Wilderness first aid certification

This weekend I took my first WFA course at an REI in New Jersey, put on by NOLS. My motivation was simple. Someone asked me how much first aid knowledge I'd gained during my year at the Tracker School. My humble response was "none whatsoever". Beyond a basic CPR course many years ago, I had no first aid training at all, let alone wilderness-specific first aid. 

I felt naked, knowing how ill-prepared for a wildnerness emergency I was.

Before I detail the basic WFA protocol, I want to caution the reader. This post is meant to start a conversation and/or be a review for others who have been through a WFA certification. If you have not been through one, DO NOT TAKE THIS AS ADVICE. It would be totally inadequate, and probably inaccurate, as a stand-alone "course". You could very easily die or kill someone by misunderstanding the information I am about to present. 

This post is a teaser, designed to inspire you to sign up for a REAL WFA certification course. It is not meant to help you navigate any type of emergency. 

OK, with that aside...

There is a fundamental distinction between "urban" first aid and WFA. 

Urban first aid is defined as being able to get help (EMTs, ambulance, etc) in under 1 hour. With urban first aid, the focus is on getting help as soon as possible: call 911, then do your ABC's and do CPR if necessary.

Greater than an hour from help and you are in a WFA situation. The protocols and rules of thumb are very different for WFA. The basic premise of WFA is that, barring more advanced medical expertise, you need to focus on assessing the injured/sick person. There are basic treatments you can offer the wilderness patient for most emergencies, but the primary skill of the WFA certified individual is assessment.

The first thing the instructors had us do was memorize these 5 lines:

1. I'm number one.

2. What happened to you?

3. Not on me.

4. Any more?

5. Dead or alive?

They represent the first 5 steps you must follow in any WFA situation.

1. I'm number one:
You're hiking along in backcountry, and in the distance you see a crumpled body at the base of a small cliff. You DO NOT rush up to the person. From a distance, you assess the scene. Is it safe? Are rocks falling down the cliff side? Is there an angry bear or crazy person with a gun nearby? If you rush into a scene without assessing for ambient dangers, you could very easily create a more severe WFA situation by adding yourself to the list of injured people. You do not approach an injured or sick person in the back country until you are reasonably certain it is safe to do so.

2. What happened to you:
Try to figure out what the mechanism of injury (MOI) was. Did the person fall? From how high? Was the person burned? By what? What exactly caused that giant gash in her leg? Figure out what caused the injury if at all possible. This will be important for deciding whether or not there may have been a spinal injury.

3. Not on me:
Don't get someone's blood, spit, pus, vomit, piss, or shit on you. Hopefully you carry gloves in your medical kit. Rain jackets, plastic bags, and bandannas can be used. Take care of this before touching the injured person.

4. Any more:
At first you see only 1 injured person, but if you stop to look around for others, you might see the guy 10 feet away who is even more badly injured. The idea is to get to the person who is worst injured first. At the very least you need to know how many injured people there are.

5. Dead or alive:
This is essentially the CPR or not CPR decision node. CPR was not taught at the WFA course, but if you know it, and the person is dead, this is the time to use it.

The next piece of executing WFA is called the 3 C's:

Conscious?

Consent

Control

The first is fairly obvious. You have implied consent if the person is unconscious or unresponsive. If they are conscious, you need to ask them if it's OK for your to help them out. If they say no, that would be sort of weird, but it is their right. "Control" refers to the head. For any injury, you should immediately stabilize the person's head and neck. If she has a spinal injury and you fail to secure the head and neck, they could go from a recoverable injury to paralyzed for life or even dead.

With that done, you can now move on to the WFA ABC's, which are similar to CPR ABC's.

A - airway

B - breathing

C - circulation

D - decision about 'da spine

E - environment, expose

Airway:
If the person is conscious, you ask them to open their mouth and stick out their tongue. Have them spit out any gum. Remove any loose items such as broken teeth or other debris. These are "stop and fix" items, so if you find a problem, you don't move on to the next letter until it is solved. If no airway problems, move on to breathing.

Breathing:
Again, if the person is conscious, have them take a deep breath. Ask if they feel any pain or have other difficulty breathing. Listen for abnormalities. If the person is no longer breathing, this would be the time to give rescue breaths if you know CPR. If the person is having trouble breathing because they are in a crumpled position, this would be a good time to move them, taking care to stabilize the head and neck. Otherwise, move on to circulation.

Circulation:
Both inside and outside the body. If there is circulation inside the body, the person has a pulse. If not, the person does not have a pulse and you need to jump on her chest if you know CPR. If there is circulation outside the body, that person is bleeding and you need to stop the bleeding immediately. Do a quick full-body check, examining your gloved hands for blood after each time you touch different parts of the body. With no circulation problems, you can move on to decision about da spine.

Decision:
Based on the MOI, decide whether or not to continue holding on to the head and neck. If the person fell from more than 3 feet, you automatically assume a spinal injury and maintain stabilization. If you don't know the MOI, you assume spinal injury. Better safe and awkward than sorry and paralyzed. Having made your decision, you move on to E.

Environment/expose:
What is the ambient temperature? If it's -20 F and the person obviously has hypothermia, it's time to wrap her in a hypo-wrap (more on that later). If it's 100 F and the person is badly dehydrated, get her in some shade. If it is sunny and the person is on his back, provide sunglasses or other protection. At this point you also need to expose any injuries the person is complaining about. "My shoulder really hurts". OK, you need to see the SKIN on that shoulder. "I got stabbed in the junk". You need to provide some privacy if possible, and examine the groin at skin level.

The most critical parts of the assessment are over, so you can take a deep breath and relax a bit at this point (unless the person died or something).

Next up is a head-to-toe, full-body examination. Starting at the head, you gently but firmly check everywhere on the body for abnormalities. Anywhere you do find an abnormality, stop and examine the area at skin level.

Start with the skull and face, lightly pressing different areas and asking if it hurts (if the person is conscious). Same with the neck. Then you lightly press the length of both collarbones and squeeze each shoulder. Grasp the person's rib cage near the top and have them take a deep breath. You are assessing for rib/lung injuries. Do the same further down on the rib cage. Have the person locate their belly button with a finger and divide the abdomen into 4 quadrants. Lightly press each quadrant and check for pain or stiffness. Next place your hands on the hips, at the highest points of the pelvis. Lightly press down. Do the same, but on the sides, pressing in.

At this point, ask the delicate question of "is there any reason I should check your groin area?" If no (hopefully), continue the scan at the thigh. Go all the way down each leg, checking to see that the knee can bend normally. Stick your fingers inside the shoe, inside the sock of each foot to see if it is warm or cold. Next, have them push down on your hands with their feet as they would push a gas pedal. Have them pull their toes up against your hands. Check for differing ability to push or pull across the two legs. Now grasp a random toe on each foot and have them tell you, without looking, which toe you have.

It's time to move back up to the arms. Check them the same way as with the legs, making sure the elbows work. Have them squeeze your hands and wiggle their fingers, and grasp a random finger and ask them to verify which one it is.

Finally, you need to carefully roll the person on his side, preferably toward you and pulling at the shoulder and waist. You need to check the spine from neck to sacrum. Then you check to either side of the spine, again taking time to check every little area and asking if there is pain. This step can and should be done FIRST if you find the person on his back or side.

Now it is time to check vital signs - pulse, rate of respiration, and rough guess about body temperature. You should check these repeatedly, writing down each time and set of vitals.

The last step in this part of the pyramid is to ask relevant questions about the person's recent history, using SAMPLE:

S - Symptoms

A - Allergies

M - Medications

P - pertinent history

L - Last in/out

E - Events

Have they been experiencing any unusual symptoms, like abdominal pain, lately? Do they have any allergies? Take any meds? Had any drugs like alcohol, caffeine or other that day? Do they have any conditions like asthma or seizures? When was the last bowel movement and urination?What happened just before the accident? When was the last time they ate and/or drank? 

Now you must come up with a plan. 

Do you need to evacuate? Do you need to RAPIDLY evacuate (more on this later)? How are you going to get the person out? Maybe you need to leave her there, alone, while you go for help. In that case you need to leave all the info you acquired with the person in case someone else finds her. What is a longer term solution for stabilizing the head and neck, if that is what is needed? Maybe you don't need to leave at all. Maybe you just need to rehydrate the person or bandage a small cut (more on that later).

With your plan in place, you need to offer any treatment you can. This obviously depends totally on the injury or sickness (more on that later).

I am planning some injury-specific posts and videos for the near future. Please leave a comment for any specific requests, or points of clarification, or if you see any inaccuracies in what I have presented.

I am much more confident about my ability to handle an emergency in the woods after this course. The WFA course included many, many practice scenarios; I have written this post not from my notes, but from memory. After writing it out, I checked it against my notes and it matches. That is how well the WFA course drilled these steps.

I am a little confused about certain details, like: don't you have to do the ABC's to assess whether the person is dead or alive (5. Dead or alive?)? Why do you then do them again in steps A-E? But I feel much less vulnerable to bad decision making or freezing up in the event of an emergency. I think I will renew my CPR certification next, and am considering taking the 9 day wilderness first responder course.

The instructors gave us little fold-up waterproof booklets with a variety of potential injuries and sicknesses and how to treat them, whether evac should be rapid or not, etc. On the front is a pyramid to help us remember all the steps I outlined above. It doesn't match what they taught us 100%, but it is close. I altered it a bit to match what they taught us.