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Wilderness First Aid

Jeremy B. · · Unknown Hometown · Joined May 2013 · Points: 0
Scott O wrote: No, you're definitely wrong. If someone doesn't have a pulse, do CPR. If someone is apneic, but does have a pulse, provide respirations.
This is correct. Unfortunately the CPR basic courses have dispensed with the concept of checking for a pulse. (Too difficult for the average person, apparently.) The CPR pro courses teach as Scott describes.
Kent Richards · · Unknown Hometown · Joined Jan 2009 · Points: 81
SpencerB wrote:Does anybody have experience/opinions about the wilderness first aid course offered by awls.org/bwls?
I have no direct experience with them, but the descriptions of their courses, their history (started at University of Utah School of Medicine) look solid. Added to the fact that they're listed on the same Outside Magazine page with WMI, WMA, and SOLO (all of whom I've taken first aid courses from), I'd definitely consider them.
Gunkiemike · · Unknown Hometown · Joined Jul 2009 · Points: 3,492
Jeremy B. wrote: This is correct. Unfortunately the CPR basic courses have dispensed with the concept of checking for a pulse. (Too difficult for the average person, apparently.) The CPR pro courses teach as Scott describes.
This. CPR (Basic or whatever it was I took most recently) = no checking for pulse. If not breathing, commence CPR. I asked about this, as I had always been taught to check for a pulse, and was told, "If they're not breathing, the heart isn't going to beat much longer."
WinstonVoigt · · Unknown Hometown · Joined Feb 2015 · Points: 115

Hey Andre,
Being in DC most of the EMS courses there are going to centered around urban EMS. When I lived and worked as an EMT in DC (MedStar Washington Hospital Center Emergency Dept.). I directed my questions to the National Institute of EMS, I think they're on 14th street. Like what most people on this thread have been saying, WFR or WEMT are going to be the most applicable courses for you. I did WFR through NOLS/WMI in 2005, maintained cert. through 2009, then did EMT in 2010 and I've maintained my National License as well as my state licenses through 2017. (while working in Emergency Depts.)
For general utility, go WFR, you'll learn more about how to get someone stabilized, use your resources effectively, and its way easier to maintain licensure from one cycle to another. EMT is great, but more expensive, time consuming and much harder to maintain licensure (if you plan on doing so).

IMO: NOLS/WMI are gold standard, you will probably have to travel to take the course though (probably somewhere cool!).

-Winston

Kent Richards · · Unknown Hometown · Joined Jan 2009 · Points: 81
Jeremy B. wrote: This is correct. Unfortunately the CPR basic courses have dispensed with the concept of checking for a pulse. (Too difficult for the average person, apparently.) The CPR pro courses teach as Scott describes.
If the simpler version works, it make sense to go with it. The fewer decisions people need to make in an emergency, the better...

I'm curious about cold water drownings, though. I remember being taught that chest compressions when there is a pulse can do a lot more harm because they circulate the cold blood.

Still, maybe the stats show that the average person can't check the pulse well-enough to feel a slow weak pulse anyway, and that with the general population of unskilled rescuers it doesn't make a difference if they check.
Truck Thirteen · · Unknown Hometown · Joined Nov 2011 · Points: 0

Check out his class. It is local to DC. The physician that runs the class is a climber. Great class.

wildmedmd.com/

Truck13

WinstonVoigt · · Unknown Hometown · Joined Feb 2015 · Points: 115

@Kent
The issue with cold water drownings and compressions (or violent bumping/jarring the patient) isn't due to circulation of cold blood. It's due to the irritability of the heart when it's cold. When the heart is cold it is much easier to "piss it off" and send it into Ventricular Fibrillation (V Fib) which will kill the patient unless they're defibrillated. Circulation of cold blood/fluid is actually indicated in certain trauma and cardiac cases because it increased the likelihood of recovery, decreasing the damage done by escaped cellular enzymes and it in turn increases the viability of tissue status/post resuscitation.

With extended periods of exposure to cold the heart rate can drop, for the average Jo, finding a pulse in a cold patient whose vasculature is peripherally constricted is next to impossible. When in doubt, go for the femoral and/or carotid and wait a full 30 seconds. If you don't feel anything, start pumping because either they have a rate that can't support tissue perfusion, or they're in Vfib, which also can't support tissue perfusion (AKA they're dead or they will be soon).

Lee Green · · Edmonton, Alberta · Joined Nov 2011 · Points: 51
WinstonVoigt wrote:@Kent The issue with cold water drownings and compressions (or violent bumping/jarring the patient) isn't due to circulation of cold blood. It's due to the irritability of the heart when it's cold. When the heart is cold it is much easier to "piss it off" and send it into Ventricular Fibrillation (V Fib) which will kill the patient unless they're defibrillated.
That's one factor. Another is that hypothermic patients don't respond to either defibrillation or antiarrhythmics until they're warmed above 92-93 F. Put the patient into VF and you've painted yourself into a corner. So don't do chest compressions unless they are actually pulseless.

There is an issue with circulation of blood though. It's not because it's cold, it's because the blood in a hypothermic patient's extremities is acidotic and potassium-rich. Bring that back into the central circulation, and you trigger VF. That's why you rewarm the core first, and the extremities only after the core is warm. It doesn't contraindicate CPR though. If the patient has no pulse, well...
Kent Richards · · Unknown Hometown · Joined Jan 2009 · Points: 81
Lee Green wrote: That's one factor. Another is that hypothermic patients don't respond to either defibrillation or antiarrhythmics until they're warmed above 92-93 F. Put the patient into VF and you've painted yourself into a corner. So don't do chest compressions unless they are actually pulseless. There is an issue with circulation of blood though. It's not because it's cold, it's because the blood in a hypothermic patient's extremities is acidotic and potassium-rich. Bring that back into the central circulation, and you trigger VF. That's why you rewarm the core first, and the extremities only after the core is warm. It doesn't contraindicate CPR though. If the patient has no pulse, well...
So, is the primary problem that the heart is cold, or is the primary problem that the heart doesn't like acidotic, potassium-rich blood?
TDoyle · · Milford, MA · Joined Mar 2012 · Points: 140

in relation to the cold water drowning discussion, this happened recently:

abcnews.go.com/US/wireStory…

in the words of a WMI instructor: "you're not dead until you're warm and dead."

WinstonVoigt · · Unknown Hometown · Joined Feb 2015 · Points: 115

@Lee
Excellent point!

@Kent
You've named two of the many problems that arise with hypothermic patients. The heart and its conduction are your first tier problems. The temperature makes the heart irritable and prone to converting to dangerous rhythms. Controlling for acidosis and K+ are what are going to kill your patient next. K+ in high concentrations will stop heart tissue contraction (K-Cl is used in lethal injections I believe), and acidosis is secondary to tissue hypoxia (organs and tissues are dying).

You aren't going to control for K/Lactate in the backcountry, that's when your training comes into place....ie: how do you evac this patient?

Em Cos · · Boulder, CO · Joined Apr 2010 · Points: 5

This guy wants to take a weekend wilderness first aid course and I can't believe anyone would recommend that he become an EMT.

I have taken WFA, WFR, and EMT (because I worked as an EMT for years) - as well as lots of recerts.

The EMT course only makes sense if you want to work as an EMT. It is a much larger commitment of time, money, and energy and at the end of it, you will have a lot of skills that are useless in the backcountry, and you will be lacking a lot of skills that could be very useful in the backcountry. For example, EMTs learn about giving patients O2, starting IVs, etc that WFRs won't learn since they are unlikely to have that equipment in the backcountry. EMTs do not learn how to realign shoulder dislocations or improvise stretchers or organize a stretcher carry team, as the EMT training assumes you are within reasonable distance of a hospital. Furthermore, EMTs operate under the supervision of a medical director. They have standing protocols approved by the medical director, and other situations where they will get specific approval in the moment. A fully trained EMT who is off duty cannot legally do many of the things they know how to do because they are not under that medical supervision. So as an EMT, if you are off duty, even if you stumble across an ambulance full of medical equipment, cannot (technically, legally) do much beyond first aid anyway.

I've taken WFA and WFR courses with all the major providers, WMA (wilderness medical associates) was by far the best one I took, but I do think that has a lot to do with the quality of the individual instructor. WFA is a weekend course and is a great place to start if you are new to first aid, and may be all you need if you will be out with one partner on weekend warrior type trips. WFR is industry standard, and if you think you might want to work in the outdoor industry in any capacity it is a worthwhile investment. It is also better, more in-depth training and may be worthwhile on a personal level if you are frequently out on longer trips, or with larger groups, hours or days from the nearest emergency services. Even so, if you are new to first aid, WFA may still be a good place to start - it will give you the basic groundwork to get the most out of your WFR course.

Even if you do want to work search and rescue down the road, I would recommend starting with WFR and not EMT - If you go that road you may eventually want WEMT (wilderness EMT) but to start out the WFR will be far more useful.

Good luck!

dp- · · east LA/ north Orange County · Joined Apr 2012 · Points: 0

You want the four day WAFA (wilderness advanced first aid) from WMA. It's a lot more info than the 2 day WFA. They also have a bridge course if you want to upgrade the WAFA to a WFR later. I think WMI only offeres the 2 day or the WFR, and anything from the Red Cross won't have any backcountry info.

OldRag Rocks · · Rockville, MD · Joined Apr 2007 · Points: 195
Truck13 wrote:Check out his class. It is local to DC. The physician that runs the class is a climber. Great class. wildmedmd.com/ Truck13
That class looks awesome.

Has anyone taken a class with Dr Smith? She has a 3 day class in May that looks really good. Here's her explanation of what the class covers:

"Wilderness Medicine Field Course is a 3 day outdoor intense seminar in Emergency Medicine in the Wilderness. WMFC teaches the physician, the non physician medical provider, RN, ATC, PA, PT, EMT, Police officer and the avid athlete how to apply emergency medicine assessment, treatment, rescue and techniques to the patient in the non hospital environment. The course teaches the attendee how to function in woodland, flat water, swift water, mountainous and steep rock terrain. We travel by running, hiking, rock climbing, mountain bike, flat water kayak and life-jacketed swift water float thru choice Montgomery County, Maryland parks emphasizing skills in that environment. Surgical techniques of emergency suturing, chest tube placement, and surgical airway also taught. See course website at wildmedmd.com See also May 16-18 for a sooner course. Both courses 8am to 8pm each day, provide your own carry along food and beverages and you set up your own nightly accommodations. Syllabus and packing list mailed to fully registered students. "

Looks good right?
OldRag Rocks · · Rockville, MD · Joined Apr 2007 · Points: 195
Em Cos wrote:This guy wants to take a weekend wilderness first aid course and I can't believe anyone would recommend that he become an EMT. I have taken WFA, WFR, and EMT (because I worked as an EMT for years) - as well as lots of recerts. The EMT course only makes sense if you want to work as an EMT. It is a much larger commitment of time, money, and energy and at the end of it, you will have a lot of skills that are useless in the backcountry, and you will be lacking a lot of skills that could be very useful in the backcountry. For example, EMTs learn about giving patients O2, starting IVs, etc that WFRs won't learn since they are unlikely to have that equipment in the backcountry. EMTs do not learn how to realign shoulder dislocations or improvise stretchers or organize a stretcher carry team, as the EMT training assumes you are within reasonable distance of a hospital. Furthermore, EMTs operate under the supervision of a medical director. They have standing protocols approved by the medical director, and other situations where they will get specific approval in the moment. A fully trained EMT who is off duty cannot legally do many of the things they know how to do because they are not under that medical supervision. So as an EMT, if you are off duty, even if you stumble across an ambulance full of medical equipment, cannot (technically, legally) do much beyond first aid anyway. I've taken WFA and WFR courses with all the major providers, WMA (wilderness medical associates) was by far the best one I took, but I do think that has a lot to do with the quality of the individual instructor. WFA is a weekend course and is a great place to start if you are new to first aid, and may be all you need if you will be out with one partner on weekend warrior type trips. WFR is industry standard, and if you think you might want to work in the outdoor industry in any capacity it is a worthwhile investment. It is also better, more in-depth training and may be worthwhile on a personal level if you are frequently out on longer trips, or with larger groups, hours or days from the nearest emergency services. Even so, if you are new to first aid, WFA may still be a good place to start - it will give you the basic groundwork to get the most out of your WFR course. Even if you do want to work search and rescue down the road, I would recommend starting with WFR and not EMT - If you go that road you may eventually want WEMT (wilderness EMT) but to start out the WFR will be far more useful. Good luck!
Thanks Em Cos - that's good advice. I think a WFA is a good place to start and I may have found a good option with the Wilderness Medicine Field course list in my previous comment.

Much obliged to all for their thoughtful responses.
Lee Green · · Edmonton, Alberta · Joined Nov 2011 · Points: 51
Kent Richards wrote: So, is the primary problem that the heart is cold, or is the primary problem that the heart doesn't like acidotic, potassium-rich blood?
Both, really. The former makes it prone to VF and hard to defibrillate. The latter makes it really easy to put someone into VF with well-intentioned attempts to help if you don't know what you're doing.
Em Cos · · Boulder, CO · Joined Apr 2010 · Points: 5
Andre Dahlman wrote: The course teaches the attendee how to function in woodland, flat water, swift water, mountainous and steep rock terrain. We travel by running, hiking, rock climbing, mountain bike, flat water kayak and life-jacketed swift water float thru choice Montgomery County, Maryland parks emphasizing skills in that environment. Surgical techniques of emergency suturing, chest tube placement, and surgical airway also taught.
I don't know anything about this course beyond what I'm reading here, but I would suggest doing more research on it before committing. It does not seem to claim to offer any certification, or be affiliated with any accredited program. I would be extremely skeptical of a 24 hour course with no prereqs that teaches surgical airway, suturing, and chest tubes. That is, 24 hours minus the time taken up by all the running, hiking, climbing, biking, kayaking, and floating.

If you are going to devote the time and money for a 3-day course, I would go with a widely recognized one that will earn you a legit WFA cert. I'm not certain of the legalities and I don't have the time or inclination to research this particular program, but I wouldn't be surprised if you could be in serious trouble if something went wrong after a graduate of this class botched a field tracheotomy. That could definitely be considered operating outside your scope of practice with inadequate training/certification to back it up.
OldRag Rocks · · Rockville, MD · Joined Apr 2007 · Points: 195
Em Cos wrote: I don't know anything about this course beyond what I'm reading here, but I would suggest doing more research on it before committing. It does not seem to claim to offer any certification, or be affiliated with any accredited program. I would be extremely skeptical of a 24 hour course with no prereqs that teaches surgical airway, suturing, and chest tubes. That is, 24 hours minus the time taken up by all the running, hiking, climbing, biking, kayaking, and floating. If you are going to devote the time and money for a 3-day course, I would go with a widely recognized one that will earn you a legit WFA cert. I'm not certain of the legalities and I don't have the time or inclination to research this particular program, but I wouldn't be surprised if you could be in serious trouble if something went wrong after a graduate of this class botched a field tracheotomy. That could definitely be considered operating outside your scope of practice with inadequate training/certification to back it up.
You raise some good concerns. Still Dr Smith seems pretty legit and the course seems much more involved than the WFA weekend course I've seen. I wouldn't expect to come out of the course brig able to do a tracheostomy but it does seem to offer a lot of useful skills.

As far as the cert goes I'm not intending to be a guide or anything so I'm not sure it matters to me whether a cert is offered - really I'm most concerned with getting a few skills that will keep me and my partners a little safer should something go wrong. I likely won't be able to commit to a week long WFR course and right now this looks like the best option.

But would be very interested to here a few more opinions on this course
Kent Richards · · Unknown Hometown · Joined Jan 2009 · Points: 81

+1 to what Em Cos said on several accounts:

We covered tension pnuemothorax depressurization and cricothyrotomies in W-EMT. Now -- even beyond the legal concerns Em mentioned -- with the outdoor recreation I do, I'd rather spend my time learning / practicing for other problems that I'd expect to be more "typical". I don't carry a hypodermic needle in the field, and would aggressively seek other alternatives to cutting a hole in someone's throat or chest with my climbing knife. The instructors (ER doctors) offered to show us suturing, but made sure we knew it was "off the record" because it was out of our scope of practice (even as EMTs).

You'll never be able to learn it all, and some people will die no matter how much first aid you learn. Spend your time on what's going to cover the most bases.

Similarly, the course claims also to cover a lot of outdoor skills. Firemaking, orienteering, water purification, ropes training, high-angle rescue, swiftwater rescue...

Real high-angle rescue and swiftwater rescue trainings are multi-day just themselves. I took a one-day survival course that covered firemaking, emergency shelter, water purification, wild edibles -- and that wasn't enough time to really cover the material well. With all this extra stuff in the curriculum, I don't understand how there could there be much usable first aid taught in this course.

First time through, learn first aid in a classroom setting where you're not also having to deal with logistics, weather, self-care, etc. Then, take the skills out into the field and practice them on your own with the gear you actually have on hand.

Take a separate climbing self-rescue class to learn how to get you or injured climbing buddies out of a bind. High-angle rescue is for SAR and professional rescuers.

Em Cos · · Boulder, CO · Joined Apr 2010 · Points: 5

Agree with everything Kent Richards said.

Andre Dahlman wrote: As far as the cert goes I'm not intending to be a guide or anything so I'm not sure it matters to me whether a cert is offered - really I'm most concerned with getting a few skills that will keep me and my partners a little safer should something go wrong.
Even if you don't plan to work in the outdoor ed field, part of the value of getting a standard WFA cert from a nationally recognized organization is knowing they have a proven track record. My main point is that 24 hours is a very short amount of time. Every WFA, WFR, WFR-recert, and EMT course I've taken was very involved and intense, and WFA was a jam-packed 20 hours just to cover the bare bones first aid basics. Even an extremely basic lay-person First Aid CPR course usually takes at least 4 hours. (btw, do you get first aid/cpr cert out of this? For a 3-day course, you probably should.. which can be useful even if not working in the outdoor industry).

Even in my 10-day WFR course and 15 week EMT Basic course, we did not get up to learning surgical airways and suturing. In a 24 hour course that teaches you those things, and has time to take you hiking, climbing, kayaking, etc... not to mention teaching shelter and fire building, there simply wouldn't be enough time left for a solid, thorough overview of first aid basics.

Andre Dahlman wrote: the course seems much more involved than the WFA weekend course I've seen. I wouldn't expect to come out of the course brig able to do a tracheostomy but it does seem to offer a lot of useful skills.
I think it seems a little too involved. At best, it is an overambitious agenda for the instructional time that you have. My gut feeling is these advanced surgical techniques (as well as the smattering of "survival skills") are included because they are flashy, they will entice people to sign up. I'm sure it would be a very fun weekend but I am doubtful you will come out of the course with the useful skills you are hoping for. You may even end up worse off than taking no course at all... you know the saying a little knowledge is a dangerous thing? Well on that timeline, I don't see how you could possibly learn enough about high angle rescue, swift water rescue, or first aid for it to be anything but a VERY little, dangerous knowledge.

All that aside, ask yourself what your goals are. You said you wanted to learn some first aid skills that will serve you and your partner while on climbing trips. Do you, then, want to waste any of the time and money you've devoted to that goal learning to build a fire? Learning swift water rescue? Standing around while many of the non-climbers in your first aid class learn how to put on a harness and rappel?

Take a WFA course that focuses on first aid. Separately, take a climbing self-rescue course. High angle rescue (even if it could be taught well in half a day) has many overlapping skills but assumes a fundamentally different context and goals than self- and partner-rescue. And, if you can, get your partner(s) to take these courses with you. None of these skills and knowledge will help you if you are the one that gets clonked on the head (as I learned myself the hard way once.)
Guideline #1: Don't be a jerk.

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