Wilderness Medical Associates (WMA) offers a variety of courses, including Wilderness First Responder (WFR), Wilderness First Aid, Wilderness Advanced First Aid, Wilderness EMT and Wilderness Advanced Life Support. I recently obtained WFR Certification and attempt to provide an idea below about the course content for WFR and the responsibilities associated with a WFR certification. For more information please visit: http://www.wildmed.com/main.html.

WMA, founded in 1978 by Peter Goth, MD, was developed to provide medical training and risk management for Outward Bound schools in the United States. Unlike conventional First Aid and EMT training curricula that are designed for an urban environment, the focus of WMA was to prepare for settings that do not render themselves to 911 and ambulance access. These would be settings defined as Wilderness Context where access to definitive care would be more than two hours away, with unique concerns of delayed rescue transport, prolonged exposure to severe environments, and limited availability of medical equipment, requiring improvisation.

WFR training covers a great deal of general medical information about the vital systems of the body. How these systems interact and how they respond under duress is covered in an exploratory manner, giving the students a sense of understanding of the compensation mechanisms involved. This information is useful in identifying problems in emergency situations.

Significant time was devoted to practical sessions and to realistic rescue simulations over the nine-day course. Each simulation was videotaped and used subsequently in classroom discussions. Frequent simulations that were backed up with group scrutiny reinforced the understanding of basic concepts rather than the rote memorization of grocery lists of signs, symptoms and treatment procedures. At the heart of the training was the Patient Assessment System (PAS) including sizing up the scene (before starting appropriate action), completing an initial assessment (find it, then fix it) and doing a focused exam (complete and then treat.)

The PAS is integrated into a SOAP note that would be presented to the rescue party, or to definitive care provider upon delivery. SOAP stands for :

• Subjective information: includes the story that the patient or party members provide, and the SAMPLE history - all provided by Q & A with the patient.
• Objective findings: includes results from the physical exam and the vital signs that the examiner observes and measures.
• Assessment: finds the problems and notes anticipated problems. The severity of the findings may necessitate an evacuation that would then have to be integrated into the Plan.
• Plan: identifies appropriate treatment and evacuation including ETA, time for next contact.

Respiratory component of Basic Life Support (BLS) is taught with the PROP acronym that stands for Position, Reassurance, Oxygen and Positive Pressure Ventilation (PPV - mouth-to-mouth resuscitation). CPR, spine stabilization with appropriate carrying systems and airway management are all part of the BLS training.

There is one major emphasis in terminology in the use of the term "shock." Shock in WFR training is defined as "inadequate perfusion pressure" versus Acute Stress Reaction (ASR). Inadequate perfusion pressure can be due to

1. massive loss of fluid due to external or internal bleeding, or severe dehydration
2. heart failure, or inadequate pump or
3. vascular dilation due to spinal trauma, septic shock, systemic infection, or anaphylactic shock

ASR is a fight-or-flight response that the body produces which is hard to control by the patient. It is a temporary condition controlled by the autonomic nervous system. Reassurance and time are typically all that is required for recovery.

Litter construction methods are covered to evacuate patients that cannot walk out, or that have to be spine stabilized. Splinting of broken bones is encouraged after Traction Into Position (TIP). TIP is not encouraged for joint fractures unless circulation, sensation or mobility (CSM) is compromised distal to the injured joint.

Wilderness Protocols are introduced as legal guidelines to be adhered to by a WFR trained and certified caregiver. Wilderness protocols can be applied on a patient if the caregiver is WFR trained and certified, has preauthorization from a doctor and is in the wilderness context; i.e., more than two hours to definitive care. The protocols are:

• Treatment of severe asthma with injectable epinephrine
• Treatment of anaphylaxis with medications
• Reduction of simple dislocations that include toes and fingers of the hand not including the thumb, patella and the shoulder
• Wound care, impaled object removal if it will cause more damage during transport, and if it can be done safely and easily Æ treating the wound as an open wound.
• Decision to initiate CPR. CPR cessation after 30 minutes.
• Spine assessment guidelines to clear a patient to walk out.

Other topics discussed include myocardial infarction, upper and lower airway problems, burns, frostbite, chest wounds, infections, emergency child birth and female reproductive complications, neonatal resuscitation, altitude and diving related problems, hypothermia, heat exhaustion, heat stroke, hyponatremia, drowning and near drowning, lightning, and toxins. Search and rescue basics as well as guidelines in operating with helicopter crews are covered.