Wilderness medicine training: When have I actually applied it?

Originally published June 3, 2019.

This past weekend I took my biannual wilderness first responder (WFR) and CPR re-certification courses. Between refreshes on the patient assessment system, prerequisites for a FSA, and rescue breaths, I thought about the instances over the past eight years when I’ve had to apply my training.

As a new WFR in 2011, I remember being intimidated by the number of medical scenarios for which I’d been “trained” (with 80 hours of classroom-only instruction). For those who feel similarly, or for those who are interested in the operations of an organization like mine, I thought I would share my experiences. By the end of the 2019 season, we’ve run exactly 100 trips with about 750 total clients.

For the sake of patient confidentiality, I have changed the client names unless noted.

Context

The medical situations I have encountered are partly a function of my:

• Role,
• Clientele,
• Trip length, and
• Locations.

I guide backpacking trips, and specialize in high routes and long-distance trails. My clients tend to be 30- to 60-years-old and in above-average fitness, and skew male by a 2:1 margin. My trips are 3 to 7 days long, and I run them mostly in the Mountain West, and sometimes in Alaska and the eastern woodlands.

If you will be leading, say, month-long canoe trips in the Boundary Waters with at-risk teens, your experiences will probably be different.

Trends

I don’t keep a detailed record of every blister, sprain, and evacuation. Anecdotally, at least, I think our safely record has steadily improved, which I attribute mostly to:

• More stringent vetting of clients, to ensure that we have like-abled groups and that every client is reasonably qualified for their trip;
• More experience around clients, enabling us to recognize telltale warning signs and to know the limits of our clients better than they do; and,
• Greater familiarity with the terrain, conditions, hazards, and common itineraries of our go-to locations.

What do these factors have in common? They’re all preventative. Unforgivably, in my opinion, the NOLS WFR curriculum omits any discussion about ways in which medical situations can be avoided — it’s entirely reactive.

Evacuations

I’ve had five medical evacuations, only one of which was assisted.

Phil had a detaching retina, which was unrelated to the trip. We evacuated him at a road crossing a day later.

Ethan strained his knee while crossing a wet rocky moraine in Alaska. We self-evacuated by packrafting down the Little Delta River.

Jennifer experienced an intestinal blockage, which had happened to her six months earlier, too. We slowly walked her out to a nearby trailhead, and her partner drove them to a nearby hospital. Years later, she was diagnosed with Crohn’s disease.

Paul suffered a deep cut on his heel when a nearby boulder shifted, wedging his foot. I think I could see his Achilles tendon. He heroically self-evacuated, which involved a 25-mile hike with 5,000 vertical feet of gain, and then drove himself to the hospital.

Vic (real name, with permission) severely strained his lateral collateral ligament (LCL) when he stumbled on a washed-out trail and hyper-extended his knee. A helicopter evacuation was necessary due to his shock-inducing pain and our location in the upper Kern River, where we were separated from the nearest trailhead by 20 miles and a 13,000-foot pass.

Finally, Charles from Ohio came down with debilitating acute mountain sickness that led to severe dehydration/malnutrition. His symptoms started on Day 1 (10k), subsided fully on Day 2 (7k), returned on Day 3 (<10k) and remained bad on Day 4 (9k) and Day 5 (<7k). We exited a day early in Yosemite Valley, where he bounced back quickly thanks to an IV saline injection.

Run of the mill

The prospect of another evacuation (or worse) makes me anxious, sometimes to the degree that I think about closing my program. Thankfully, they’re the exception, and most of our medical issues are easily manageable.

Feet

The worst blisters I’ve seen belong to Guy. He developed hot spots on the first afternoon, but we didn’t address them until camp. There, I found deep quarter-sized blisters on both forefeet, and swore to never make that mistake again. Guy was remarkably tough, and still managed to finish a 7-day John Muir Trail thru-hike.

Maceration is common on wet trips. Most clients are familiar with my recommended treatment, and guides are good about forcing clients to stay on top of it.

Aches, pains, and overuse

Few of our clients arrive already trail-hardened. Most are professionals, have families, and are involved in their community. Their training time is limited, and thus mostly restricted to short-but-intense exercise (e.g. running, HIT workouts, yoga). They’re unaccustomed to spending long days on their feet and carrying an overnight kit.

To prevent and address ensuing aches and overuse injuries, we recommend a personal supply of ibuprofen, and we moderate their effort early on so that they don’t fall apart after the turnaround. Sometimes I also ask every client to specify their biggest physical complaint and to assign a pain rating (out of 10), which gets better results than simply asking, “How does everyone feel?”

The most common debilitating overuse injury has been tendentious along the IT bands. I can think of three cases: Tanner, Mike, and Chris. With Mike and Chris, it was known beforehand, and unfortunately it flared up despite precautionary measures, resulting in some uncomfortable mileage. With Tanner, I take part of the blame — it occurred before I learned to govern groups for the first half of a trip — when clients are fresh, they want to charge hard, and not everyone is good about checking their egos at the door.

Hydration & nutrition

I have no notable stories about dehydration. My best prevention tactic is periodically asking clients when they last peed. When seven clients report peeing at lunch or even more recently, and one client reports last peeing at the trailhead, it’s clear who needs to drink more.

Nutrition seems best managed by watching for changes in a client’s personality or performance. A lack of calories could explain why, say, a normally pleasant client seems slightly agitated, or why a front-of-the-pack client gets dropped on a climb.

Two clients have tried to follow strict keto diets, and both Sam and Sawyer bonked hard after a few days. It seemed as if their bodies lacked the necessary fuel for full functionality, so they were shadows of themselves. The solution was having them trade their jerky and pork rinds for the chocolate and Fritos that other clients had.

Insects

Heavy mosquito pressure has been a non-issue because we:

• Researched the conditions beforehand and knew what to expect;
• Wore headnets and full-coverage permethrin-treated clothing;
• Hiked and camped where the bugs were less bad, like atop ridges and on open gravel bars.

Five years ago Bob, Samantha, and Adam all contracted Lyme disease after a May trip in the Blue Ridge Mountains, and thankfully were quickly treated. On our more recent West Virginia trips, we alerted clients to the risk, recommended precautions (e.g. repellents and permethrin-treated clothing), and tried to steer clear of tick-infested areas like meadows. I can’t say if these measures made a difference — it was unseasonably cold and wet, and we didn’t find a single tick.

Strains, sprains, breaks, and cuts

Rhett hyper-extended his knee slightly on Stanton Pass, which we pushed over before dinner on Day 2. To further illustrate our erred judgement, an hour later Bill scraped his shin on sharp talus, cutting through most of the skin. We should have just saved the pass for the next morning, when we would not have been tired.

On an off-trail descent Matt badly sprained his ankle, which we taped for extra support. Interestingly, the incident occurred after the most difficult section. I regret not stopping the group after that part and forcing them to refocus.

After Paul was badly injured (discussed above, one of our evacs), the group was shaken and in a mild panic — it seemed urgent to get Paul out quickly. We divided up Paul’s gear and began descending rapidly down a tight canyon that involved multiple crossings of a small creek. One client, Bill, was carrying his own backpack and Paul’s near empty pack, which made for an unwieldy load. He slipped during one of these crossings and landed hard on his hand. We splinted it later that day, when it became clear to Bill that he could not just simply walk off the pain. A post-trip X-ray revealed that he’d broken two or three metatarsal bones.

There’s a lesson there: After an emergency, check your level of panic and that of the group, and bring it back to near-normal to avoid a subsequent emergency.

Altitude

At our Mountain West locations, the trailheads are at 7,000 to 8,500 feet, and all the trails climb higher. I learned quickly that clients would need to acclimate more cautiously, especially if they lived at sea level. In two out of my three trips in 2011, clients developed acute mountain sickness:

• Ben from Missouri threw up his dinner on the first night,
• David from Oklahoma was nauseous for most of the second day, and
• Kayree from Ohio was a walking zombie after we hit 10,000 feet.

The number of altitude-related issues has declined, because most clients now arrive at least two days early, giving them full days to acclimate and work through the initial symptoms (e.g. headache, fatigue, restless sleep). But they still happen. For example, in 2018 Rick from Seattle responded badly and had to be walked out, despite acclimating properly.

Giardia and GI distress

The guides carry a group supply of Aquamira drops, which in my program has achieved excellent results. Only five clients have developed giardiasis, always after returning home and always after admittedly drinking unpurified water, intentionally or accidentally.

Katie and Elizabeth developed flu-like symptoms (e.g. muscle aches, weakness, diarrhea, fatigue), presumably contracted from another client or from another traveler. The solution was over-the-counter medications and rest, and a day-hike for everyone else, which gave them an opportunity to recover and finish the trip.