compared to Celox-A.

    The authors point out how important it is to control severe bleeding early in the course of a patient’s therapy, because at a certain point, bleeding leads to organ failure and a vicious cycle of severe acid-base imbalances, more bleeding, and the complications that might occur from blood transfusions. The different hemostatic agents, be they free granules poured into a wound or gauze impregnated with active substances, need to be readily available, easy to deploy, effective in a short period of time, not painful, and without complications. There are more than a few agents that fit the bill, so it’s important to be objective about the pros and cons of each agent. In this study, it was confirmed that they all work roughly equally effectively, so the choice often comes down to comfort of the user with a particular product and personal preferences.

    What was surprising as an outcome in the study was the observation that a standard (nonmedicated) gauze dressing was as effective as any of the hemostatic agents. That contradicts some of the current rhetoric that I have heard at medical meetings from experts on wound care, who are beginning to swear by the use of hemostatic agents. If it is true that there are circumstances in which hemostatic agents do not add any benefit to the clinical process of stopping or limiting bleeding, we need to know, so that we don’t waste precious time and money deploying these agents. Obviously, if these agents are beneficial, we need to know about that as well.

    A practical observation of this particular study was that a rolled, impregnated (with hemostatic agent) gauze introduced into a bleeding wound should first be unrolled prior to application, to avoid creating a congealed mass of gauze and blood that cannot be properly manipulated and positioned within the confines of the wound.

    Copyright Paul Auerbach

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    by Paul Auerbach, M.D.

    As most of you know, I am sometimes sent outdoor health equipment and supplies to evaluate. I’ve recently received a few items worthy of mention.

    Sawyer Squeeze Water Filtration System Sawyer Squeeze Water Filtration SystemFirst, there is the Sawyer Products ‘Squeeze’ Water Filtration System. Advertised to be able to endure filtering 1 million gallons of water for the purpose of water disinfection/purification, this 0.1 micron filter is rated to be able to remove sediment, bacteria, protozoa, and cysts from water. It uses an in-line series of a bag (to contain the unfiltered water: 3 bags are supplied in sizes of one each at 32 ounces, 16 ounces, and 12 ounces) connected to a filter that simply screws onto a fitting at one end of the bag. The water is then squeezed through the hollow fiber-containing filter and exits the system through a discharge port similar to the pop-up closure top found on many water bottles, such as those used by cyclists.

    It is easy to use, extremely lightweight, and convenient to pack and carry. The kit comes with a 60 milliliter syringe to be used to backwash (clean) the filter should it become less efficient, because it is becoming clogged with whatever has been removed from the water by the unit. You can learn more about this product and others from Sawyer Products at

    Copyright Paul Auerbach

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  • 11/20/11--21:18: Stinging Nettles
  • by Paul Auerbach, M.D.

    Hikers often brush up against injurious plants, such as poison oak or thorny shrubs. One particularly vexing plant is the “ubiquitous weed, Urtica dioica,” commonly known as stinging nettles. As described in an article entitled “Mechanism of Action of Stinging Nettles” (Wilderness & Environmental Medicine:22,136-139,2011) by Alexander Cummings and Michael Olsen, direct contact exposure to the weed causes immediate stinging and burning sensation on the skin. The authors exposed mouse skin to the plants and looked at this skin using an electron microscope. They found smooth nettle spicules that had pierced the skin surface, a few of which retained their bases, which appeared empty of liquid contents. The authors concluded that the mechanism of action of stinging nettles skin reaction was both biochemical and mechanical, likely caused by impalement of spicules into the skin.

    Spicules of a stinging nettle, photo courtesy of Randy A. Nonenmacher (CC BY 3.0) Spicules of a stinging nettle, photo courtesy of Randy A. Nonenmacher (CC BY 3.0)The spicules are present as small “hairs” that are found on the stem and undersides of the leaves of the plant. Even light touch against the plant can cause a reaction, which is often characterized as instantaneous burning, itching, and sometimes a slight swelling of the skin. The nettles have been found to contain biologically active chemicals, which might account for part or all of the reaction. This current study shows that spicules, in whole or in part, are retained in the skin. To what extent the mechanical effect of spicule retention contributes to the reaction is yet to be determined, but it is certainly possible that there is such a mechanical effect.

    It is not known if removing spicules soon after they enter the skin might be helpful, but it seems logical to make the attempt. There aren’t great ways to do this, because the spicules are so tiny and numerous. It is possible that a peeling method, in which the sticky side of adhesive tape is applied to the skin and then removed, might be helpful. It is certainly worth a try, if someone encounters stinging nettles and can rapidly get their hands on some tape (e.g., is carrying it with them).

    Copyright Paul Auerbach

    Reposted with permission from the Medicine for the Outdoors Blog

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    by Paul Auerbach, M.D.

    Led by Scott McIntosh, MD and his colleagues, the Wilderness Medical Society has published "Practice Guidelines for the Prevention and Treatment of Frostbite" (Wild Environ Med 2011:22;156-166). These guidelines are intended to provide clinicians about best evidence-based practices, and were derived from the deliberations of an expert panel, of which I was a member. The guidelines present the main prophylactic and therapeutic modalities for frostbite and provide recommendations for their roles in patient management. The guidelines also provide suggested approaches to prevention and management of each disorder that incorporate the recommendations.

    In outline format, here is what can be found in these guidelines:

    • Introduction
    • Methods
    • Pathophysiology of Frostbite
    • Classification of Frostbite
    • Prevention
    • Field Treatment and Secondary Prevention
      • Scenario 1: The Frozen Part Has the Potential of Re-freezing and Will Not Be Actively Thawed
      • Scenario 2: The Frozen Part Can Be Kept Thawed and Warm With Minimal Risk of Refreezing Until Evacuation is Completed
    • Immediate Medical Therapy – Hospital (or High Level Field Clinic)
    • Other Post-Thaw Medical Therapy
    • Conclusions
    • Disclosure
    • References

    The science and medicine of frostbite and other cold-induced injuries are not without discussion, opinions, and some controversy. These Practice Guidelines are an excellent beginning point for persons interested in the topic.

    Read it Online

    Read the Journal Article online at Wilderness & Environmental Medicine Journal.

    Copyright Paul Auerbach

    Reposted with permission from the Medicine for the Outdoors Blog

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    by Paul Auerbach, M.D.

    Ski season is upon us. Many experts (including myself) are of the opinion that helmets should be worn by all downhill skiers and snowboarders to help prevent head injuries. One of the “con” arguments proposed by some persons who object to wearing helmets is that they interfere with skiing in such a way as to perhaps make it more dangerous. In their opinion, this might occur by obscuring peripheral vision or diminishing the perception of sound. A very important article entitled article entitled “Do Ski Helmets Affect Reaction Time to Peripheral Stimuli?” (Wilderness & Environmental Medicine:22,148-150,2011) has recently been published by Gerhard Ruedl and colleagues from the Department of Sports Science at the University of Innsbruck in Austria.   

    The investigators sought to determine whether or not ski helmet use affects reaction time to peripheral stimuli. They used the Compensatory-Tracking-Test (CTT) in a laboratory situation to study 10 men and 10 women during four conditions in a randomized order: wearing a ski cap, wearing a ski helmet, wearing a ski cap and goggles, and wearing a ski helmet and goggles.

    The CTT is performed by using a video projector that projects on a screen. The subjects being studied are seated at a table and instructed to respond to visual stimuli that appear on the screen, notably including the periphery of vision. The results were interesting. The lowest (quickest) mean reaction time (approximately 477 milliseconds) was noted for persons wearing only a ski cap. This was not statistically significantly different from the mean reaction time noted for persons wearing a ski helmet (approximately 478 milliseconds). The persons wearing both the goggles and cap or helmet had longer mean reaction times (514 milliseconds and 498 milliseconds, respectively). Note that all of these times are around one-half second.

    What are the take-aways from this study? First, it is important to note that this is a simulation that involved only one measure—peripheral vision. It did not take into account the influence of sound. It was not a field experiment, so the influences of extraneous factors were not included. Such factors might be sounds (e.g., ski and wind noise, talking, etc.), thickness of helmet or design of goggles, ambient weather (e.g., sunshine or cloud cover), speed of travel on skis and snowboard, and so forth. However, it somewhat counters the notion that wearing a helmet per se diminishes reaction time to external visual stimuli, regardless of the situation. Furthermore, in a very controlled setting, the differences in reaction time are very, very small—approximately 30 milliseconds (30/1000 of a second), which would not seem to be a huge factor in causing ski accidents. So, while more studies need to be somehow accomplished in more realistic field settings, this is a good start to dispelling the automatic notion that wearing protective helmets is harmful to skiers wishing to avoid the sorts of accidents that cause head injuries.

    Copyright Paul Auerbach

    Reposted with permission from the Medicine for the Outdoors Blog

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    by Paul Auerbach, M.D.

    For management of a serious (even life-threatening) allergic reaction, I have been teaching adults to administer epinephrine (adrenaline) by injection for years. This can be a lifesaving intervention. The Emergency Medical Services (EMS) community now concurs that EMS personnel should be trained to recognize a serious allergic reaction and be allowed to administer epinephrine. In a recent issue of the journal Prehospital Emergency Care (2011;15:570-576), there is an article by Jacobsen and Millin entitled "The Use of Epinephrine for Out-of-Hospital Treatment of Anaphylaxis: Resource Document for the National Association of EMS Physicians Position Statement" that details the use of epinephrine for this purpose.

    The major new thrust of this document is to highlight the fact that the intramuscular (IM, directly into the muscle) injection route of administration is preferred, rather than the traditional primary recommendation to inject into the tissue space just under the skin layers ("subcutaneous"). This is because injection into the muscle tissue results in smoother and more reliable drug absorption, with higher peak therapeutic levels of the drug achieved sooner than with subcutaneous injection. The lateral thigh is often used for the IM injection; the outer upper arm is most commonly used for the subcutaneous injection. In an "autoinjector pen" used to administer epinephrine (often referred to by the brand name “EpiPen”), the needle may not be long enough to reach the muscle tissue of a large and/or obese person. However, if the epinephrine is injected into the subcutaneous tissue, it will in all likelihood still be effective, albeit perhaps not as quickly following the injection.

    Here is advice about how to give epinephrine for a severe allergic reaction:

    Administer aqueous epinephrine (adrenaline) 1:1,000 in an intramuscular or subcutaneous injection (depending on the depth obtained by the needle). The adult dose is 0.3 to 0.5 mL; the pediatric dose is 0.01 mL/kg of body weight, not to exceed a total dose of 0.3 mL. For weight estimation, 1 kg equals 2.2 lb. The drug is available in preloaded syringes in certain allergy kits, which include the EpiPen autoinjector and EpiPen Jr. autoinjector, the Twinject autoinjector (0.3 mg or 0.15 mg doses; 2 doses per unit), and the Ana-Kit. Instructions for use accompany the kits. The EpiPen and Twinject epinephrine products are generally easier for laypeople to use, because they require less dexterity to accomplish injection with them. The Twinject autoinjector and Ana-Kit syringe are configured with enough epinephrine for a second (repeat) dose, which is sometimes necessary. The Twinject is a true autoinjector for the first dose; the second dose is delivered as a routine injection from a concealed syringe and needle.

    For dosing purposes, the EpiPen and Twinject 0.3 mg autoinjector should be used for adults and children over 66 lb (30 kg) in weight. Children 66 lb and under should be injected with the EpiPen Jr. or Twinject 0.15 mg autoinjector.

    Take particular care to handle preloaded syringes properly, to avoid inadvertent injection into a finger or toe. Do not intentionally inject epinephrine into the buttocks or a vein. Epinephrine should not be exposed to heat or sun, but does not need to be kept refrigerated. If clear (liquid) epinephrine turns brown, it should be discarded. When administering an injection, never share needles between people.

    Copyright Paul Auerbach

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     I want to let everyone know about the release of the 6th Edition of Wilderness Medicine, the premiere textbook on the subject, edited by our frequent contributor Dr. Paul Auerbach. There are not too many books out there that I personally consider as "classics" in our field (titles like Mountaineering: The Freedom of the Hills comes to mind), for wilderness medicine, this book is a classic. I've used previous editions of this book for teaching first aid and it was one of my core reference books when writing the first aid chapter in The Backpacker's Field Manual. I'm really excited to see this new edition and that there will be an ebook version. At over 2,300 pages it's no wonder that this textbook is widely referred to as "The Bible of Wilderness Medicine."

    This is one book that I recommend that every serious outdoor program have on the shelf as the ultimate reference guide. It covers every conceivable aspect of wilderness medicine in articles written by experts from around the world. What makes this book stand out is the combination of the breadth of coverage and its great readability. I try and keep current on wilderness medicine issues, but as a non-physician, reading things like the New England Journal of Medicine often leaves me scratching my head at the super-technical things that I don't have the background for. This textbook, written for both medical professionals and non-medical provides a great balance. Don't let the price tag deter you, any textbook of this magnitude is worth every penny. The book is available from the publisher as well as on in hardcover and Kindle format and at Barnes and Noble in hardcover and Nook format.

    From the Publisher:

    "Quickly and decisively manage any medical emergency you encounter in the great outdoors with Wilderness Medicine! World-renowned authority and author, Dr. Paul Auerbach, and a team of experts offer proven, practical, visual guidance for effectively diagnosing and treating the full range of emergencies and health problems encountered in situations where time and resources are scarce. Every day, more and more people are venturing into the wilderness and extreme environments, or are victims of horrific natural disasters...and many are unprepared for the dangers and aftermath that come with these episodes. Whether these victims are stranded on mountaintops, lost in the desert, injured on a remote bike path, or ill far out at sea, this indispensable resource--now with online access at for greater accessibility and portability-- equips rescuers and health care professionals to effectively address and prevent injury and illness in the wilderness!

    From Paul Auerbach:

    I’m thrilled to let you know that the 6th edition of the textbook Wilderness Medicine, for which I serve as Editor, is now available. The book is the culmination of more than three years’ work, and the publisher (Elsevier) has done a terrific job with the layout. The book contains 114 chapters, including a tremendous amount of information new to this edition.

    This is the big reference book for medical and rescue professionals, educators, scientists, explorers, and others with wilderness medicine interests and activities. The depth of topic coverage underlies much of my other writing. The contributors have gone the extra mile to update their previous work, make new contributions, and do their best to create a comprehensive, encyclopedic work. I’m grateful to have had the opportunity to mold this edition, and am particularly pleased that the publisher allowed me to add chapters on matters related to wilderness preservation. I hope you find it an informative, useful, and fascinating book.

    Here’s the Table of Contents:

    PART 1 - Mountain Medicine

    • High-Altitude Medicine and Physiology
    • Avalanches
    • Lightning Injuries

    PART 2 - Cold and Heat

    • Thermoregulation
    • Accidental Hypothermia
    • Immersion Into Cold Water
    • Nonfreezing Cold-Induced Injuries
    • Frostbite
    • Polar Medicine
    • Pathophysiology of Heat-Related Illnesses
    • Clinical Management of Heat-Related Illnesses

    PART 3 - Burns, Fire, and Radiation

    • Wildland Fires: Dangers and Survival
    • Emergency Care of the Burned Victim
    • Exposure to Radiation From the Sun
    • Volcanic Eruptions, Hazards, and Mitigation

    PART 4 - Injuries and Medical Interventions

    • Injury Prevention: Decision Making, Safety, and Accident Avoidance
    • Principles of Pain Management
    • Taping and Bandaging
    • Splints and Slings
    • Emergency Airway Management
    • Wilderness Trauma and Surgical Emergencies
    • Wound Management
    • Improvised Medicine in the Wilderness
    • Hunting and Fishing Injuries
    • Tactical Medicine
    • Combat and Casualty Care
    • Wilderness Orthopedics
    • The Eye in the Wilderness
    • Foot Problems and Care
    • Wilderness Dentistry
    • Management of Facial Injuries
    • Wilderness Cardiology
    • Wilderness Neurology
    • Chronic Diseases and Wilderness Activities
    • Mental Health in the Wilderness

    PART 5 - Rescue and Survival

    • Wilderness Emergency Medical Services and Response Systems
    • Search and Rescue
    • Technical Rescue, Self-Rescue, and Evacuation
    • Litters and Carries
    • Helicopter Rescue and Aeromedical Transport
    • Essentials of Wilderness Survival
    • Principles of Meteorology and Weather Prediction
    • Jungle Travel and Survival
    • Desert Travel and Survival
    • Whitewater Medicine and Rescue
    • Caving and Cave Rescue

    PART 6 - Animals, Insects, and Zoonoses

    • Protection from Blood-Feeding Arthropods
    • Mosquitoes and Mosquito-Borne Diseases
    • Malaria
    • Arthropod Envenomation and Parasitism
    • Tick-Borne Diseases
    • Spider Bites
    • Scorpion Envenomation
    • Bites by Venomous Reptiles in Canada, the United States, and Mexico
    • Envenoming and Injuries by Venomous and Nonvenomous Reptiles Worldwide
    • Bites and Injuries Inflicted by Wild and Domestic Animals
    • Bear Behavior and Attacks
    • Alligator and Crocodile Attacks
    • Wilderness-Acquired Zoonoses
    • Rabies
    • Emergency Veterinary Medicine

    PART 7 - Plants

    • Seasonal and Acute Allergic Reactions
    • Plant-Induced Dermatitis
    • Toxic Plant Ingestions
    • Toxic Mushroom Ingestions
    • Ethnobotany: Plant-Derived Medical Therapy

    PART 8 - Food and Water

    • Field Water Disinfection
    • Infectious Diarrhea From Wilderness and Foreign Travel
    • Nutrition, Malnutrition, and Starvation
    • Dehydration, Rehydration, and Hyperhydration
    • Living Off the Land
    • Seafood Toxidromes
    • Seafood Allergies

    PART 9 - Marine Medicine

    • A Brief Introduction to Oceanography
    • Submersion Injuries and Drowning
    • Emergency Oxygen Administration
    • Diving Medicine
    • Hyperbaric Medicine
    • Injuries From Nonvenomous Aquatic Animals
    • Envenomation by Aquatic Invertebrates
    • Envenomation by Aquatic Vertebrates
    • Aquatic Skin Disorders
    • Safety and Survival at Sea

    PART 10 - Travel, Environmental Hazards, and Disasters

    • Travel Medicine
    • Non-North American Travel and Exotic Diseases
    • Natural Disaster Management
    • Expedition Medicine
    • Global Humanitarian Medicine and Disaster Relief
    • Natural and Human-Made Hazards: Disaster Risk Management Issues

    PART 11 - Equipment and Special Knowledge

    • Global Crimes, Incarceration, and Quarantine
    • Wilderness Preparation, Equipment, and Medical Supplies
    • Ultrasound and Telemedicine in the Wilderness
    • Outdoor Clothing for the Wilderness Professional
    • Nonmedical Backcountry Equipment for Wilderness Professionals
    • Ropes and Knot Tying
    • Wilderness Navigation Techniques and Communication Methods

    PART 12 - Special Populations and Considerations

    • Training for Wilderness Adventure
    • Exercise, Conditioning, and Performance Training
    • Children in the Wilderness
    • Women in the Wilderness
    • Elders in the Wilderness
    • Persons With Special Needs and Disabilities
    • Wilderness and Endurance Events
    • Ranch and Rodeo Medicine
    • Wilderness Medicine Education
    • Medical Liability and Wilderness Emergencies
    • The Ethics of Wilderness Medicine
    • Native American Healing

    PART 13 - The Wilderness

    • The Changing Environment
    • Biodiversity and Human Health
    • Health Implications of Environmental Change
    • Wilderness Management and Preservation
    • Leave No Trace
    • Space Medicine: The New Frontier
    • Appendix - Drug Stability in the Wilderness


    The hard copy book and e-reader versions both come with access to Elsevier’s

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  • 01/25/12--08:42: Lightning Safety Awareness

    by Paul Auerbach


    This post relates information learned in a recent issue (Volume 22, Number 3, 2011) of the journal Wilderness & Environmental Medicine, published by the Wilderness Medical Society.

    In an article entitled “Lightning Safety Awareness of Visitors in Three California National Parks” by Lori Weichenthal et al, the authors set out to assess the level of lightning safety awareness among visitors at three national parks in the Sierra Nevada Mountains of California.

    Having recently enjoyed a wonderful trip to Yosemite National Park (one of the study sites) and gotten caught in a powerful thunderstorm replete with multiple lightning strikes and wind-driven sheets of rain and icy hail, this is timely for me and very important for anyone who spends time outdoors.

    There were no surprises in the conclusions derived from this study, but the investigation reinforces the notion that we don’t recall all that we need to know, or may have never fully understood lightning safety in the first place. 

    For instance, while participants in the national parks knew that lightning is more likely to strike in the afternoon, they were not aware of the dangers of seeking shelter in a small cave or group huddling. Few people understood proper body position, and other than avoiding metal objects or isolated tall trees, the respondents had too many errors (in my opinion) with respect to advice such as avoiding water or thick groves of trees. The authors appropriately concluded that there exist many educational opportunities, which can take many forms, including trailhead awareness placards, park visitor pamphlets, public service announcements, and national park web site education portals.

    Here is some information on lightning avoidance from the 5th edition of the book Medicine for the Outdoors

    1. Know the weather patterns for your area. Don’t travel in times of high thunderstorm risk. Avoid being outdoors during a thunderstorm. Carry a radio to monitor weather reports. Lightning can lash out from many miles in front of a storm cloud, in seemingly clear weather. If you calculate (see above) that a nearby lightning strike is within 3 miles (5 km) of your location, anticipate that the next strike will be in your immediate area. The “30-30 rule” specifies that if you see lightning and count less than 30 seconds before hearing thunder, seek shelter immediately. Since thunder is rarely heard from more than 10 miles away, if you hear thunder, it is best to curtail activities and seek shelter from lightning. Do not resume activities outdoors for at least 30 minutes after the lightning is seen and the last thunder heard.

    2. If a storm enters your area, immediately seek shelter. Enter a hard-roofed auto or large building, if possible. Tents and convertible autos offer essentially no protection from lightning. Tent poles are lightning rods. Metal sheds are dangerous because of the risk of side splashes. Indoors, stay away from windows, open doors, fireplaces, and large metal fixtures. Inside a building, avoid plumbing fixtures, telephones, and other appliances attached by metal to the outside of the building.

    3. Do not carry a lightning rod, such as a fishing pole or golf club. Avoid tall objects, such as ski lifts and power lines. Avoid being near boat masts or flagpoles. Do not seek refuge near power lines or tall metal structures. If you are in a boat, try to get out of the water. If you are swimming in the water, get out. Do not stand near a metal boat. Insulate yourself from ground current by crouching on a sleeping pad, backpack, or coiled rope.

    4. Move off ridges and summits. Thunderstorms tend to occur in the afternoon, so attempt to summit early and be heading back down by noon. In the woods, avoid the tallest trees (stay at a distance from the tree that’s at least equal to the tree’s height) or hilltops. Shelter yourself in a stand of smaller trees. Avoid clearings—you become the tallest tree. Don’t stay at or near the top of a peak or ridge. Avoid cave entrances. In the open, crouch down or roll into a ball.

    5. Stay in your car. If it is a convertible, huddle on the ground at least 50 yards (46 m) from the vehicle.

    6. If you are part of a group of people, spread the group out so that everyone isn’t struck by a single discharge.

    7. If your hair stands on end, you hear high-pitched or crackling noises, or see a blue halo (St. Elmo’s fire) around objects, there is electrical activity near you that precedes a lightning strike. If you can’t get away from the area immediately, crouch down on the balls of your feet and keep your head down. Don’t touch the ground with your hands.

    More Lightning Safety Resources on

    Lightning Resources


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    I just got back from skiing at Jackson Hole last week. Like much of the west the snow pack has been really low all winter. Jackson Hole only had a 44 inch (old) base when I arrived. Starting with the day I arrived (Wednesday, January 18) the snow started falling and in a series of storms over 55 inches fell over the next five days. With an old base it created what the Bridger-Teton Avalanche Center rated as "Considerable Avalanche Danger."

    On returning to the east coast I read about a significant avalanche in the Teton Backcountry on Mt. Taylor. This slide has created a significant buzz in the backcountry skiing blogosphere since it was intentionally triggered by a professional guide who the made a ski cut above a popular line, intending to release an small avalanche and make the slope safer for him and his party. "The huge slide ran 2,600 vertical feet and took out previous tracks and part of the uphill track. It crossed Coal Creek and ran up over the opposite slope and left a 30-foot-deep deposit of snow and debris. No one was injured in the incident, but search and rescue teams responded to make sure no one was buried or carried." Truly a killer avalanche if anyone had been it it's path. The skier who triggered the avalanche skied down the slope with his beacon on to see if anyone was caught in the slide. Search and Rescue teams also responded to the slide but no one was caught in it.

    You'll see a broad range of comments online at with points of view from "this is no big deal" to "hugely irresponsible behavior." I encourage you to browse the comments and you'll see the range of attitudes some of which espose responsible decision-making and others who suggest that 'what you do is your own business.' Some of these I found just plan scary and I hope I am never downslope from people who think the latter.

    One point that I want to make here is that the decisions that we make in the backcountry, don't just affect us and our group. Although no one was hurt in this avalanche, other groups could have been below resulting in potentially catastrophic results. One common risk management error is "the expert on his/her own turf" which could be one explanation for this behavior. Being in "our element" sometimes blinds us to the potential risks and the fact that one has skied an area "1,000 times" doesn't somehow make you safer. Sure, site knowledge like slide paths, previous avalanche history and stability are all pieces of data, but not a license to make decisions that put other people at serious risk.

    (Please visit the site to view this video)

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    Petzl Meteor Helmet TMI am dating myself, but when I started rock climbing, almost everyone wore helmets. It was as essential a piece of gear as your harness and shoes. But in the decades that followed, helmets became passe. Part of that change had to do with climbing styles and style (fashion) in climbing. Some comes from a misunderstanding of risk and people assuming that helmets are only to protect you from rockfall (no rockfall means no helmet needed). But it's not that simple, let me tell you my friend Dan's story.

    Dan was lead climbing in the Gunks in New York in the late 80's and he was wearing a helmet. In part that's because he was an EMT and in medical school and he valued his brain. Dan took a lead fall and pendulumed, smacking the side of his helmet against the rock (no rock fall here). He hit so hard that his 1980's (heavy) fiberglass helmet cracked and Dan hung in the air unconscious for 20 minutes while his belayer held him in place, unable to lower him and other climbers initiated a rescue. For those of you with first aid training, he had a Traumatic Brain Injury (TBI) and was immediately transported to the local ER. He regained consciousness on the way and was treated and eventually released. But his medical problems didn't stop there. He had significant short term memory loss for the next 6 months. If you told him that you had a bagel for lunch and then asked him what you had for lunch, he couldn't remember. It was pretty hard being a medical student when you can't remember what your patients tell you from moment to moment. He also had double vision in one eye from retinal damage due to the impact. When he looked straight ahead with his right eye he saw double but if he looked down his vision was normal. He ended up having surgery to cut and resew the muscles in his right eye so that the right eyeball was 'tilted' up. Then when he looked straight forward he was looking out of the bottom of his eye and could see normally. Dan was convinced that without a helmet he would have died or had permanent extensive brain damage. I've continued to wear a helmet ever since.

    Helmets are not just for rock fall, they're also for falls on rock. Some climbing areas are know for loose rock so people wear helmets there and not in other places. But falls on rock are a lot more common and it's not just lead falls. Inverted falls can happen in lead and sport and can easily result in head impact. We now know a lot more about TBI in sports thanks to research on football, hockey, soccer and boxing injuries. Repeated small TBIs can lead to permanent damage just as a dramatic high impact whipper like Dan's can. Traumatic Brain Injury is serious business so any climber needs to keep both of those things in mind when making the decision about wearing a helmet. Helmet technology has come so far in the last five years with lighter designs that the excuses about it being too heavy no longer hold water.

    Toddler without helmet


    There's a Facebook photo that recent caused a lot of controversy, a single mother climbing with a toddler on her back with lots of people saying it was irresponsible. What I found most irresponsible is that the woman and her belayer both had helmets on but the toddler didn't. Both adults considered the hazard of climbing required a helmet but the toddler had no such protection. Crazy if you ask me.

    The British Mountaineering Council (BMC) is running a helmet safety campaign to educate climbers about helmet use and I applaud them for this effort. You can read more about their campaign along with guides to helmets at the following sites:

    Yes, I wear a helmet biking, whitewater kayaking, Telemark skiing and climbing. Brain buckets may have once been a derogatory term, but thanks to Dan's lesson, I value my brain and am happy to keep it safe in a bucket, especially now that they are so stylin'.

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    by Paul Auerbach, M.D.

    The general consensus in the medical community regarding helmet use and skiing (also snowboarding) is that helmets should be worn to prevent or lessen head injuries related to falls and collisions. While a helmet may not significantly lessen deceleration forces upon the brain incurred by a sudden stop at high speed, they almost certainly somewhat soften the blow and are useful to prevent skull fractures. As they become standard equipment for recreational skiing, we will learn more about the psychology associated with their use.

    “Risk-taking Behavior in Skiing Among Helmet Wearers and Nonwearers” is an original research article by Lana Ruži?, MD, PhD and Anton Tudor, MD, PhD in a recent issue of Wilderness & Environmental Medicine (22, 291-296, 2011). The objective of the study was to examine differences in on-the-snow ski behavior between helmet wearers and non-wearers. Using a survey taken of 710 skiers, the predictive power for risk-taking behavior was tested for gender, age, educational level, level of skiing, years of skiing, and helmet usage. Independent predictors for overall risk could be correlated with younger age (less than 35 years of age), male gender, higher skiing level, and helmet usage. Significantly higher risk was assessed for male helmet wearers, while this was not seen to be significant for female helmet wearers. The group found to be most prone to risk-taking behavior was the male occasional helmet wearers 

    It has been shown previously that male skiers generally take more risks than do female skiers. It is new information that wearing a helmet appears to increase risk-taking behavior, perhaps even further, in young males.  What should we make of this? Perhaps wearing a helmet contributes to a feeling of invincibility, or creates an impression in the user that regardless of behavior, a helmet will be protective. Skiers and snowboarders should be made to understand that the benefits of wearing a helmet might possibly be neutralized by risky behavior. Risk profiles for high-speed impacts decline with age, but that should not obviate the need for a helmet. The elder brain is less tolerant of injury, and there is a higher likelihood that a significant blow to the head will result in bleeding within the skull.

    Perhaps the largest elephant in the room is the notion I have heard offered by some that if one is not wearing a helmet, he or she is more likely to ski with caution, in order to avoid a collision or fall. This sounds good, but has never been proven. Furthermore, despite all best intentions, collisions occur because skiers catch an edge, are impacted by a colliding skier, slip on ice, or due to a myriad other reasons to precipitously strike the ground or a foreign object with their heads. The takeaway here is that a helmet is not a license to throw away caution, but it appears that this may be the interpretation by young, male skiers. We need to inform them otherwise.

    Copyright Paul Auerbach

    Reposted with permission from the Medicine for the Outdoors Blog

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    I've been receiving emails about the recent online publication of a study in the Annals of Emergency Medicine titled“Ibuprofen Prevents Altitude Illness: A Randomized Controlled Trial for Prevention of Altitude Illness With Nonsteroidal Anti-inflammatories.” the study was highlighted by several of the health blogs and newspapers.

    Eighty-six study participants took either ibuprofen 600 mg or placebo three times a day, beginning 6 hours prior to ascent from 4,100 feet (1,240 meters) to 12, 570 feet (3,810 m) in the White Mountains of California. The study looked at the incidence and severity of acute mountain sickness (AMS) as measured by the Lake Louise Questionnaire AMS score.

    The ideal way to prevent AMS is to ascend slowly and acclimatize. Some folks don't want to do this, others may not be able to do it, and some folks still need assistance from medications. The standard has been acetazolamide (Diamox) which is well studied and received an endorsement in the recent WMS Consensus Guidelines for Prevention and Treatment of Altitude Illness.

    Acetazolamide (Diamox) works by stimulating breathing, which facilitates acclimatization. We don't know how ibuprofen, an anti-inflammatory medication, works in AMS treatment. It might dampen an inflammatory component to AMS. This remains an active area of research.

    In the recent study 69% of the people taking placebo and 43% of the ibuprofen group developed AMS. The severity of the AMS score was less in the ibuprofen group, but it did not meet the predetermined level of significance the authors hoped for.

    Ibuprofen is appealing because it is non-prescription and readily available. Both medications have their side effects - pick your poison. This study suggest ibuprofen might work faster than acetazolamide, which should be started the day prior to ascent.

    I don't think this study knocks acetazolamide (Diamox) from the altitude medication podium. I'm always skeptical of the latest and greatest drug for altitude illness. They come and they go. We need to see this work replicated, controlled for ascent profile, dehydration and other causes of headache and compared head-to-head with acetazolamide.

    In the meantime , given no contraindications or adverse side effects,it is reasonable to use Ibuprofen as a non-prescription medication for prevention of AMS symptoms. If you have a history of AMS talk with your doctor about your choice of medication. Acetazolamide, with it's proven effect on acclimatization, and it's ability to smooth out erratic breathing during sleep,might be a better choice for you.

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  • 05/07/12--15:52: Classroom Medicine
  • I recently sat through a wilderness medicine class by a well-meaning instructor who, despite decent credentials, had never cared for anyone in the wilderness.  This is just after reading a poorly crafted wilderness medicine text.  Instead of listening to the talk I made a list of things that drive me nuts in wilderness medicine education. 

    At the top of the list is classroom medicine.  These are tools, techniques and advice that work in a clean, controlled world and fail in the reality of the field.  Years ago we taught, I taught, not to apply warmth to a severely hypothermic patient because they were in "a stable metabolic icebox."   Then I knelt next to my first severely hypothermic patient and the shallowness of this advice was clear.  I had no illusions I would warm this patient in the field, but not applying heat to stabilize his temperature made no sense.  I read advice to keep frozen feet frozen all night by keeping the foot outside a sleeping bag.  This fell to the axe of reality when I stared at my own frozen foot in a tent on a cold winter's night.  We used to think tourniquets implied amputation and that open chest wounds need to be sealed with three-sided dressings to allow air to escape.  This classroom advice did not survive the test of the battlefield.  If your skepticism meter is pegging over words of dubious wisdom, ask the instructor if he has ever done this to a real patient.  You'll be surprised how often the honest answer is no. 

    High on my list are inaccurate statements of frequency.  If I believed all the tales of drama I hear from someone who heard from someone who heard, I would not leave home without an auto- injector of epinephrine in a hip holster, locked and loaded.   If I believed the NOLS incident data history, solid enough to generate multiple medical papers, I can argue that anaphylaxis is rare in the wilderness.  But I won't make that argument.  A snapshot is not the entire picture.  Data is often a matter of context.  We don't know the true incidence of anaphylaxis, or many other ailments, in the outdoors.  Statements of frequency need to be viewed with healthy skepticism.

    In the same vein I recently read that the risk of a lawsuit from reducing a dislocation in the field is high.  Based on what cases or data?  I've heard outdoor experts say that the most common injury on NOLS courses is a laceration from slicing cheese.  The real answer, sprains and strains, is easily accessible in the published literature.  When you see or hear numbers, ask for the source, and ask for the conflicting evidence.  If the educator is worth his salt he will tell you the breadth of science on this question and why he choose to believe this particular study.  Consider any unreferenced number to be junk.

    I'm also skeptical of resumes, credentials and endorsements.  Resumes can be exercises in creative writing, exaggerating or underselling experience.  Credentials often tell us of educational accomplishments, not experience.  Endorsements might be earned, but they can also be purchased-- a source of income for an organization willing to sell their name.  These badges don't tell us whether the person has ever seen a patient, seen a patient in the wilderness, spent much time in the wilderness or whether they have ever had to make a real decision in the field.

    In my upper echelon of molar grinders are statements of absolutes.  These often reveal inexperience, not expertise, and as William Osler MD said"are made at the expense of a clean conscience."  There isn't an “accepted” splint.  There are splints that are crafted based on available resources and splinting principles.  There is no single evacuation plan.  There is only what we create based on sound plans, sound assessments and sound judgments.  There are many lists of classic signs and symptoms, there is rarely a classic patient. 

    Last, but not least, is the phrase "our curriculum is evidence-based."  This is an intriguing statement since quality evidence in first aid is rare, and in wilderness first aid it is almost non-existent.  I prefer to say"evidence-informed."  It acknowledges that our choices are a blend of science, experience and opinion.  

    Am I a curmudgeon?  Probably.  Am I innocent of these sins?  Probably not.  But I am aware.  I'm trying to be virtuous and I do have the good fortune of being surrounded by colleagues who enjoy calling me to task when I slip.

    Take care

    Tod Schimelpfenig

    Curriculum Director

    NOLS Wilderness Medicine Institute

    May 2012

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    by Paul Auerbach

    Probiotics are live microorganisms that are purposefully ingested by humans to improve their health—the thought is that probiotics improve “digestive health.” The specific microorganisms are commonly of the genera Lactobacillus,Bifidobacterium, and/or Bacillus. For instance, one or more probiotic preparations may be taken to re-populate the bowel with normal bacteria (in other words, to have the “friendly bacteria” represent more than 85 percent of the bacteria present) after a person takes a course of antibiotics, which strip the bowel of its normal microorganisms. Probiotics have been recommended to diminish the symptoms of irritable bowel syndrome.

    A common question is whether or not probiotics are useful as part of the treatment of infectious diarrhea. To attempt to answer this question, Jeffrey Horn, MD prepared a brief article entitled “Do Probiotics Reduce the Duration and Symptoms of Acute Infectious Diarrhea” (Annals of Emergency Medicine 58[5]:445-46, 2011). In this analysis, he reviewed 63 published studies that looked at the effect of probiotic versus placebo or no probiotic on the duration and symptoms of acute infectious diarrhea. Specifically noted were primary outcomes of duration of diarrhea, diarrhea lasting greater than or equal to four days, and stool frequency on day two after intervention.

    In this evaluation, probiotics appear to reduce stool frequency and shorten the duration of acute infectious diarrhea by one day.  The author notes that these results were obtained when probiotics were used along with standard rehydration therapy. He also notes that probiotics were not associated with any significant adverse effects. No mention is made of whether or not probiotics were administered with or without antibiotics or any other specific therapy, such as an antimotility agent. It is presumed that these were not used, but that the published studies evaluated were limited to the consideration of probiotics versus no probiotics, without other confounding factors. 

    So, should we add probiotics to the recommendations for treating acute infectious diarrhea? It appears safe to do this and not to pose any harm to the patient. The drugs can be obtained inexpensively compared to the cost of an additional day of diarrhea, if that means a day lost to activities that are important to the patient or that generate revenue. If antibiotics are going to be used to treat infectious diarrhea, until further notice, it makes sense to wait for the antibiotic course to be completed or nearly completed prior to initiating administration of the probiotic(s). For how long should the probiotic be taken? Some people take probiotics every day, so the course of therapy can probably not be too long. At a minimum, it would be recommended to take a dose of the probiotic(s) once or twice a day for at least 7 to 14 days.

    Reprinted with permission from

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  • 06/03/12--18:23: Support for Ankle Sprains
  • by Paul Auerbach

    Sprained ankles are the bane of existence for hikers, trekker, and joggers—indeed for most athletes or anyone who has the opportunity to twist a foot on an uneven service, stepping over a rock, or falling into a hole. The classic first aid treatment is “RICE”—rest, ice, compression, and elevation. The utility of rest is obvious, because it allows the stretched or torn ligaments to heal and avoids a repeat injury. Ice is the application of cold, which helps to limit swelling and pain in the early post-injury hours (usually recommended for the first 24 hours). Compression is generally applied with an elastic bandage (such as an Ace wrap) to limit swelling and perhaps create a bit of stability to the ankle joint. Elevation means trying to keep the injured part at an altitude above the level of the heart, which perhaps lessens swelling and thereby promotes mobility and perhaps healing.

    In an article in the European Medical Journal entitled “Acute ankle sprain: is there a best support?”(2011, 18:225-230) authors Gabrielle O’Connor and Anthony Martin looked at acute lateral ankles sprains, which account for 85 percent of all ankle sprains. In an emergency department in Ireland, they peformed a prospective randomized controlled clinical trial to compare the outcomes in terms of ankle function, pain improvement, and return-to-work times in adults presenting within 24 hours of a first-time acute lateral ankle sprains, among three external supports. The three modalities that were compared were a double Tubigrip compression bandage, Elastoplast bandage, or no support (compression). They were able to include 54 patients, who were divided approximately equally between the three groups, across a spectrum of ankle sprains judged to be mild to severe.

    In this study, the patients who were treated with Elastoplast bandaging had a tendency to better average ankle function at the times when this was evaluated at 10 and 30 days after the injury, compared to the other two modalities. They also showed a return to work an average of two days earlier. So, while there was not a statistically significant difference in ankle function between the modalities, it appeared that compression was subjectively useful.

    What to make of this for the outdoor enthusiast? I think that it confirms the overall clinical impression that there is value for compression, even if it is not a miracle part of therapy. Compression helps limit swelling, which might otherwise cause it to be difficult to fit into boots or other footgear (although the wrap itself will change the foot and ankle dimensions while it is in use). It also somewhat limits motion and provides a bit of stability to the ankle, which is important if the risk factor of continued activity is present. Lastly, decreasing motion also reduces pain, provided that the wrap itself is not too tight.

    Reprinted with permission from

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  • 06/10/12--18:13: Hand Injuries Not to Miss
  • by Paul Auerbach

    Hand injuries are common in outdoor enthusiasts. Some of these injuries are easy to diagnose, and others are more difficult, usually because the signs and symptoms are subtle or because the examiner is inexperienced. Emergency physicians, such as me, need to be hyper-vigilant in order to avoid making a mistake in diagnosis. In the field, when there are environmental stresses, poor lighting, noise, and perhaps even danger, it is even more difficult to make the diagnosis. 

    A recent article in the European Journal of Emergency Medicine points out “Four hand injuries not to miss: avoiding pitfalls in the emergency department (18:186-191, 2011). Dr. Philip Yoong and his colleagues discuss ulnar collateral ligament of the thumb injury, Bennett’s fracture at the base of the thumb metacarpal bone, the volar plate avulsion fracture that occurs to the middle phalangeal bone of a finger, and avulsion of the flexor digitorum profundus tendon. Let’s consider practical field aspects of each of these in turn. Remember that these are all injuries that will eventually be referred to a hand specialist, so the point is to suspect these injuries so that they do not remain undiagnosed and under-treated.

    The thumb has three bones: the metacarpal (closest to the wrist) and two phalanges. The metacarpophalangeal (MCP) joint is between the metacarpal bone and the closest phalanx. It is stabilized from side-to-side motion by two ligaments­­—the radial collateral ligament (lateral, or outside: on the side of the radius bone) and ulnar collateral ligament (medial, or inside: on the side of the ulna bone). Injury to the ulnar collateral ligament occurs then there is a force applied that pulls the thumb away from the hand—like hyperextending a hitchhiking motion. This might happen by falling forcefully while holding a ski pole. The term “Gamekeeper’s thumb” describes a chronic ulnar collateral ligament injury caused by the force created by Scottish gamekeepers who broke the necks of rabbits between the thumb and index finger. How does one make the diagnosis? Although this may be difficult because the examination is limited by pain, when accompanied by the appropriate history, one notes that stressing the thumb away from the hand at the MCP joint causes much more motion on the injured than uninjured side. Depending on whether or not the tear is partial or complete, the victim may be treated with immobilization alone or require surgical repair. In the field, this injury should be immobilized and the victim brought to a hand surgeon as soon as is practical.

    A Bennett’s fracture is a break in the base of the thumb metacarpal bone. On X-ray, one sees an angled break in the bone that extends into the joint between the metacarpal bone and the trapezium bone, which is a bone in the wrist. If there has been much displacement of the thumb metacarpal bone at the fracture site, then the joint may become unstable, leading later to osteoarthritis with pain and stiffness. Thus, this fracture is best treated with surgery to achieve proper alignment and fixation for healing. How does one make the diagnosis? Any person with a history of injury to the hand who has pain and swelling of the base of the thumb might have this fracture, so the thumb should be properly immobilized and the the victim brought to an emergency facility for X-rays as soon as is practical.

    There are three bones that comprise a finger: proximal (close in), middle, and distal (furthest out) phalanges. A volar plate avulsion describes a situation where the joint between the proximal and middle phalanges, known as the proximal interphalangeal (PIP) joint is injured by a hyperextension motion. In this process, a fibrous structure (volar plate) that connects the palm side of the proximal and middle phalanges across the PIP joint is ripped loose to a lesser or greater degree. Depending on the degree of injury, which is determined by examination and x-ray, surgery might be necessary to achieve proper alignment and allow healing. How does one make the diagnosis? With the history of a hyperextension injury, the victim often shows pain on the underside of the PIP joint, swelling, reduced range of motion, and perhaps bruising. If a dislocation at the PIP occurred and was put back into place, this is indicative of the type of injury that would be accompanied by a volar plate disruption. In the field, the joint should be properly splinted and the victim brought to a hand surgeon or emergency department as soon as is practical.

    Finally, there is injury to the flexor digitorum profundus tendon. This is the tendon that creates flexion (downward bending) of the finger at the furthest joint (distal interphalangeal [DIP] joint). The injury is created by a force that pulls the tendon (and sometimes some bone with it) off its insertion (attachment) to the distal phalanx. After this occurs, the finger can no longer be flexed. How does one make the diagnosis? The finger may be swollen at the DIP joint and beyond to the fingertip, painful at this location, and perhaps bruised. To diagnose that the tendon doesn’t work, hold the PIP joint straight and ask the victim to try to flex the DIP joint. In the field, the finger and DIP joint should be splinted in a position of function. Prompt referral to a hand surgeon is essential, because if this injury is not repaired with surgery within 7 to 10 days, primary repair may not be possible. This would mean that any further improvement would only happen with more complicated surgery, which is less likely to achieve 100 percent return of function.

    Reprinted with permission from

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    What’s the most dangerous thing that your outdoor program does?

    The answer: Vehicles.

    Driving is statistically the most dangerous activity for any outdoor program. Because vehicular accidents can be so serious many programs have specific risk management protocols--things like mandatory driver training, specific vehicle driving protocols, specialized license requirements like a Commercial Driver’s License (CDL) or background motor vehicle checks on drivers. Those are just some of the proactive risk management strategies to help reduce the potential for vehicular accidents.

    If driving in vehicles is so dangerous, what about other activities that expose your participants to vehicles, like crossing high trafficked roads? Isn’t this a high risk activity? I say the answer is yes. And yet many programs don’t specifically have a Road Crossing Protocol. I think road crossing has been seriously overlooked as a risk management issue for outdoor programs. Why is that?

    Let’s take a look at another ‘crossing protocol.’ Most programs have specific protocols for river crossings like unbuckling hipbelts and chest straps to be able to shed the pack quickly. When you come to a river crossing, you assess a whole range of factors to determine if the crossing is hazardous including (but not limited to):

    • depth of the river
    • speed of the current
    • width of the river
    • possible downstream hazards like strainers and waterfalls
    • water temperature

    Based on this data you determine if there are significant risks in doing the crossing. If the river is only 6 inches deep and 5 feet across, you may decide that people don’t need to implement a protocol like unbuckling their hipbelts before stepping across. If it’s 3+ feet deep and 30 feet across you’d initiate the protocol to undo hipbelts. There might also be a series of other specific actions you would take to safely cross the river. If crossing a river can be hazardous and need special protocols to reduce the risk, why not specific protocols for crossing roads?

    The first reason that road crossing has often been ignored is that not all programs operate in areas where travelers have to deal with road crossings. If you are running your backpacking program in the Wind River Range in Wyoming or the Hundred Mile Wilderness in Maine, roads simply aren’t an issue. If, on the other hand, you run trips up and down the Appalachian Trail for example, road crossings can be a daily occurrence. Having run programs for over thirty years on the Appalachian Trail, I can tell you that there are some significantly dangerous road crossings along the AT.

    Here are a few that I’ve come in contact with. The first is on the Appalachian Trail in New Jersey at Route 206 in Culver’s Gap. The AT crosses Route 206, a busy, high trafficked road that can present real hazards to a group at certain times of day. The next is in Harriman State Park in New York. The AT (also called the Ramapo-Dunderburg Trail) in the park crosses the Palisades Parkway. The Palisades is a two-lane divided highway with no shoulder and a grassy median in the center. I’ve crossed it safely with a group in the early afternoon when there is little traffic. At rush hour it is a constant stream of cars traveling 65+ mph in both directions. There is literally no way to get across until the traffic dies down. And these are just some of the examples.

    So what can you do to address the risk associated with high speed vehicular traffic on roads?

    1. The first thing I advise your program to do is to assess the areas that you are traveling in and determine if road crossing is a hazard in specific locations. If you find that to be the case then you should approach the issue just as you would any other identified hazard—assess the hazards and develop strategies to mitigate them.
    2. Next implement a Road Crossing Protocol that teaches your staff how to assess the hazards of a particular road crossing and specific guidelines for how to reduce the risk of the road crossing. What I present here is a sample road crossing protocol for your consideration.


    Sample Road Crossing Protocol

    Our trips must often cross roads. This can be hazardous due to the unpredictable nature of drivers and traffic. In order to safeguard all members of the group, leaders should be cautious and use good judgment. The procedures below outline the expectations for leaders crossing roads:

    Like river crossings we can identify a number of factors that can increase the risk level of road crossings:

    • “Density” of vehicular traffic
    • Width of Roadway
    • Speed of the traffic
    • Type of vehicles (trucks and buses have a much longer stopping distance than cars)
    • Visibility in both directions for crossers to be able to see oncoming traffic and assess the scene
    • Time required to cross the road (in relation to the amount and speed of vehicular traffic and visibility)
    • Visibility for drivers (is it dawn, dusk, foggy, rainy?)
    • Road conditions (is the road wet, icy, etc.)

    Let me give you an example from the Palisades Parkway in Harriman State Park. At one of the trail crossings there is a curve in the road to the north limiting visibility. In timing the traffic on one occasion I noted that from the time the vehicle was first visible coming from the north to the time it got to the trail crossing was 19 seconds. Timing a person with a full backpack crossing the road at a walking pace it took about 10 seconds. If the car is traveling 65 MPH then the extra 9 seconds is not a lot of leeway. A car can travel hundreds of feet in 9 seconds and even if the driver sees the person and steps on the brakes immediately, the car still requires a significant distance to stop and is coming closer to the person every second.  What if the person has trouble getting across the road? What is the driver is distracted or texting? What if the road conditions are slippery or the tires or brakes on the car are bad? Based on this risk assessment I determined that we should implement a Road Crossing Policy (described below).

    • Know your route ahead of time: Know when and where you must cross a road. As you plan the day’s route, keep these road crossings in mind. When will they occur: early morning, mid-day, late afternoon? Obviously, having to cross a road in the dark can also increase the accident potential. Have an idea what type of road you are crossing. Is it a backcountry road with little or no traffic or a busy interstate? Will it be empty at certain times of the day and extremely busy at rush hour? Check the guidebooks to the area for specific information and include a plan of how/when to cross the road ahead of time.
    • Assess the crossing:When you arrive at the crossing area, assess the situation for a good place to cross. Where is the point you are supposed to arrive at on the other side of the road in comparison with your point of departure? Is it straight across the road, diagonal, or do you have to walk down the roadway for a distance? Also assess the visibility at the crossing point, taking into account your ability to see or hear oncoming traffic and their ability to see you. You should have good visibility down the road in either direction. If you have good visibility for traffic, have the group members cross the road as they would any roadway, looking carefully in both directions and proceeding across when it is safe to do so.
    • Compensate for Reduced visibility: If the crossing spot does not have such visibility, post a watcher at a location along the road to give you that visibility. You may need more than one watcher so as to monitor traffic from both directions simultaneously. Watchers are there to signal to the other group members when it is safe to cross the road. Watchers should be off the road on the shoulder. All trip members should understand the crossing signals from the watcher, and not cross until they receive that signal. Adapting signals from the AWA Canoeing Safety signals, one arm straight over head means SAFE TO CROSS FROM THIS DIRECTION. ONLY signal in the affirmative meaning that it is OK to cross. No signal means it is not year clear to cross. In any crossing situation the group members should look carefully in both directions and move across the road reasonably quickly. One of the leaders should be on hand at the crossing site.
    • Cross one person at a time: When you decide you are going to implement this protocol, the most controlled way to cross a busy road is one person at a time. That way there is only one person moving to keep an eye on. If a vehicle is coming that person can respond. Having multiple people crossing at once means that Person A might go one way and Person B go another, increasing the possibility that someone might be hit.
    • Crossing roads at night: It is best to avoid crossing roads at night. It may be safer to camp (even illegally) and get up early to make up mileage than to cross a busy road at night. Leaders must use their best judgment on what is the safest course of action. If you do decide to cross at night, you should use the precautions listed above. In addition, each group member should have a flashlight out to be able to see the road surface they are crossing. If you need to use watchers, they should be posted with flashlights. Three on-off flashes of the light in quick succession from the watchers means SAFE TO CROSS FROM THIS DIRECTION.
    • Walking along roads: If your route requires that you walk along a road for any length of time, you should use the following procedures: Walk on the side of the road with the widest shoulder (if there is one). Walk in a single file line. It may be better (as runners often do) to walk on the side of the road facing traffic so you can see oncoming traffic and more quickly move away if needed. One leader should be in front and one in the rear to manage the group. Be especially careful at curves where drivers may not be able to see you. Walking along long sections of road a night should be avoided whenever possible. If you must walk, everyone should have a headlamp and should walk on the side of the road facing traffic to maximize your visibility.
    • Unloading buses: Buses should be unloaded from the curbside. Pull things through the luggage bays whenever possible to avoid unloading on the street side.
    • Crossing near buses: If you are dropped off by bus along a roadside, make sure that you have good visibility in either direction before crossing in front of or behind the bus. Either wait for the bus to pull out before you cross, or use the road crossing procedures outlines above.
    • Crossing with canoes: Portaging a canoe across the road means understanding that you are transporting a bulky object and will be moving more slowly. When you have to cross a road with canoes it is important to follow the procedures above. In addition, the canoes should be emptied of all gear so that they can be carried quickly. Find the best route across the road and use that area. Post watchers (in both directions if necessary to signal cars to slow down and/or to indicate when it is safe to cross using the methods outlined above). Two to four people should carry the canoe at waist level, on the bow and on the stern. Do not carry the canoe over your head, it is too difficult to quickly jettison the canoe.

    Now that I’ve explained the protocol, let me go back to the Palisades Parkway example. It was early afternoon so traffic was not very heavy. However the lack of visibility to the north because of the curve meant that a car would suddenly appear with only 19 seconds ‘warning.’ We sent one person down to the corner who could see significantly farther north. When that person saw that it was clear of traffic she raised her arm over her head indicating that it was clear to cross. That allowed people to cross to the grassy median. Then we implemented the same system for the next two lanes of traffic coming up from the south.

    Protocols are one thing, judgment is another. There is a famous quote from Paul Petzoldt, founder of the National Outdoor Leadership School. He said, “rules are for fools.” Taken out of context a lot of people have interpreted this statement to mean that Paul rejected protocols. On the contrary. Drew Leemon, NOLS Risk Manager, once asked Petzoldt what he meant. Petzoldt explained that protocols were useful and necessary, for example, a protocol that requires people to wear life jackets on the river is a good thing. What he meant was that you can’t write a protocol/rule for every situation and the person who thinks you can take some huge rule book into the wilderness to just decide how to handle all situations is a fool. In the end Protocols work hand in hand with Instructor Judgment. A Road Crossing protocol (or any protocol) is a tool. It requires judgment to decide when to use the tool to effectively reduce hazards. I don’t use the Road Crossing protocol every time I cross a road, just like I don’t unbuckle a hipbelt every time I cross a stream. The job of the instructor is to assess if the road crossing presents a significant hazard. If it does, the protocol provides a tool to mitigate the hazard.

    In order to offer a ‘complete’ risk management perspective on this, you should consult with your legal counsel about the potential liabilities associated both with having or not having a road crossing protocol. This is not (at least not yet) an ‘accepted industry standard’ like lightning protocols are. As a result, you need, with legal advice, to determine if this in your program’s best interest from a legal liability perspective. I believe that it does mitigate many of the hazards of road crossings, but risk mitigation is not necessarily the same thing as liability mitigation. Some legal experts might argue that people (specifically adults) cross roads all the time and are fully capable of making their own decisions about crossing safety so having a protocol places an increased burden on the program to manage an individual’s safety. In this case, the legal advice might be to not have a protocol and assume no responsibility for managing people’s risk when crossing roads. However, if you work with minors then they might be considered not to have the experience to assess the hazard and make appropriate decisions. My personal feeling is that this is fundamentally an ethical issue first and a legal issue second. If I know of a hazard that my participants are not aware of or would not consider (regardless of their age) then it is my moral obligation to inform them of the hazards and, I believe, to take a step further than that which is to provide a protocol for mitigating the hazard.

    For more information on managing risk I suggest you read theRisk Assessment and Safety Management (RASM) model which I developed and which is in use by outdoor programs throughout the US and internationally.

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    by Paul Auerbach

    There are two excellent photographs of a rattlesnake bite victim that appear in the June 10, 2010 issue of the New England Journal of Medicine (362;23:2212). Entitled “Rattlesnake Envenomation” in the IMAGES IN CLINICAL MEDICINE feature, they show the bitten finger and the effects on the torso of a man who presented for medical care within a half hour of having been bitten by a rattlesnake. He was treated with antivenom prior to being admitted to the hospital.

    The finger image shows the local effect of the venom in this victim, which could have caused tissue destruction (but did not, which is most likely attributable to the timely administration of a sufficient amount of antivenom). The torso image shows the extensive bruising associated with the blood clotting disorder that developed because of the systemic effects of the venom, which combined to prolong bleeding time in this victim. Despite the initial administration of antivenom, the victim continued to develop his bleeding problem, so was administered additional antivenom, which is needed to counteract the venom effects. The patient had a full recovery, which is a credit both to the victim (for promptly seeking medical care) and to the treating physicians, who knew how to properly treat a venomous rattlesnake bite with antivenom.

    For the benefit of anyone who might suffer a rattlesnake bite, here are instructions about what to do in the field:

    • If a person is bitten by a snake that could be poisonous, act swiftly. The definitive treatment for serious snake venom poisoning is the administration of antivenom. The most important aspect of therapy is to get the victim to an appropriate medical facility as quickly as possible.
    • Don’t panic. Most bites, even by venomous snakes, do not result in medically significant envenomations. Reassure the victim and keep him from acting in an energy-consuming, purposeless fashion.
    • Retreat out of the striking range of the snake, which for safety’s sake should be considered to be the snake’s body length (for pit vipers, it is actually approximately half the body length). A rattlesnake can strike at a speed of 8 ft (2.4 m) per second.
    • Locate the snake. If possible, identify the species. If you cannot do this with confidence (which is really only important for the Mojave rattlesnake and coral snake), you might be able photograph the snake using a digital camera, but be careful. Do not attempt to capture or kill the snake, for fear of wasting time and perhaps provoking another bite. Never delay transport of the victim to capture a snake. If the snake is dead, take care to handle it with a very long stick or shovel, and to carry the dead animal in a container that will not allow the head of the snake to bite another victim (the jaws can bite in a reflex action for up to 90 minutes after death). If you are not sure how to collect the snake, it is best just to get away from it.
    • Splint the bitten body part to avoid unnecessary motion. Allow room for swelling within the splint. Maintain the bitten arm or leg in a position of comfort. Remove any jewelry that could become an inadvertent tourniquet.
    • Transport the victim to the nearest hospital.
    • Do not apply ice directly to the wound or immerse the part in ice water. An ice pack placed over the wound (as one would do for a sprain) is of no proven value to retard absorption of venom, but may be useful for pain control. Application of extreme cold can cause an injury similar to frostbite, and possibly lead to enough tissue loss to require amputation.
    • Application of the Extractor Pump is at best controversial, and is no longer recommended by snakebite experts. The manufacturer claims that if the device is applied according to the instructions provided, it can remove venom without the need for a skin incision. Animal research appears to refute this notion, and even to suggest that by using the device for a rattlesnake bite, it might cause concentration of tissue-toxic venom under the suction cup, leading to a more severe reaction.
    • If the victim is more than 2 hours from medical attention, and the bite is on an arm or leg, one may use the pressure immobilization technique: place a 2 in by 2 in (5 cm by 5 cm) cloth pad over the bite and apply an elastic wrap firmly around the involved limb directly over the padded bite site with a margin of at least 4 to 6 in (10 to 15 cm) on either side of the wound, taking care to check for adequate circulation in the fingers and toes (normal pulses, feeling, and color). An alternative method is to simply wrap the entire limb at the described tightness with an elastic bandage. The wrap is meant to impede absorption of venom into the general circulation by containing it within the compressed tissue and microscopic blood and lymphatic vessels near the limb surface. You should then splint the limb to prevent motion. If the bite is on a hand or arm, also apply a sling. It should be noted that this recommendation is controversial, in that some experts believe that localizing venom in a single area might lead to an increased chance for tissue damage.
    • An alternative to the pressure immobilization technique is a constriction band (not a tourniquet) wrapped a few inches closer to the heart than the bite marks on the bitten limb. This should be applied tightly enough to only occlude the superficial veins and lymph passages. To gauge tightness, the rescuer should be able to slip one or two fingers under the band, and normal pulses should be present. The band may be advanced periodically to stay ahead of the swelling. It is of questionable usefulness if 30 minutes have intervened between the time of the bite and the application of the constriction band (or pressure immobilization technique). Again, this recommendation is controversial, for the reasons mentioned in the previous paragraph.
    • The impression of most snakebite experts is that incision and suction are of little value and probably should be abandoned. It appears that little venom can actually be removed from the bite site. Furthermore, the incision may set the stage for inoculation of bacteria, infection, and a poorly healing wound. Mouth contact with the incision may cause a nasty infection that leaves a noticeable scar; there is also the risk of transmission of blood-borne disease to the rescuer.
    • “Snakebite medicine” (whiskey) is of no value and may actually be harmful if it increases circulation to the skin.
    • There is no scientific evidence that electrical shocks applied to snakebites are of any value. On the contrary, there are experiments that refute this concept.
    • The bite wound should be washed vigorously with soap and water, and the victim treated with dicloxacillin, erythromycin, or cephalexin.
    • If the victim is many hours or days from a hospital, assist him to walk out or arrange for a litter rescue, allowing frequent rest periods and adequate oral hydration. Splinting and positioning (e.g., elevating or lowering) the bitten part are secondary to any effort to reach a facility where antivenom can be administered.
    • Watch for an allergic reaction caused by the snakebite. This might cause the victim to be short of breath with or without an airway obstruction from swelling of the mouth, tongue, and throat. Once the victim is in the hospital, the severity of envenomation will be ascertained, and the victim treated with antivenom if necessary. Such therapy must be carried out under the supervision of a physician, because serious allergic reactions to antivenom are possible.


    Reprinted with permission from

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      by Paul Auerbach

      Heatstroke is a life-threatening emergency. Therapeutic cooling measures need to be undertaken rapidly in order to prevent the catastrophic organ failure associated with markedly elevated body temperature.

      The general dictum is to cool the victim to a normal body temperature, but to take care not to go further into the territory of hypothermia ("overshoot"), which theoretically might create another set of difficulties. But perhaps there is an opportunity now for new thinking regarding cooling a heatstroke victim in dire circumstances.

      In an article entitled "Successful Treatment of Severe Heatstroke With Therapeutic Hypothermia by a Noninvasive External Cooling System" (Annals of Emergency Medicine 2012;59:491-493), Dr. Jen-Yee Hong and colleagues report treating a near-fatal case of exertional heatstroke using induced therapeutic hypothermia (33o C [91.4o F]) by a noninvasive external cooling system. After treatment, the patient recovered completely, without any neurological sequelae at one year. Prior to cooling, the victim had multi-organ dysfunction, including seizures, lung injury, and coagulopathy (diffuse bleeding).

      This is a very important case report, because external cooling devices are much more commonly found these days in emergency departments because they are used to cool patients to protect their brains after they have been resuscitated from cardiac arrest, or in certain other situations where there has been a dangerous period of lack of oxygen to the brain.

      The specific device used for this patient was the Medivance Arctic Sun System, which is a noninvasive (no direct access to the bloodstream is obtained) cooling system designed for external temperature management. It circulates chilled water through pads directly adhered to the patient's skin. While this is a single case report and it is impossible to know if merely cooling the patient from a hyperthermic (hot) condition to a normal body temperature would have been sufficient to achieve the same outcome, it is very important to note that going beyond a normothermic condition to a hypothermic (cold) condition did not appear to be harmful and may very well have been helpful, for theoretical reasons noted by the authors.


      Outdoor Ed Note: Thanks Paul for this update. The heat waves happening across the U.S this summer are of particular concern for outdoor programs where physical activity is combined with high heat and humidity. Heat stroke can be an immediately life-threatening illness.

      Here are a few other good sources about Exertional Heat Stroke (EHS). One critical observation from a number of these articles is advanced recognition of the problem. The person who is "'falling behind' his friends, or collapsing during or shortly after an exercise is suspected to suffer from heat stroke. Staff should be taught to look for these signs and take immediate vigorous steps.

      Exertional Heat Illness and Competition - Position Paper by the American College of Sports Medicine (PDF Version)

      "Cooling Techniques for Hyperthermia" at Medscape.

      Exertional HeatStroke in Israeli Defence Forces (PDF)

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    • 07/19/12--08:09: When to Use Tourniquets
    • Re-posted with permission from Wilderness Medical Associates International.

      I am not sure that there is a consensus about their use but here is my opinion about tourniquets in remote and hostile environments.

      In brief:

      1.  Learn how to use one and practice with it.

      2.  Apply to stop bleeding not controlled by well-aimed direct pressure.

      3.  Use something wide and firm (but not hard) that can apply circumferential pressure.  The pressure should be sufficient to stop bleeding.  Make sure that it is in good shape and not a knock-off.

      4.  Place proximally (upstream) and as close to the wound as possible.

      5.  Don’t release in the field if the patient is in shock, has an an amputated limb, or has a wound site that cannot be monitored for re-bleeding.

      6.  For a long evacuation, wait an hour before trying to release it.  If bleeding starts again, re-secure.  Note the time and leave it in place until definitive care is reached or arrives.

      7.  Under dangerous circumstances, one may be applied before a thorough evaluation is possible.  These should be applied to the proximal thigh or arm if there is any question about the location and/or number of wounds.  Carefully check the wound when it is safe and feasible. As indicated, leave, reposition, or release it or add a second one proximally.

      The following is an explanation of my above opinion.  None of this should be misconstrued as a blanket endorsement to buy and carry one on all trips.

      Tourniquets have a checkered history and hyperbolic claims continue to muddy the water.  Past and current combat experience in the SW Asian theaters has drawn renewed attention to them because injuries to limbs have been a major source of life-threatening bleeding. There, they are being used successfully to control obvious and potentially serious bleeding.  In the later case, they are applied before a proper assessment is possible e.g., multiple casualties, continued live fire.  The tourniquets used are relatively cheap and can be lifesaving if used properly.  As with anything in medicine, nothing works 100% of the time.

      In civilian practice, it is relatively rare for death from limb bleeding to occur because properly applied, well-aimed direct pressure failed. Still, tourniquets have their use outside of theater (e.g., mass casualty), so knowing how to use one is important. The relevant questions include what, where and for how long.

      A good tourniquet
      ought to be soft (but not mushy) and wide.  Within limits, wider is better. To be effective, the circumferential pressure needs to be sufficient to stop bleeding. A sphygmomanometer (BP cuff) might be ideal except that they usually will not maintain adequate pressure for a long enough period of time. They and similarly designed devices are also bulky and fragile. The gauges break easily and the fabric, bladder and tubes are vulnerable to sharp objects. Cordage, like a rope or 550 cord (parachute), is not a good choice either because of the potential for direct skin and neurovascular injury.

      There are a variety of more serviceable versions. Two of them, the CAT (combat application tourniquet) and SOFTT (special operations forces tactical tourniquet), have worked reasonably well in combat. They are compact, inexpensive and easily applied, even by the patient.  Their advantages are a tradeoff for effectiveness.

      One needs to have enough remaining limb to hold the tourniquet. I have heard intelligent people argue that they should never be applied to forearms and legs (lower).  Generally, I disagree and experience would seem to bear that opinion out.  They should be applied as close to the wound as possible.  When circumstances prevent a proper assessment for location and number of wounds, some recommend using only the proximal arm (upper) and/or  thigh as default positions.

      If limb bleeding will not stop, especially with a thighanother applied in parallel, proximally, may help. Stay off joints.  Controlling junctional (e.g., in the groin) bleeding remains problematic.

      How long:
      People fear tourniquets because prolonged use can lead to neurovascular damage and tissue death. We know that tissue death from impaired circulation can occur in as little as two hours. We also know that tourniquets have been left on for over 16 hours without any notable harm.

      Releasing a tourniquet has its own risks and there are circumstances where removal never makes sense.  These later would include limb amputation, shock, the inability to monitor the wound or continued bleeding.  Intermittently releasing them to temporarily restore circulation has been reported to lead to unrecognized, ongoing blood loss and patient death.   On a long evacuation, if the conditions seem otherwise safe, waiting 1 hour before attempting a removal seems like a reasonable time interval.  If bleeding starts again, resecure,  note the time and leave it in place.

      Improper application is an important cause of failure.  They can also fail when they breakdown from environmental exposure or from poor construction (e.g., older version knockoff).  Always check your equipment before heading out and replace anything questionable.  Practice with any tool before you need it for a real emergency.

      There are plenty of good resources online that cover step-by-step application and the identification of knockoffs (e.g., date printed on webbing, red tip on the end of webbing).

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      Re-posted with permission from Wilderness Medical Associates International.

      Walking through the first aid aisle at your local outfitter store can be overwhelming. While there are many excellent prepared kits on the market, often enthusiasts choose to create and specialize their own.  Your kit will be different based on where you are camping and hiking. Trips at altitude, near marine environments or canyoning, and desert trekking each have unique needs that would require you augment your kit accordingly.

      Below is a “basic kit list,” to which you can add on as your number of adventurers, length of trip, level of training, or destination dictate. An asterisk marks items that you might include for your week-long trip. For your overnight, you can feel comfortable paring down the quantities.

      Personal Protection:

      • Gloves (Nitrile) – Vinyl is too porous, and latex is a common allergen.  Bring a few more pair than you think you need. You use one pair of gloves each time you clean a wound, and gloves aren’t designed to be re-used. If your gloves have been in your kit for a long time, check them to make sure they didn’t degrade in heat or cold. Have these easily accessible so that you are inclined to use them when needed.
      • CPR mask and airway management- you can get a quality mask with a filter for around $12. “Keychain” masks are better than nothing, but have a short life span when put to use. If you have been trained to use airway adjuncts, include some—they are a little bit of weight for a lot of good.
      • Wound care (probably the most common supplies I use on trips):
      • 1” athletic tape- one roll per person per week for hiking/skiing/climbing trips (really). It’s good for blister prevention, blister covering, ankle taping, and much more.
      • Gauze/ dressings (4-6) – different sizes and a few nonadherent (great for burns or abrasions).
      • Adhesive bandages (8)- various styles.
      • Roller gauze or vet wrap (2)- something to keep the gauze next to the wound that won’t cut off circulation. Vet wrap lasts longer than roller gauze.
      • Waterproof/ breathable (occlusive) wound dressings (2-3)*- an invaluable addition to wound care if you will be out for a few days. On a clean wound, this can create an environment conducive to healing that lasts a couple days. These are generally 2” x 3” or larger.
      • Tweezers- invest in a good pair (sharp and pointy), which will only cost a couple dollars more than a cheap pair.
      • Small magnifier- for wound cleaning. Be sure you have a reliably bright light source for wound exploration.
      • Wound cleaning*- a 60cc syringe (check the local feed store) with an irrigation tip is cheap and lightweight and gives better pressure than anything we could improvise.
      • Trauma shears (1)- there are some cool tiny ones (4”) on the market that only cost a few dollars and work great.
      • Blister care- Moleskin, foam, gel pads, or whatever your flavor. Duct tape should not be used on open blisters.

      Musculoskeletal injuries:

      • Compression wrap(s)- 3” works great for supporting ankles or knees.
      • Aluminum foam splint (1)
      • Triangular bandages (2)- these are multi-functional.


      Over the counter medications:

      • Pain management- ibuprofen and acetaminophen work in different ways. Bring what you prefer, and pack a few grains of rice if you have bottles of tablets. It keeps the tablets from becoming a paste in moist conditions.
      • Gastrointestinal meds*- antacids such as calcium carbonate, anti-diarrheal such as loperamide, or whatever works for you.
      • Antihistamines- diphenhydramine for allergic reactions. Epinephrine injectors are prescription only and should be carried by those who require them.
      • Topical antibiotic cream*- good for small, shallow wounds. No need to get a huge tube, and beware of antibiotic allergies among your group.

      Random other things and debatable items:

      • Your Field Guide of Wilderness & Rescue Medicine
      • Timepiece
      • Extra waterproof zip bags- these can be packaged with your SOAP note, pencil, and local emergency numbers.
      • Stethoscope*- If you are comfortable listening to lung sounds, I would recommend this for aquatic or altitude trips.
      • Oral glucose gel*- If you have honey in your camp kitchen, it will suffice. Many coffee shops have honey packets available as condiments- perhaps pick up a few with your purchase.
      • Temporary dental filling*- maybe not for a week-long trip, but it’s small, cheap, easy to find in the store, and can turn a trip around to the good easily.
      • Antifungal cream*- miconazole or clotrimazole would be good for a longer trip.

       Comfort care to be carried by individuals, depending on the environment:

      • Aloe*
      • Throat lozenges*
      • Lip balm
      • Sunscreen
      • Insect repellant
      • Contact care
      • Personal medications- asthma inhalers, etc.

      Much of this can be bought at local pharmacies, “feed and seed” stores, grocery stores, or through online retailers.

      Pick your vessel. You might be inclined to choose a zippered nylon clamshell with organizer pouches or see-through dividers. Or, if you are an ultralight hiker, you may choose waterproof zip-top bags. For paddling trips, dry bags or dry cases may be preferred if you can keep the inside dry (but I wouldn’t want to haul a dry box on a mountaineering trip!) Regardless of your outside package, it is worth the extra few minutes to compartmentalize your contents by thought- something that makes sense to you, like: big wounds; little wounds and blisters; common pills (like ibuprofen); uncommon pills (like GI meds); etc. I use a vacuum sealer when I am more worried about water seepage or risk management (this makes it inevitable to see if something’s been used, and then program managers know to seek out an incident report or replace stock).

      Have a great trip!

      *This assumes your survival gear (the rest of the ten essentials) is packaged elsewhere.

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      Wilderness First Aid (WFA) courses are taught by multiple individuals and programs.  They have become a standard for people working and recreating in the outdoors.  Are they effective?  Can the participants remember the information?  Can they perform the skills?

      To investigate these questions NOLS Wilderness Medicine Institute (WMI) conducted a research project to measure retention of WFA skills and knowledge.  There is literature on skill and knowledge retention in CPR and first aid, but nothing we could find on WFA courses.

      The research was conducted with our colleagues at the University of Utah; Scott Schumann PhD, Jim Sibthorp PhD and Rachel Collins MS.  At the conclusion of an open enrollment WFA course the study participants were given a written exam and an assessment of their confidence in their ability to perform their WFA skills.  At either 4, 8 or 12 months post course they returned to complete a scored skills-based scenario, familiar to anyone who has taken a WMI WFA course.  They also repeated the WFA knowledge and self-efficacy measures they took at the original training.   You can read the detailed study methodology, results and limitations at the Journal of Wilderness and Environmental Medicine  


      Our findings are not surprising. 

      • We quickly forget what we do not practice. The longer the time from training, the more we forget. 

      • Written tests do not correlate with performance on practical tests.

      • Our opinions on our competence may not correlate with our practical performance. 

      The study participants demonstrated poor skill proficiency when taking vital signs, obtaining a medical history, and conducting the focused spine assessment (a selective spine immobilization protocol).  These results are consistent with studies that show first aid knowledge and skills, or any skills or knowledge for that matter,  deteriorate in the absence of repeated practice. 

      The poor skill retention seen in this study brings an interesting perspective to the complaints we hear about the burden of biannual recertification of WFA/WFR.  The American Heart Association suggests practicing medical professionals refresh their BLS skills more frequently than every 2 years.  We cannot assume that laypeople will retain their skills any better than practicing professionals.  Bravo to those organizations with ongoing training for their staff.

      The study did not look at teaching competency, but it does beg these questions.  The content may be basic first aid, but in our (albeit biased) opinion the volume of stuff in a WFA requires a skilled educator to have any chance for competent graduates.  WFA courses are taught by skilled educators and outdoor medicine practitioners, and they are taught by people who obtain a WFA instructional credential online with no verification they can teach effectively, have ever touched a patient or spent a night outdoors.  Buyer beware.   

      These results raise the question of the appropriate role for this certification.  The WFA course was designed as an introductory layperson first aid course for those close to help or assisting a more highly trained provider and is described in this context in the Scope of Practice document.  It has unfortunately evolved into a wilderness trip leader credential.

      We must also pause and ponder all the content people want crammed into this course.  Of everything we could teach, what needs to be learned by a layperson to practice wilderness first aid?  We have grown to expect more from this course than we can deliver in 16 hours of instruction.

      WMI doesn't find these results discouraging, nor did we choose, as can happen in product research, to bury the negative results.  We empirically assessed and now report our outcomes.  We have already revised our WFA curriculum.  We cut unnecessary content detail, including the focused spine assessment.  We found more practice time in a busy agenda.  We are developing other educational tools to increase retention.  We're excited to continue to evolve an important curriculum that is accurate, realistic and practical.


      Tod Schimelpfenig

      Curriculum Director

      NOLS Wilderness Medicine Institute

      Reference: Schumann SA , Schimelpfenig T , Sibthorp J , Collins RH. An examination of wilderness first aid knowledge, self-efficacy, and skill retention . Wilderness Environ Med. 2012;23:281–287

      September 2012

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      by Paul Auerbach

      Our National Parks are a treasured heritage, and one of the ways in which we appreciate the outdoors. Millions of visitors flock to the parks in order to camp, hike, climb, swim and most of all, appreciate the wonder and natural beauty of America. As with any other outdoor setting, there are risks of injuries and illnesses. A recent cluster of cases of hantavirus pulmonary syndrome apparently originating from Curry Village in Yosemite National Park this summer points this out.

      Hantaviruses (such as the sin nombre virus) cause a syndrome characterized by a combination of fever, lung failure, kidney failure, shock, and bleeding. The viruses are spread in the excreta of rodents; in the United States, hantavirus pulmonary syndrome (HPS) has been linked to the deer mouse (Peromyscus maniculatus) and white-footed mouse (P. leucopus), as well as to the cotton rat (Sigmodon hispidus) and rice rat (Oryzomys palustris). The animals shed the virus in saliva, urine, and feces. Aerosols are the most likely route of transmission from rodents to humans. Insect bites have not yet been implicated in transmission. The virus found in the U.S. is not known to cause human-to-human transmission.

      The deer mouse is a creature that is adept at squeezing through very small openings. In the case of Curry Village at Yosemite, mouse nests have been found in the wall spaces of tent cabins, and mice have tested positive for the virus from around the park.

      HPS  has been reported in most states west of the Mississippi River, as well as in a few eastern states. In Louisiana and Florida, two hantavirus species, bayou virus and Black Creek virus, have been identified. A person infected by the virus has an incubation period of 1 to 6  weeks after exposure, and then suffers from fever, muscle aches, headache, cough, dizziness, abdominal pain, nausea and vomiting, and diarrhea for a few days; this is followed by difficulty breathing, mottled skin on the limbs, shock, and, sometimes, bleeding. In the U.S., approximately a third of victims die.

      Most victims have had an interaction with rodents, such as when cleaning a barn or capturing the animals. Unfortunately, there is not yet any specific therapy beyond supportive care. Because a person with hantavirus infection may become seriously ill at a rapid rate, it is important to promptly bring any suspected victim to medical care.

      To avoid unnecessary exposure to hantavirus, it is recommended that wilderness enthusiasts observe the following precautions:

      • keep food and water covered and stored in rodent-proof containers
      • dispose of food clutter
      • spray dead rodents, nests, and droppings with disinfectant before handling (wear gloves)
      • clean and disinfect cabins and other shelters thoroughly before using
      • don’t make camp near rodent sites
      • don’t sleep on bare ground 
      • burn or bury garbage promptly 
      • discard food that looks like it may have been chewed upon by rodents
      • use only bottled or disinfected water for campsite purposes.


      Reprinted with permission from

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      The Wilderness First Aid (WFA) course, widely taught by numerous providers, can be burdened with unrealistic expectations of the topics and skills that can be taught in a basic layperson first aid program.

      In 2010, sensing a need to clarify what first aid skills and knowledge are realistic and practical for a WFA provider representatives from the major wilderness medicine educators created a WFA Scope of Practice (SOP) document.  The SOP is in essence a job description of what a WFA provider should know and what skills they should and should not be able to perform. 

      The original writing group convened this fall to review and update the WFA SOP.  Two years have passed since the original document and with the publication of the WFA Skills Retention Study a review was timely.  The latest version articulates the minimum skills and knowledge base for a WFA provider.

      Another ongoing project is a review of the medical evidence supporting WFA practices.  Several representatives of wilderness medicine schools are on this Wilderness Medical Society working group.  We hope to see publication of this work in 2013. 

      This SOP document is not binding on anyone.  It is not crafted as a curriculum.   It reflects the consensus of a group of providers who created and have taught this course to tens of thousands of students over three decades and who are actively engaged in the practice of wilderness first aid.  It is our hope that it provides some guidance to those who teach WFA and guidance for the outdoor program manager deciding on the appropriate certification for their staff and for the consumer who is choosing between different certifications.  

      We invite observations and comments, which can be submitted to any member of the working/writing group, and for organizations/individuals to indicate their support for this work by adding their signatures.


      Tod Schimelpfenig

      Curriculum Director

      NOLS Wilderness Medicine

      December 2012