Wilderness First Responder Course

Yellowstone National Park at the Lamar Buffalo Ranch
January 2-11, 1999

Aras Kriauciunas
 

In August of 1998 I was reading a Backpacker magazine article which talked about the importance of having good first-aid training when in the backcountry. In an urban environment, skills are often limited to calling "911" and waiting for the ambulance to arrive. Even at the more advanced levels of certification, training is primarily concerned with packaging the patient for rapid transport to an emergency room. Adventuresome groups often find themselves several days from advanced medical assistance, meaning that whatever situations arise must be dealt with independently.

An accident in 1975 led to the development of modern wilderness medicine. A boy had become injured on Mt. Washington in New Hampshire. His arm was so severely fractured that he lost circulation to his hand. By the time he was transported to the hospital, the hand had to be amputated. The emergency-room doctor said that the hand could have been saved if the boy’s arm had been straightened in the field (thus restoring circulation). Frank Hubbell, a paramedic assisting with the rescue, decided a need existed for advanced training in this area. He went on to found the Stonehearth Open Learning Opportunities (also known as SOLO), which was the first wilderness medicine school in the nation.

As mentioned above, there are several fundamental differences which distinguish backcountry medicine from traditional (front-country) medicine. These are as follows:

• Professional medical care (e.g., hospital emergency room) is much further – often several days.
• The environment may be more severe (temperature, terrain, limited access to water).
• Lack of specialized equipment, often forcing improvisation to handle a given situation.

Several standardized levels of training are currently available. They range from a weekend First Aid course to the Emergency Medical Technician level (the front-country equivalent would qualify you to work with an ambulance crew):

• Wilderness First Aid: (16 hours / 2 days. $100-$200) This is the standard introduction to backcountry medicine: patient assessment, trauma, environmental concerns, some wilderness rescue, and equipment improvisation. The majority of the time is spent on concepts, with practice time taking a secondary role.
• Advanced Wilderness First-Aid: (36 hours / 4 days. $200 - $400) This class builds on the WFA class, with more time devoted to practice.
• Wilderness First Responder: (80 hours / 10 days. $400 - $750) Patient assessment and treatment skills are presented with greater emphasis on practice. A lot of time is spent on practical scenarios. The WFR (pronounced "woofer") course is the standard certification required for wilderness guides and outdoor leaders who work for organizations such as the National Outdoor Leadership School (NOLS) and Outward Bound.
• Wilderness Emergency Medical Technician (EMT): (180 hours / 3-4 weeks, $1500-$1800) Instruction is aimed at rescue-team members, backcountry rangers and medical professionals who work in remote settings.

The three largest, most widely respected, schools are:

• SOLO (www.stonehearth.com)
• Wilderness Medicine Institute (www.wildernessmed.com)
• Wilderness Medical Associates (www.wildmed.com)

After looking at the information offered by the schools (via their websites), I found a course offered by the Wilderness Medicine Institute (WMI) at Yellowstone National Park. The sponsor was the Yellowstone Institute, which was sponsoring the class at its Lamar Buffalo Ranch. This ranch, which takes its name from its role in raising the buffalo to repopulate the herds in Yellowstone, consists of a group of tiny cabins and a large bunkhouse (which contains the classroom, kitchen and bathroom/shower facilities). It is located in within a secluded setting in the northeastern part of the park.

After registering, I received my introductory packet. In addition to containing an outline of the course material and schedule, it noted that weather does not determine the class schedule, and that the lows at this time of year are often –20F or –30F. Also, I needed to provide either snowshoes or cross-country skis to be used in the final rescue scenario. This was clearly not going to be a "theory" course.

The next morning class started promptly at 8am. The student group was diverse. From Alaska and Montana we had a few professional guides (two of who worked for companies dealing with troubled youth). One student had traveled from Sweden for the class – she needed the certificate to work for an adventure kayaking company. The majority of the remainder were students at the University of Montana at Bozeman. Representing the midwest were an engineer from Iowa (me) and a chemist from Indiana.

The class was taught by two instructors. Lance Taysom drove down from Idaho, where he works as a nurse in the Emergency Room. He is also a Flight Nurse, and has been teaching EMT classes for 9 years. Jeff Holmes, from Utah, is an EMT-B who is taking a year off before continuing on to medical school. Both of them brought a tremendous amount of expertise to the class. WMI is very selective when hiring new instructors – the acceptance rate is in the 3%-5% range. Given the published requirements for submitting an application (EMT & wilderness medicine background), their instructors are among the best in the business.

Our first priority was to learn about patient assessment. In order to provide patient care following well-defined protocols, accurate and complete assessment of the patient is vital. This includes obtaining information about the accident (also referred to as the "Method of Injury", or MOI), nature and severity of suspected injuries, as well as general background information (allergies, medications, and previous history of similar injury).

At the start of the class, we worked in pairs to simulate an injury, and our partners had to diagnose the injury based on their assessment techniques. The interesting thing was that we had not yet been taught how to do anything else. This meant that we would report that the patient was suffering from a broken rib, which was really too bad, since it looked painful but there was nothing we could do about it.

The remainder of the day was spent learning about emergency breathing and CPR. As part of our review of the circulatory system, we also learned a lot about shock – its causes and treatments. Understanding the reason WHY shock occurs made it fairly straightforward to predict it and initiate treatment as our scenarios became more complex. A major advantage of this course was that it taught why the body reacted as it did. Thus, our skills were not limited to rote memorization, but rather, to the understanding of fundamental principles which we could then adjust to fit our particular scenario.

The third day of the course continued to build on what we had already learned. We were introduced to what was the third fundamental rule in providing backcountry healthcare – management of spinal cord injuries. When dealing with a patient who has suffered a traumatic injury where the potential for spinal injury exists, the existing treatment protocol states that you must act as if such an injury has in fact occurred until you can ascertain otherwise. We learned how to move people and put them into a litter (a basket used for carrying people in the backcountry) for transport. To make things more interesting, our scenarios were now starting to move away from the parking lot into deeper snow.

After the third day our foundation was complete. This consisted of how to approach the patient/accident scene, completing a patient assesment and maintaining perspective of priorities when caring for a patient. This is particularly important in the wilderness, where exposure to the elements carries more importance than it would in the city, since fewer options are available to reverse the effects of severe cold (or heat). The remainder of the class was spent discussing the myriad of things which could happen to the human body, and what options were available for recognizing and treating these problems. (The list of topics covered appears at the end of this writeup).

It is worth noting that the course diverged here from the training received in a typical frontcountry Emergency Medical Technician - Basic (EMT-B) course. Although the fundamentals are the same (patient assesment, care of potential spinal injuries), the remainder of the course for the EMT-B concerns itself primarily with buying enough time for the unstable patient to get them to the Emergency Room. A general goal of the EMT-B is spend AT MOST 1 hour with the patient, preferably much less. In a backcountry situtation, things are just starting to get really interesting. Part of the difference is due, of course, to the different types of problems and general physical fitness encountered while in remote areas. Nonetheless, the EMT-B is taught NOT to diagnose a patient (that is the job of the Emergency Room physician), while the Wilderness First Responder is taught that a correct diagnosis is important so that an appropriate response may be effected (continue on, send a runner, call for a helicopter evacuation, etc.).

The concepts learned in the classroom were reinforced through practical scenarios. In general, the difficulty of handling a scenario had a lot to do with the location. In the classroom, where it’s bright and warm, even the most difficult injuries were fairly straightforward. It was slightly more difficult to handle problems outside in the parking lot because of the cold snow and blowing wind. The challenges grew a little bit when the "victim" was found in the deeper snow (i.e., not on a plowed surface). Care had to be taken not to lose any equipment, and to maintain focus on patient care (versus on how cold your hands were getting trying to build a leg splint). One notch higher up were those scenarios which took place after then sun had gone down. Your sole source of illumination was from the headlight strapped to your forehead. The most challenging were those which took place far from any trails, and involved additional challenges such as a steep hillside. And, of course, they were at the end of the day when the students were tired and it was very dark!

One of the more surprising scenarios was after we had completed the section on hypothermia. This was in the morning, and we had gone outside to do a practice scenario soon afterwards. Since the emphasis was on technique, we improvised with the things which were not handy (e.g., food, hot chocolate). These we had pretended to give to the patient, much as a young child pretends to serve food at a tea party.

In the afternoon, the instructors decided to break us up into three groups. One would consist of all of the women, while the men would make up the two remaining groups. Also, we were told to make this rescue as realistic as possible. Thus, if we would normally provide hot chocolate, we needed to be sure to have hot chocolate available. The class met outside, fully armed with hypothermia rescue gear. Lance asked if anyone was not ready. All was quiet. He then announced that our patients would "present themselves". On this cue three students jumped into the creek, and started running and splashing away from the group. After enough distance had been covered to separate the three groups, they stopped and flopped down in the stream. The rest of the class stood there, bewildered, finding it hard to believe what they had just seen. The instructors yelled, "Go! Go! Go! There are your patients!!"

We ran down and pulled our patient from the water. We rapidly removed all of the wet clothing and placed our patient into two sleeping bags. The shivering was not simulated, and our team worked rapidly to warm up our patient. The exercise was valuable, and underscored the practical difficulties in treating such a patient. For example, it is much easier to simulate undressing a wet and shivering victim than it is to do it for real (wet clothes stick to the patient). This is the type of practical experience which simply cannot be obtained in a classroom setting.

At the halfway point in the course, the students were getting tired of studying and practicing all day. This was pretty typical, and coincided with our free day. Class was officially over at 5:00. The class drove out to Cook City (20 miles, which took about 45 minutes on the icy roads) for dinner. Good beer and pizza was accented by some friendly pool games. On the way home I had to stop a few times for moose and elk in the road. Not the sort of hazards one typically sees in the midwest.

Two other students joined me early the next morning to go look at the wildlife. The Lamar Buffalo Ranch sits in the middle of the Lamar River Valley, which has been termed the "Serengeti of North America". In the wintertime the vast herds of elk, buffalo and moose come down from the mountains to where the weather is not quite so harsh. As the week progressed, more and more appeared every day. We had not seen any coyotes or wolves, and were hoping to spot some that day. Although this did not happen, it was very impressive seeing the huge herd of elk (several hundred) and buffalo roaming around in the wild. Unlike a zoo where the fenced in area is only a few acres, here they had miles and miles of open field to roam in.

After breakfast the majority of the class drove back out to Cook City for a variety of winter activities. Small groups formed to do telemark skiing in the backcountry, snowshoeing, sledding and snowboarding through the trees. I opted to try my new snowshoes out, and hiked up the side of a mountain with the snowboarding group. We followed a snowmobile trail which wound its way through the woods. Near the top, I descended straight down. The snow was around 6-8 feet deep, and so it was important not to fall down, since it would be difficult to get back up. Walking down was very similar to walking down the side of a sand dune. Lock your foot out, and dig in with the heel when landing. Big steps, let the snow cushion the landing. A lot of fun! I was very surprised at how fast I came down from the mountain.

Our day off was much different than what the WFR class had experienced a year ago. Lance was the instructor then as well, and told us the story. Two of the students had opted to rent snowmobiles, while the rest of them were telemark skiing. They were still in town when the alarms went off, so Lance took his group of students to the Fire Hall, which was the focus of any crisis. He introduced himself, and asked if they needed any help. The ranger indicated that no help was needed at this time. Listening in on the radio, he heard that there had been an avalanche, and that several snowmobilers had been caught in it. There were three people buried in the snow.

Lance explained to the ranger that he was teaching a Wilderness First Responder class, and that him and his students would be able to help if they were on the scene. When they arrived, Lance discovered that one person had already been uncovered (he had been buried about 8 feet down). Two people were busy providing emergency breathing and CPR. As Lance came closer, he saw that they were the two students who had rented snowmobiles. Everything was ok, so he continued up the hill to look at the other two victims. One had just been uncovered, and so two more of his students initiated CPR. Unfortunately, the three victims had been buried for about an hour. Given their high level of exertion at the time the avalanche hit, there was no chance of hypothermia to slow down their bodily functions. All of them died in spite of receiving excellent care from trained personnel immediately upon being recovered.

This story was a good sanity check to our enthusiasm. It is one thing to participate in practice scenarios, another altogether to be the first recuer at the scene of an accident. As I spent my free day snowshoeing, I wondered how well I would perform if I came upon a real accident...

The next morning we were back in class. Lance came up to me as I was getting ready to go outside and asked me if I wanted to be a "surprise victim". I told him that was long as I did not have to run into a creek I was ok with it. He gave me a syringe full of fake blood and told me to fake a nosebleed during the morning meeting (which was held outside). Once we were outside, and he gave the cue, I hid the syringe in my hands and acted like my nose had started bleeding. By the time we were finished, my hands were dripping with blood, and my face was a mess. As a bonus, the class learned how to treat a bloody nose.

Our confidence level was growing, and in the afternoon we were given a group of case studies dealing with emergency situations at high elevations. We read through High Altitude Cerebral Edema (not enough room for the brain in the skull due to swelling) and High Altitude Pulmonary Edema (lungs fill up with fluid) problem reports. Sitting in the classroom, it was easy to perform a diagnosis and rescue plan. "Move the patient to a lower elevation" – this might not be so easy if you are on an icy ledge at 18,000 feet and a storm has just come in, reducing visibility to zero. In a warm classroom, however, it’s pretty easy to do.

One our most interesting scenarios came at the end of a long day. Our instructors told us that this would run over the allotted class time by at least 30 minutes, and so they were going to make it an optional exercise. Everyone chose to participate, since this is how we really learned things. We had 10 minutes to get ready, then we would be briefed.

When everyone was outside, we were told that an avalanche had taken place on the hill nearby. There were three victims. Our job was to find them and treat them for their injuries.

I arrived at the command center with rescue equipment, and was told to head up to the left, where two groups were already conducting an initial patient assessment. I climbed up the hill and found Asa, the Swedish student, working on a patient who had broken her leg. We started working on a splint. The patient up the hill had more severe injuries, and was carried out past us on a litter by a group of students. It looked pretty challenging to haul something like that down a steep hill.

We decided that Deanne, our patient, could be moved on a sled, which was easier since it required fewer people and did not tie up the litter which was needed by the third team. After moving her down, Asa and I moved up to help the last team. Their victim had suffered severe injuries. Rescue breathing and CPR had been ongoing for about 30 minutes when we arrived.

We moved the patient, who was on a backboard, to a litter for transport. As we made our way down the hill, we stopped every ten paces to resume CPR. After pausing for about 30 seconds, we picked the patient up again and moved another ten paces. Although it took a lot of effort to move someone in this fashion, it was required since patient care needed to be continued. Amazingly enough, when we arrived at the command center, the patient coughed and was able to resume breathing on his own. It is hard to say for sure, but maybe it had something to do with Lance announcing that the practice scenario was over.

As the end of the class drew near, there remained a few hurdles. The practical and written exams on the last day were going to be a challenge. A lot of information had been presented, and some of us were regularly up until midnight reviewing and studying in order to absorb it all. On top of that, the night before the final exam was going to be our "Mock Rescue Scenario". Given the type of practice scenarios we had performed already, there was some discussion as to how intense this might be.

Our instructors announced that the mock rescue scenario was intended to give us a feel for long term patient care. The scenario was that we were out on a day-hike with some hiking partners whom we did not know very well. A patient would "present themselves" and we would have to care for them. Since no timeframe was given, we should be prepared to stay out all night providing care.

Class let out at 4:30 that day. We had exactly one hour to get our gear together, have it loaded in the two vans which would transport us and eat dinner. People were scrambling around, conferring with their teamates (group size was 4) and trying to eat as quickly as possible. At 5:30, the vans were being loaded and we were on the road by 5:40. A lot of nervous tension. The instructors had indicated that we were not going to stay out all night, but at the same time, they were a bit vague as to how long the scenario would continue.

My group consisted of myself (wearing snowshoes), Gavin (a professional guide wearing telemark skis), Dan (wearing cross-country skis for the first time) and Erin (wearing only boots because she had not received that packet telling her to bring gear for the rescue scenario). We followed Lance into the woods. Dan was encountering a lot of problems with his skis (i.e., he kept falling down). Erin was ok as long was we were on a trail – when we broke off to the side, she consistently dropped into the snow up to her waist. Progress was slow. I took the lead, looking into the trees for signs of our patient.

I was a bit in front in when Gavin cried out in pain. – he had placed his ski wrong and severely twisted his ankle! I rushed back to see what was going on. He had placed his ski wrong and severely twisted his ankle! We realized that we now had a victim, and we knew how to handle this scenario. After performing the full patient assessment, we diagnosed a compound fracture of the tibia (lower leg). A piece of "bone" was sticking through (apparently applied by Lance an hour earlier). Traction was applied to reset it, and we splinted it.

The next order of business was to build a shelter for the night. I found some trees nearby to provide shelter, and scooped out the snow in between. Unfolding a sheet of heavy-duty plastic on the top (over skis and poles) provided a snug shelter. We moved Gavin in, and were all sitting pretty snug when Lance showed up with a photographer from a Wyoming newspaper to see how things were going.

When we got back to the ranch, all of the students had fun talking about how their scenarios had unfolded. One group had simply built a shelter around where their patient had fallen. Another had built a nice fire to warm everyone up – this is where the reporter and photographer ended up. The consensus was that it was a lot of fun, and educational to realize how much we had learned. Two weeks ago my first-aid expertise consisted of applying a band-aid, and now I was pleased that the injury I was treating was "only" a compound fracture of the tibia.

The next morning it was "show time". Our written examination consisted of 100 questions. While this was in progress, students went out in pairs to take the practical final. The task was to arrive on the scene, diagnose and treat the patient correctly observing all of the wilderness medicine protocols we had learned. If we made a crucial mistake early on, the instructor would point it out and we would restart (i.e., no need to fail the exam because of test jitters). If mistakes were made during the exam (e.g., a splint was not tight enough), the opportunity would be presented to retest. If a student failed to pass at this point, no more retesting would be performed today. The only option was to schedule a retest within 6 months at another WFR class. Even though we knew the material very well, there was always the possibility that we would forget a step because it was a "pretend" emergency.

Our patient, Jeff, had fallen while rock climbing. A physical examination revealed a fractured tibia (bone in the lower leg). We improvised a fixed leg splint from a mattress pad and some webbing. After we had taken some vitals, he asked us to describe how we would move the patient to a hospital, as well as any problems we might expect to encounter. Overall, the test was one of the easier scenarios we had to solve – the fact that it was pass/fail was the most challenging aspect.

After the written exams were graded, the class ended. I was now a Wilderness First Responder!
 
 

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