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.


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.

I offer 3- to 7-day backpacking trips, mostly in the Mountain West.


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.


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.

Vic badly strained his LCL during a stumble on a washed-out trail, and is my only client who has needed a helicopter evac.

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.


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.

Guy developed bad forefoot blisters on Day 1. We should have stopped to address them earlier, but instead waited until camp.

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.


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.

Alan warms himself over our campfire in Alaska. We’d intentionally camped on the open gravel braids, where the wind kept the mosquitoes at bay.

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.

Thirty-six hours after Matt sprained his ankle on an off-trail descent, it had become very bruised. With supportive tape and caution, he finished the trip.

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.


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.

Disclosure. I strive to offer field-tested and trustworthy information, insights, and advice. I have no financial affiliations with or interests in any brands or products, and I do not publish sponsored content

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Posted in on October 1, 2019


  1. dgray on June 3, 2019 at 3:41 pm

    I’m curious if you use some kind of PLB on these trips, and if so do they change the dynamics in deciding about how to evacuate? I find it interesting that 3 out of 4 evacuations did not choose to push the button despite fairly serious sounding incidents. Is this a financial issue? Pride? Not wanting to endanger rescue personnel when you could make it on your own? Thanks for any insights as I think through these issues myself.

    • Andrew Skurka on June 3, 2019 at 4:24 pm

      Good question. On all of my trips, guides carry satellite communication, either a satellite phone or inReach, or both. With that, we can coordinate with medical providers, land agencies, and rescue teams.

      If you can self-evac, that’s preferable, because evacuations put others at risk. Two out of the four were easy self-evacs — there was no threat to life or limb, and the patients could move under their power. The Achilles incident was iffy — there were concerns about infection and mobility. But helicopters were unavailable (they were plucking people off Half Dome to escape a fire) and so we were on his own. Thankfully, Paul retained mobility.

      The strained LCL was an insignificant injury, far from being life threatening. But we had no practical means of getting him out. Vic was immobile, and he went into shock both times that we moved him, each only 200 yards at a time — once to a campsite, and again to an opening big enough for a helicopter. No way was he going to ride out on a horse.

      • Dæv S. on June 4, 2019 at 7:39 am

        Good article. Interesting you’ve not had encounters with snakes, spiders, and other creatures requiring first aid

        What are your thoughts on search and rescue (SAR) insurance and medical transport costs? ie: Did your client get billed for a chopper rescue? I’ve purchased a COSAR (Colorado SAR) or Hunters/Fishing Licenses, but $$ med evac is not covered per link. https://drive.google.com/file/d/1Ez8AgVPX6K5ytGCmwGK3KRpDO3juBSWG/view

        • Andrew Skurka on June 4, 2019 at 7:59 am

          Its not surprising that I’ve had no issues with snakes or spiders — most of my trips are run at elevations above their habitat. I see rattlesnakes occasionally on the foothills trails where the mountains meet the plains at ~5500 feet, but never in the higher mountains. The only snake I’ve seen in the High Sierra was at 5,000 feet, a few miles outside Road’s End in SEKI.

          It’s bad policy to consider the evacuation cost when considering the appropriate evacuation method. That said, the cost of rescues in the US does not get passed on to the victim, unless there is gross negligence involved. SAR groups do not want to discourage people calling for help when they need it, and most SAR groups are funded with federal, state, and/or local appropriations that assume some amount of response costs.

          For each location where we guide, we have developed an emergency protocol that lists SAR contacts (among other things). It’s good info to have on-hand when you need it.

        • Roger on June 6, 2019 at 9:40 am

          I have dive insurance that covers evac through DAN. I just hiked 5 days down in Grand Canyon. I called before we arrived and they let me know I was covered if I had to be helicoptered out of the Canyon. The piece of mind was great.

          And since I spend many weekends a year 15-40 miles off shore, murdering fish with a speargun and way out of range of self-rescue having insurance like this is the ONLY responsible thing for me in my opinion.

          I should look to see if coast guard bills for rescue. I assumed they did.

  2. Michael on June 3, 2019 at 5:45 pm

    Is your FAK PDF from 2016 pretty much unchanged or have you made changes from what you’ve learned the past 3 years?

    • Andrew Skurka on June 3, 2019 at 7:05 pm

      It’s pretty unchanged. In fact, I use those lists every time that I prep my first aid, foot care, and repair kits.

  3. Travis Briles on June 4, 2019 at 12:48 am

    I’ve always wondered…is part of the reason your personal and guided trips been overwhelmingly in North America because it would simplify a rescue should it come to that?

    • Andrew Skurka on June 4, 2019 at 8:12 am

      Keeping my trips in North America (and specifically the US) is much more of a business decision than a liability decision.

      If I offered international trips, I run into issues with logistics, taxes, and insurance; and the price becomes prohibitive to many more people.

      Things get more complicated when I run trips out-of-state. Specifically, I have to fly, not drive; I need to ship or fly gear and food; I have to register file taxes in another state; and I must comply with payroll regulations of a different state. But out-of-country trips escalate these complications to another level.

  4. James Lantz on June 5, 2019 at 8:21 pm

    Thanks for all the info. It’s great to hear that SAR does not pass down the cost of an evac to the hikers. I would not have known.

    What do you carry in your first aid kit? Is there any items that you found that you use more than others? Does it change based on where you hike?

  5. Geoff on July 10, 2019 at 2:48 pm

    Andrew, thanks for all of this great info. I’m wondering if you’ve had any close encounters with lightning and how you counsel your groups on navigating the frequent summer afternoon thunderstorms in the Rockies and Sierras.

    • Andrew Skurka on July 10, 2019 at 3:07 pm

      No notable close encounters with groups. We manage it in the conventional ways: rise early, get a bunch of miles done in the morning, adjust the route or itinerary if the skies are looking crappy.

  6. Jeff on April 6, 2020 at 7:34 am

    Hi Andrew,

    Regarding client vetting, are there fitness/conditioning standards that you suggest to prospective/hopeful clients on future hikes? Besides hiking more, as our trails are closed right now, I’m looking at a way to stay fit and be ready for longer trail days this and future summers and hopefully a guided trip with you. I’ve tried searching your page but it looks most of the training articles are geared toward ultramarathonning 🙂

    Best regards,

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