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Sunday, May 24, 2009

TEOTWAWKI Medical Skills: Thoughts on Becoming a "Woofer" (Wilderness First Responder), by Richard B.

Most people I know prepare for medical emergencies by buying a first-aid kit, maybe taking a class, maybe buying some additional supplies, and calling it good. In an urban setting we typically expect to have professional assistance in less than an hour, but natural or man-made disasters could change this to days, weeks, months – or longer. I often work and play outside – skiing and motorcycles, construction and heavy-equipment, and off-grid living. I’ve fallen from horses, bicycles, and a roof. I live in earthquake and volcano country, and I’ve helped raise three sons.

I’ve been motivated for more than 40 years to be ready for whatever comes my way – “expect the unexpected”. And part of my prep has led me to study “improvisational backcountry medicine”.
In an emergency, providing medical care requires knowledge, practice, equipment and supplies, and the right mind-set. Emergencies are charged with emotion and unpredictability. In this brief commentary I’m advocating two things: investing (time/money) in a comprehensive training program that provides hands-on, real-world scenarios, and then, putting together a full kit that will meet the needs of your current or probable family/community, and allow you to fully utilize your skills.

As a teen--in the 1960s--I took Red Cross courses (First Aid, Lifesaving, and Water Safety Instructor). Then the Army sent me to Vietnam for a couple of years where I had the “opportunity” to get some up-close and personal trauma-care experience. A decade later I went to back to school and earned a nursing degree. And just recently I took a Wilderness First Responder (WFR or “woofer”) class, eighty hours of realistic instruction and practice with dozens of what-if scenarios (medical and trauma). Without question the WFR is the best program I know for a 360-degree approach to survival medicine.

Wilderness First Responder – The Training

A Wilderness First Responder is an individual who has completed a structured, accredited training program and passed both a written and practical exam. Most of the people I trained with had a professional motivation – they work for an organization that made the WFR credentials a requirement of employment. Our group included river-rafters, mountain climbing guides, “executive training retreat” leaders, a couple of Emergency Medical Technician (EMT)s, and Search & Rescue (SAR) volunteers. The program is designed to help you deliver individual medical-delivery skills, but just as importantly to be an effective team-member or even the medical leader (“chief medical officer”).

My class was hosted by The Mountaineers in Seattle, and conducted by Remote Medical International (RMI). There are other good providers, all over the country (and the world). The orientation of my program was wilderness recreation, but my interest is living and working off-the-grid and the training was perfect for that, also.
In class we defined “remote medicine” to mean that you have limited equipment and supplies, you’re an hour or more from additional help, and you may be the only one providing care – or your helpers may know little or nothing, and may even impede you. You are the one in charge, the one responsible. Think about the implications if the individual needing help is you, or someone you love. And then make the time to get ready. Prepare to be a survivor.

A cardinal rule of medicine is “do thy patient no harm”. If someone is down, do you stay? Do you go for help? Should you leave him on his back, on his side, or as he fell?
We used makeup and prosthetic “broken bones”, “internal organs” and protruding “broken bones” to make it all seem more real. The responders were not told in advance what to expect when they came on the scene. We had outdoor night-practice sessions. No matter their background or experience, everyone learned something new.

Quoting from the curriculum documents, here is an overview of what we covered:
Day One: Course Overview & Patient Assessment
Introductions & Course Overview
What is Remote Medicine?
Role of the Medical Officer
Medical-legal Considerations
Primary Survey
Physical Exam
Vital Signs
Patient History

Day Two: CPR
CPR for the Healthcare Provider
Considerations for Remote Environments
Oxygen Administration

Day Three: Trauma Management
Orthopedic Injuries
Neurological Trauma & Injury

Day Four: Trauma Management
Wound Management & Infection
Chest Injuries
Dental Emergencies
Lifting & Moving Patients
Patient Packaging & Transportation

Day Five: Medical Emergencies
Cardio-respiratory Emergencies
Acute Abdominal Pain
Metabolic Illness & Allergic Reactions
Medication Administration Lab

Day Six: Medical Continued/Environmental
Genitourinary Medicine
Neurological Illness
Altitude Related Illnesses
Psychological Emergencies & Rescuer Stress
Mass Casualty

Day Seven: Environmental
Frostbite & Non-Freezing Cold Injuries
Heat Illness
Immersion & Near-Drowning
Health & Hygiene
Search and Rescue & Group Management
Austere Patient Care and Survival

Day Eight: Environmental/Logistics
Dive Emergencies
Plant & Chemical Poisoning
Animal Attacks & Envenomation
Pre-Expedition Health Screening & Planning
Remote Medical Kit & Supplies

Day Nine: Testing
Practical Exam
Written Exam
Debrief & Evaluations

The Skills
And here are some of the skills we learned (and practiced, and demonstrated to each other and to our instructors!)
* demonstrate comprehension of the legal concepts related to medical care, and relate their interpretation to patient care.
* demonstrate a working professional vocabulary for communicating their patient assessment and care with other responders.
* demonstrate skill at gloving and de-gloving, and describe the techniques of body substance isolation.
* demonstrate rudimentary execution of a Scene size-up, Primary Survey, and Secondary Survey, assessing and managing the scene for safety; demonstrate rapid, effective moves out of harm's way, application and management of the tourniquet, verbalize a General Impression, assess the ABC's, and effect interventions, obtain multiple sets of vitals signs, a patient history and a thorough head-to-toe physical exam.
* demonstrate a basic skill in making SOAP notes. [Subjective (Location, age, sex, MOI/history of events, Symptoms), Objective (LOC, RR, HR, SCTM, ROM [repeat at 15 min.]), Assessment (Fracture/Hyothermis/ ...), PLAN (clean, bandage, splint, ...)]
* be able to describe the introduction of pathogens into the body, and the body's inflammation responses.
* be able to accurately assess and manage oxygen delivery, airway interventions and management, and use of the bag-valve mask (BVM).
* recognize the potential danger of thunderstorms, respond appropriately to an approaching storm, assess and manage related injuries.
* describe the management of submersion incident (drowning) casualties.
* describe and demonstrate the assessment and management of shock.
* assess and manage chest pain, satisfactorily and appropriately perform CPR, and know the backcountry protocols for initiating and stopping CPR.
* demonstrate competence in carefully approaching the study and use of medications.
* communicate the responsibility of the WFR in public health matters (water, food handling, and hygiene).
* understand North American bites and stings; recognize and manage intoxication, envenomations, and allergic reactions, provide wound care. Students can assess, measure, and administer 0.3ml volume intramuscularly.
* demonstrate command of assessing and managing the three levels of injuries to the head and provide long-term care.
* demonstrate command of spinal cord/spinal column assessment criteria, conduct a thorough physical exam for cord injury ("clear" the spine), improvise a C-collar, and demonstrate correct rolls, moves, and lifts with spinal precautions.
* demonstrate recall of prevention, assessment, and management of hypothermia, frostbite, non-freezing cold injuries.
* be able to prevent, recognize, and manage dehydration, heat exhaustion, heat stroke, heat cramps, and sunburn.
* be able to prevent, recognize, and manage high altitude problems (AMS/HAPE/HACE).
* demonstrate competence at safely conducting carries (pacstrap, split-coil, piggyback, backpack, and fireman's)
* fabricate a manageable, comfortable, and protective hypowrap.
* demonstrate correct packaging, organization, communication, and carrying skills with a spine-board and the Stokes litter.
* demonstrate competence with the fundamental principles and operations of a technical rescue, can safely tie-in, and demonstrate rudimentary team skills with communicating, anchoring, belaying, lowering and raising a low-angle-configured rescue litter.
* demonstrate familiarity with "essential" items, search-victim care items, and radio conduct.
* demonstrate knowledge of the purpose, principles, and parameters for trek planning.
* relate the principles and conduct of SAR operations, the considerations for evacuation options, and conduct around helicopters.
* demonstrate proper management of open wounds, describe infection assessment and care.
* relate the dynamics of missile wounds, the assessment criteria for evacuation, and expedient field treatment for missile, and arrow / spear injuries.
* describe evaluation and management techniques of burn injuries.
* describe the steps and technique for assessing and managing the sprained ankle, and demonstrate effective taping of the ankle.
* be able to demonstrate assessment and management of fractures; apply commercial and improvised stabilizing and traction splints.
* demonstrate ability to assess and manage dislocations, and demonstrate skills to relocate the shoulder, patella, and digits, and forearm.
* demonstrate effective teamwork in managing patients with insults to multiple primary systems.
* demonstrate organizing and managing a response to a multiple casualty scene, rapidly sorting, prioritizing, and managing patients for critical care and evacuation.
* describe the assessment and management of common EENT problems.
* demonstrate thorough, courteous technique in assessing the "medical" patient.
* assess and manage abdominal problems, demonstrate improving skills in getting a medical history, and demonstrate knowing when to evacuate the patient.
* describe assessing for, and managing diabetic emergencies.
* relate the assessment and management of common genitourinary (GU) illnesses, and instruct others in hygiene and prevention in the backcountry.

Reading about this stuff is not enough. There is no substitute for hands-on experience and developing muscle-memory. And by the way, certified WFRs are required to take a refresher every couple of years so they don’t get rusty.

Disclaimer: I mention Remote Medical International (RMI) in this article – they were great, and they provide medical training, equipment, and supplies. I have no financial stake in the firm. There are other great companies out there – search for “WFR” and you’ll turn up a handful.

About the Author:
Richard B. has worked as a general contractor, business consultant, US Army combat photographer, Registered Nurse, railroad carpenter and brakeman, and as a forest fire-fighter.


1 comment:

  1. Great Class. I wish there was something like that around here.....Ohio.