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The world of Search and Rescue (SAR) is often intertwined with wilderness medicine. In our wilderness medicine courses, we talk about SAR teams as a resource for evacuating a patient, so it’s important to understand the principles of SAR operations so we can communicate with and utilize them effectively should we need their assistance. As a trip leader and wilderness medicine provider, you also may find yourself in charge of an impromptu search or rescue for a lost student, client, or even someone from a less experienced group, in which case it can be very helpful to have an operational framework to reference as the scenario unfolds. In this three-part series, we’ll discuss the parts of a SAR response in the first article, “Foundations: What is Search and Rescue?” to provide a framework for executing any type of search and rescue, big or small. In the second article, “Applying concepts: A real-life example of a SAR incident in the Narrows,” we’ll go on a deep dive into a real story from my time working on an ambulance and SAR team in Zion National Park, where you’ll be able to apply the framework from article one to gain a better understanding of how and why the incident unfolded the way it did. Finally, the third article, “Lessons learned: Reflecting on the Narrows incident,” will debrief the story from article two, demonstrating the importance of debriefing incidents to find ways to continually improve search and rescue responses. By the end of the series, you’ll hopefully come away with an understanding of search and rescue processes and how they can be applied across a spectrum of situations, and how you as a wilderness medicine provider might fit into the SAR picture, whether you’re on a SAR team, requesting help from SAR while caring for a patient, or finding yourself leading an impromptu SAR mission.
Many years ago, I remember participating on a spring break backpacking trip with my college outdoor program. I was a first-year student and couldn’t get enough of these types of trips – I really wanted to be a trip leader and went on as many outings as I could cram into my busy college schedule. This particular trip was a five-day backpack through desert canyons outside of Hanksville, Utah. On the first day, as we packed up and prepared for the trip, the leaders reviewed some key safety policies – basic hygiene, traveling as a group, the planned route, and what to do if you become lost. That last point, which we discussed at the outset of every trip I had been on with the outdoor program, always struck me as a little funny, because weren’t we going to stick together the whole time? And weren’t we going to be on a pretty obvious trail, or walking through a confining desert canyon with no other paths? How could we become lost? The chances seemed infinitesimally slim, but nonetheless, I noted that the leaders advised that a lost person should stay put and make themselves obvious to help the group locate them. But the thoughts of getting lost soon drifted from my brain as we strode into a wash that afternoon, replaced by sunshine, red rocks, and a thin layer of desert sand crusting everything I owned. A few days into the trip, we stopped at a pothole holding good, clear water, so we dropped our packs, filled bottles, snacked and basked in the spring sunshine like lizards. After 20 minutes or so, the leaders urged us to get going again so we could make it to camp in the daylight. We were slow to leave our sunny watering hole, peeling ourselves off the warm sandstone sunbathing beds and putting on our crunchy desert shoes. As we waddled away under the weight of our packs, someone asked at the back of the line, “Where’s Amy?” Heads snapped up and eyeballs scanned. Where was Amy? And when had I last seen her? I suddenly took note of the twisting, rocky desert terrain and realized the canyon had split just behind us, where another fork joined. I wracked my brain…I know I saw Amy while we filled water, but did I notice her packing up? Had she slipped off to check something out or go pee around the corner? Amy was, at that moment, lost. The leaders quickly reacted to the erupting confusion and concern. They interviewed the group and determined that Amy had been with us at the watering hole, and that she must have gotten separated just as we were packing up and heading out, only about five minutes ago. No one had seen which direction she had gone, but the canyon walls were pretty steep, so she likely was somewhere nearby in the canyon or the other fork. They split us up into three groups - one would stay put to scan around the immediate area and make sure Amy didn’t accidentally pass us heading down the main canyon farther; one would go back to the watering hole and scan around there; the third would check out the other fork where it joined the main canyon. We would take no more than 15 minutes on this initial search before meeting back at the starting point – if we hadn’t found her by then, we’d need to come up with another plan and alert more resources. I was struck by how suddenly these events unfolded. In the course of just a few minutes, we went from an intact group to searching for a lost member. So THIS is how people get lost! Only a few minutes into our search plan, however, the two groups that searched up-canyon returned successful, Amy walking along with them. She’d gone off to change into shorts around the corner from the watering hole, got caught up checking out some cool rocks, and was surprised to see that the group had left upon return. The search teams found Amy at the confluence of the alternate fork and the main canyon, considering which way the group would have gone. After some collective sighs of relief, nervous giggles (“That could’ve been way worse!”), and a debrief of the situation from the leaders, our group, intact once again, happily carried on towards camp. For the rest of the trip, we stuck together like glue. This experience on the desert backpacking trip was a small, impromptu SAR incident — it took only a handful of minutes, and required no more resources than what our group already had, namely people, to be successful. But the process of the incident unfolded like any SAR incident would. The trip leaders functioned as the de facto incident command team (in formal settings, there is usually a single Incident Commander, or IC, assisted by a variety of section leaders such as Safety, Operations, Logistics, etc). Whether they knew it at the time or not, the leaders organized our response along the lines of a common SAR framework, referred to as P-LAST: Plan, Locate, Access, Stabilize, Transport. Each of these represents a distinct phase of a SAR incident, and when executed in order, results in an organized and efficient approach to finding and assisting a subject. The trip leaders’ first step was to make a Plan. This was composed of pulling together information, like where and when the lost person was last seen. If we hadn’t already spent days together, they might have also needed to gain more insight into Amy’s personality and psyche: Does she typically like to explore on her own? What are her interests? Has she done this before? How has she been feeling today? What are her skills and what resources does she have with her? Additionally, they needed to come up with a strategy for searching within the highest probability areas with the resources available, and quickly, to increase the chances of success before Amy had time to get even farther away from the group. Part of this strategy included identifying natural guardrails and funnels - in this case the canyon walls - that might hem the subject in. In other settings, natural features that can act as guardrails include large bodies of water, rivers, and cliffs. Terrain features that act as funnels are easy to travel along, like trails, roads, canyons, and ridgelines. Once the plan was made, the search, or Locate, phase began. Our small groups, which were functioning like hasty teams (small, self-sufficient teams that can quickly search high-probability areas), began searching in assigned zones based on where Amy was mostly likely to be found – near the point last seen (PLS) and at the potentially confusing junction where the canyon forked. The trip leaders thoughtfully left one group in place, stationed where we realized Amy was missing, to make sure she didn’t accidentally leave the search area; in SAR terminology, this is referred to as containment. Other tools that SAR teams use to locate subjects include tracking dogs, aircraft, GPS data, and even fine-toothed grid searching on foot. Luckily, our search teams were quickly successful. In any search, there is always some urgency in locating the subject quickly, because the less time they have to move away from the point last seen, the more easily they will be found. Amy had mere minutes to get separated, which meant the search area was small and likelihood was high that we’d find her. If she’d had hours, the search area would have expanded considerably. This is why it is usually easier to find a lost person if they stay put, and why our trip leaders encouraged us to do so while making our location as obvious as possible (you could shout or blow a whistle, use visual cues like smoke, bright colors, or reflectors, etc.) should we become lost during the trip. After the subject is located, they must be Accessed. In Amy’s case, there were no barriers to access – she was just standing in the canyon junction, and the searchers walked right up. But what if Amy had explored a little farther afield, and scrambled up a short but steep rock band and couldn’t figure out how to down climb it? Then we would have had a high angle rock access problem, and we might have needed to spot someone to climb up to Amy, or find an alternate route to reach her. Access problems usually intensify with water, snow, ice, rock or steep terrain. For example, rescuers may have to rappel down or climb up rock walls, ski down a snowy slope or avalanche debris, or navigate glaciers and crevasses. The Access phase may also involve rescuing the subject from immediate hazards, such as pulling someone to shore from swift water or removing them from unstable terrain like avalanches or rock slides. In a SAR incident where the subject is injured or sick, the next phase would be to Stabilize them by providing medical care and readying them for Transport. On the desert backpacking trip, there was no need for stabilization, because Amy was perfectly healthy, just a little lost. In other cases, the stabilization phase may involve treating immediate life threats, doing patient assessments, filling out a SOAP note, and devising a treatment and transport plan. Amy also didn’t need any transport assistance, so the transport phase of our mini-SAR was merely the process of walking her back to the designated meeting point, where we joyfully concluded the incident and carried on with our backpacking trip. If someone can’t transport themselves and needs to be evacuated (as is common for sick and injured patients), then the SAR team creates a transport plan based on the terrain and patient condition. This could include using vehicles like helicopters, UTVs, or boats to evacuate the subject. Or it could mean carrying them out in a litter (sturdy, human-shaped wire basket) on foot, hoisting them up or down steep terrain, or assisting them in other ways. Many SAR teams have specialized tools and equipment for dealing with transporting subjects in their unique service areas, and they spend a lot of time training on how to manage complex transports in their most challenging terrain. A SAR incident is only complete once the incident has been debriefed and all of the teams and gear required are returned and restored to their prepared state (rested, cleaned, organized, re-stocked, and ready to deploy). On our backpacking trip, the resources required were so minimal (just us humans looking for Amy for a couple minutes) that our group was ready to carry on with the trip after re-grouping at our designated meetup spot. The leaders debriefed the incident and reiterated the importance of letting people know when and where we’re going if we leave the group, and to remain stationary if we realize we’re lost. With that, we slung our heavy packs back on, and waddled down the canyon towards camp. That evening, under clear starry skies and gathered around a glowing headlamp-nalgene lantern, we reflected on our feelings from the day and what we learned. For my part, I thought about my new understanding of just how easy it can be to become lost, despite my disbelief at the beginning of the trip. I also marveled at the calmness of the leaders as they led us through the situation with Amy earlier in the day, and wondered if I’d have the skills to someday manage a group under stress so tactfully. I had no idea then that I’d go on to work professionally as a ski patroller, SAR team member, outdoor leader, and wilderness medicine instructor, and that this early experience would one day become a simple illustration of the phases of a search and rescue response. From this story, we can see how even the simplest incidents can follow the P-LAST framework, though some of the phases may be quite abbreviated in the absence of technical terrain or a sick or injured patient. Regardless of scale, following the stages of P-LAST helps organize resources and streamline a SAR response. To explore this process further, we’ll be going on a deep dive with the story of a professional SAR incident in the Narrows of Zion National Park in our next article, “Applying concepts: a real-life example of a SAR incident in the Narrows”. As you read this next story, you’ll now be able to identify the different parts of the SAR process, and perhaps reflect on what you might do if you were part of a SAR response. It’s an exciting story, involving an unreliable point last seen, navigating challenging terrain at night, a helicopter in a tight spot, and more. Stay tuned! If you have insight to share from your own experiences working with a SAR team, leave us a comment, we’d love to hear from you! About the author: Zoey is a licensed provider for WMTC and owner of Headwind Backcountry Medicine, LLC. She’s spent many seasons exploring outdoor education, recreation, and wilderness medicine from a variety of angles, and she’s excited to share pieces of her experiences here with you. Thanks for reading!
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Introduction A medical advisor who is an active member of your organization's risk management team can help prevent and reduce the severity of program-related injuries and illnesses. We recommend working with a medical advisor who is familiar with your program and an experienced outdoor person. A medical advisor can:
Standing Orders & Protocols Medical advisors use standing orders to authorize treatment and evacuation guidelines to meet an individual program's needs. For the purposes of this document, standing orders are written treatment and evacuation protocols—often in the form of algorithms—that authorize a wilderness medicine provider to complete specific clinical tasks usually reserved by law for licensed physicians (MD, DO, NP), physician assistants (PA), or nurse practitioners (NP) while in the backcountry. Standing orders may be specific to a patient or a condition and take two forms:
Best Practices Standing orders and protocols should:
Examples Examples of standing orders written for an outdoor program or guide service by their medical advisor include:
Interested in learnig more about wilderness medicine? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.
Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available. Wilderness travelers, outdoor instructors, guides, and Wilderness EMS personnel benefit from clear guidelines or protocols that address the unique circumstances encountered in the wilderness and remote settings regarding starting, withholding, and terminating resuscitation efforts for people in cardiac arrest. Because the chance of return of spontaneous circulation (ROSC) and survival with intact neurological function decreases exponentially with any delay or break in the AHA chain of survival, overall outcomes, universally poor in an urban context, are even worse in the wilderness. On-scene personnel may not have the medical, rescue, or outdoor training and experience to make an accurate risk-benefit analysis. For example, If a physician is present, they may not have the training or expertise to assess the hazards associated with a technical rescue or evacuation or know how to mitigate any environmental risks; the same holds for EMS professionals. Conversely, while many outdoor instructors and guides have the training and technical experience to assess and mitigate any risks associated with a rescue or technical evacuation, or adverse environmental conditions, they may not have the required medical training or experience to evaluate the patient’s likelihood of survival with neurological functioning intact. In addition, many outdoor programs and most recreationalists do not have timely or reliable communication with outside agencies that may be able to offer assistance. The following algorithm provides a data-driven template for a termination of resuscitation (TOR) protocol for recreationalists, outdoor trip leaders, guides, and wilderness EMS personnel; medical directors can modify the algorithm to align with regional laws and response times.  Click image to download a pdf file copy. Want to learn more about wilderness medicine? Take one of our courses. Guides and expedition leaders should consider taking our Wilderness First Responder course. Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available. Supplemental Reading 
 On August 9th the FDA approved a 2 mg epinephrine nasal spray (neffy®) for the treatment of anaphylaxis. A neffy prescription consists of two single-dose device that use a technology that temporarily loosens the spaces between the nasal cells to help epinephrine be absorbed rapidly into the bloodstream. Similar to epinephrine auto-injectors, a second dose should be given if there is no improvement in symptoms within five minutes or symptoms worsen. Interestingly, repeat dosing in the same nostril is more effective than dosing once in each nostril. Study results showed similar epinephrine levels between neffy and auto-injectors demonstrating similar increases in blood pressure and heart rate. A separate study in children weighing more than 66 pounds showed the amount of epinephrine in the blood was similar to adults who received neffy. Side effects were generally mild and short-lived in the clinical trials and similar to injectable epinephrine with the following exceptions related to the delivery method: throat irritation, nasal discomfort, a tingling or itchy nose, nasal congestion, or runny nose. No serious adverse events were reported. The spray is effective if you have nasal congestion or runny nose from a cold or seasonal allergy; however, people with nasal polyps or a history of nasal surgery may not receive a full dose and should stick with an injectable form of epinephrine. Caution: The spray will not work if frozen. Directions are simple: Insert the tip of the device fully into one nostril and firmly press the plunger. Avoid angling the tip towards inside or outside wall. Avoid sniffing during and after inhaling the drug. NOTE: While studies show the amount of epinephrine in the blood is the same for Neffy and injectable epinephrine, it has not been field tested — that will come with time. Want to know more about allergies and annaphylaxis? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.
Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available. Picture this: it’s snowing big, fat flakes; the kind that stack up quickly and fill in your tracks almost instantly. I’m skiing with some friends and we’ve been enjoying excellent new snow as a big storm sets in over the Wasatch Mountains. Now I’m perched at the precipice of new terrain, just outside the ski area boundary at the top of Catherine’s Pass. It’s clear from the faint curving lines through the slope that other people have skied there already today, but the new storm snow that rolled in this afternoon has nearly buried any sign of them. I have some inkling that avalanches are a concern, mostly from memories of ski films as a kid, but there’s a false sense of safety since we’re right next to the ski area boundary, and with careful line choice, you can ski to the base of the lift. The slope doesn’t look TOO steep, and it seems like it’s probably okay since others have been there before. Yet, I’m nervous. As a staunch rule-follower for much of my life, I liken it to the uneasy feeling that I might be breaking a rule, but a rule that no one has explicitly said or written down anywhere. How will I know if skiing this line is the right decision? But as I watch my friends drop in, spraying huge clouds of pow, whooping and hollering, I follow. As expected, I make some of the dreamiest, softest turns yet that day.
At the bottom, we catch the last lift of the day and ski an inbounds run back to the car. It’s all smiles, and that uneasiness from earlier has nearly vanished, shrouded by memories of floating through perfect powder snow. But something sticks in my gut - did I get away with something? Fast forward a few months and I’m furiously studying for the online exams of my very first Hybrid WFR course. My brain is overflowing with information about volume shock, hyponatremia, high altitude pulmonary edema…the list goes on. It’s the first time that I’ve come face to face with the risks of my hobbies. It’s the first time I’ve considered exactly how people can die from doing things that I love to do, and from forces that surround us all the time. As I study, the first verse of this classic nursery rhyme sticks in my brain: “It’s raining, it’s pouring The old man is snoring. He bumped his head when he went to bed, And he couldn’t get up in the morning.” Pre-WFR course, I never gave this rhyme a second thought, it was just a harmless play on words. I liken this to how I navigated the world, with a charmed belief that I had managed to avoid major calamity because I wasn’t engaging in anything particularly risky. Post-WFR, I had a jarring realization: did the old man develop increased ICP from bumping his head? Is this little rhyme actually a cautionary tale about monitoring a patient with a head injury? Just as the seriousness of the true meaning of the rhyme became clear, the enchanted gauze was lifted from my eyes. I saw the way I navigated the world in a different light. I came to realize that I had avoided major calamity mostly because I had gotten lucky. I flirted with all sorts of risky situations, I just didn’t know it. Ignorance is bliss, as they say; or is it just dangerous? Taking my first WFR course was a huge wake up call, because I learned the very real consequences when things go awry in the backcountry. Before, the possibility that someone could get hurt was abstract, a dull threat. Now, the exact ways someone could get injured, sick, or even die were crystal clear. The consequences of my actions came into sharp and alarming focus. With this clarity came a major paradigm shift. Instead of trusting that nothing too terrible will happen, my brain was reprogrammed to take a hard look at what’s around me. Do I have the skills to deal with the hazards present? And if I can’t identify the hazards, is it because there aren’t any, or is it because I don’t even know how to recognize them? Though wilderness medicine training didn’t provide me with every technical tool required to deal with every risk I engage with, it pushed me to think critically about the activities I do outdoors and whether or not I have the training I really need (like an avalanche course) to avoid making mistakes and paying a high price. That uneasy feeling that I might be getting away with something turned into a well-respected alarm bell. Wake up! Look around you! What are you missing here? The nagging feeling like I was breaking a rule while skiing out of bounds with my friends on that perfect, stormy day was that alarm bell. What would I have done if there had been an avalanche? We may have gotten lucky. Or maybe that slope wasn’t loaded or steep enough to slide. Either way, our ignorance was a roll of the dice. Instead of being forced to confront such ignorance through a tragic accident, we skied some amazing turns to round out an already epic day, further reinforcing our naive sense of sound decision-making. It’s not that a wilderness medicine course would have given me the skills to assess the avalanche hazard and make a more informed decision, only specific training and experience in managing avalanche terrain could give me that. It’s that after taking a wilderness medicine course, I realized that my choices could have profound and devastating outcomes, and I was depending much more on luck to avoid them than I ever considered. I became more willing to at least take a pause at the precipice. Is it possible that I’m about to get away with something? Getting away with it: it’s a common trope in the outdoors, and so often we do get lucky. Whether it’s slashing sweet powder in a precarious avalanche path, or pothole jumping in a slot canyon just a hair to the left of a rock hiding in the murky pool, or simply choosing to leave the first aid kit at home on a day hike. The problem with luck is that sometimes we associate it with actual knowledge or good judgment. How do we know? It can be very difficult to tease apart the details of luck versus sound assessment and preparedness, but through training we strive to get as close as we can. For me, wilderness medicine was the paradigm shift I needed to start moving away from just “getting away with it” and towards actual preparedness. It played a key role in motivating me to get informed, gather skills, practice problem-solving, understand my ability to assess situations, focus on prevention strategies, and recognize when I am in over my head. I started turning luck into a delightful treat, like happening upon the perfect crop of wildflowers, rather than using it as a lifeline I didn’t even know I was depending on. Maybe this story has inspired you to start gathering skills and to depend less on luck, or maybe you’re already somewhere on this journey. No matter where you are, taking a wilderness medicine course is a critical step in understanding the consequences, and how to deal with them, when things go wrong in the backcountry (and even the frontcountry). If you want to learn more, sign up for a wilderness medicine course. You can find all of our available courses here. If you like this article or have a similar story to tell, leave us a comment! We love hearing from you. About the author: Zoey is a licensed instructor for WMTC and owner of Headwind Backcountry Medicine, LLC. She’s spent many seasons exploring outdoor education, recreation, and wilderness medicine from a variety of angles, and she’s excited to share pieces of her experiences here with you. Thanks for reading! You are part of a search and rescue team looking for survivors a day after a devastating wildfire passed through your town. It's been raining non-stop for the past 12 hours making your task more difficult. Mud slides have closed a number of roads slowing evacuation and exacerbating the entire situation. As you walk the shoreline of one of the nearby lakes, you see someone waving in an attempt to attract your attention from an island roughly half a mile from shore. Borrowing an aluminum rowboat from one of the burned-out cabins, you and your partner row to the island. Once there, you are confronted by a 32-year-old mother who is wet, shivering, and seeking help for her six-year-old daughter, Jolene. Jolene is huddled in a leaky, make-shift shelter, swathed in a wet blanket. She responds to your questions with short, mumbled phrases. Her mother, Trish, reports that they fled the fire by swimming to the island yesterday, that both she and Jolene are uninjured, and that they have had no food since early yesterday. Trish said she had to swim with Jolene most of the way. The water temperature is in the mid-60s F. It's now 4:30 pm and the rain is not letting up. You are in communication with Incident Command via satellite phone. What is wrong with Jolene and what should you do? Click here to find out. Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.
Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available. Friction and pressure combine to create shear forces that stretch and irritate connective tissue within the epidermis initially creating a “hot spot.” Later, as the epidermis tears and plasma leaks into the torn tissue, a blister will form. As long as shear forces are present, the skin continues to delaminate and the blister grows until it breaks. More pressure—due to a heavy pack or persistent hiking downhill—will cause deeper damage and a more painful blister. Both the prevention & treatment of friction blisters require adding an external “sliding layer” to prevent shear forces from building within the skin. Friction Blister Prevention
Friction Blister Treatment
 Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
Introduction
Unfortunately, wounds are all too common on outdoor trips, with abrasions and full-thickness lacerations leading the list; that said, deeper wounds are not unheard of. The goal of wound care is to prevent infection and promote healing. Expedition settings bring challenges to wound management that are relatively rare in an urban environment and require a deeper understanding of the healing process and available dressing technology. Patients with a high risk for infection, especially with damage to tendons, ligaments, joints, or bones, should be evacuated for physician assessment and treatment. Clean wounds without damage to underlying structures can often be treated in the field with the right materials and constant monitoring.
The Healing Process
The wound healing process has five continuous and overlapping phases: 
Individual characteristics that inhibit healing include:
Wound attributes that inhibit healing include:
Dressings
Characteristics of Ideal Expedition Dressings
Six categories of wound dressings are discussed below. Recommendations for field use are based on the ideal characteristics discussed above for healthy individuals with no local or systemic wound infection and appear in the highlighted boxes. Infected wounds and those slow to heal should be evacuated for assessment and treatment by a physician or wound care specialist.
Transparent Micro-thin Film Dressings Transparent micro-thin film dressings are permeable to water vapor but not liquids. They help maintain a moist environment for full-thickness wounds with little exudate and abrasions. Because they are transparent, you can watch the wound heal through them. If clear fluid [serious exudide] builds under the film, switch to a foam dressing to prevent skin maceration. Alternatively, add a non-adherent gauze dressing ± additional gauze under the film to absorb excess fluid. You can also add a antimicrobial directly to the wound bed or dressing if the wound is at risk for infection. Transparent film dressings are often the best choice for wet expedition environments and can be layered with other dressings to manage exudate. Paint the surrounding skin with Tincture of Benzoin to aid in adhesion.
Transparent micro-thin film dressings [we carry Tegaderm®] are recommended:
Foam Dressings Foam dressings are effective for all wound types. They adhere to the wound’s surface and absorb excess exudate while maintaining a warm, moist wound bed; they can be left in place for multiple days. Generally, the thicker the foam, the more exudate it can absorb and hold. Some foam dressings come with a perimeter adhesive, while others require fixation. Foam dressings without perimeter adhesive can be cut to size but need a transparent film dressing or flexible medical tape [we carry Mefix®] to hold them in place. If the wound is at risk for a local infection, you can apply an antibacterial ointment under the foam. Foam dressings can also degrade moist slough on the wound surface.
Foam dressings [we carry Melpilex®] without a perimeter adhesive are recommended for low to medium exudate wounds during the proliferation and epithelialization phases to prevent maceration; they should be secured in place with a transparent film dressing or flexible medical tape [we carry Mefix®]. Flexible medical tape permits moisture to evaporate through the dressing and is water-resistant; it is preferable to transparent film dressings unless the wound will be directly exposed to water.
Dry Gauze Dressings While dry gauze dressings should never be used directly on a wound bed before the wound has completely closed, they can be impregnated with medical honey or Vaseline to create a moist environment to promote healing. Dry gauze can added as a secondary dressing to hold excess exudate or provide protective padding. Vaseline-impregnated gauze dressings are inexpensive and work well for dry or low exudate wounds; they can be held in place using a non-adhering bandage, flexible medical tape, or a transparent film dressing. For maximum flexibility and to minimize micro trash, carry roller gauze instead of individually wrapped gauze pads.
Vaseline-impregnated gauze dressings are recommended as the initial dressing for most wounds in healthy individuals during. Secure in place using a self-adhering bandage [we carry Cohere®] during the inflammatory phase when you need to change dressings during the day. [With care, self-adhering bandages can be reused multiple times.] Once exudate is under control — during the proliferation and epithelialization phases — you can secure with transparent film dressing or flexible medical tape — and leave in place for multiple days.
Dry gauze can be used as a secondary dressing to capture excess exudate the inflammatory, proliferation, and epithelialization phases or as padding to protect fully closed wounds during the maturation phase. Hydrogel Dressings Hydrogel dressings are primarily used for dry wounds or wounds with minimal exudate. They reduce pain, promote healing, and can be used with infected wounds. Once the lid has been removed, they are commonly used to relieve pain and promote healing with friction blisters. They can also degrade slough on the wound surface.
While hydrogel dressings work well for treating friction blisters [we carry Nextcare hydrogel dressings and ENGO patches], HYDROGEL DRESSINGS are NOT RECOMMENDED for full-thickness wounds in an expedition setting because foam dressings are more versatile.
Hydrocolloid Dressings Hydrocolloid dressings use gel to create an impenetrable protective barrier that prevents bacteria from entering the wound bed and maintains a moist environment. Like hydrogel dressings, they are used with dry wounds or wounds with minimal exudate; however, they should not be used with infected wounds or wounds at risk of infection because they are occlusive and can trap bacteria.
Hydrocolloid dressings are NOT RECOMMENDED in an expedition setting because foam dressings are more versatile.
Calcium Alginate Dressings Calcium alginate dressings are used with wounds with substantial exudate. They form a soft gel when in contact with exudate and conform to the contours of the wound to provide a micro-environment that helps break down dead tissue and encourage new skin cell growth. They can be used to pack deep wounds. They require a secondary dressing and fixation.
Calcium alginate dressings are NOT RECOMMENDED in an expedition setting because foam dressings are more versatile and easier to use, and medical honey can be used to fill a deep wound and promote healing.
Antimicrobials Recommendations for antimicrobials used in treating wounds in a remote setting are for healthy individuals and designed to prevent a local or systemic wound infection. Infected wounds and those slow to heal should be evacuated for assessment and treatment by a physician or wound care specialist. Povidone-iodine Solution & Chlorhexidine Use soap and water to gently wash the wound bed and surrounding skin and pat dry at each dressing change. Apply chlorhexidine or povidone-iodine solution to the skin surrounding the wound to reduce the chance of bacteria reaching the wound bed. If the risk or consequences of local infection are high, dilute a 10% povidone-iodine solution to less than 1% and wash the wound before applying the primary dressing.
10% povidone-iodine solution [we carry 10% povidone solution] is recommended over chlorhexidine because it can be used full-strength to clean skin around the wound. While chlorhexidine is faster and better than povidone-iodine in reducing bacterial migration, due to its toxicity CHLORHEXIDINE SHOULD NOT BE USED in deep wounds.
When diluted to less than 1%, it is recommended for flushing and packing high-risk wounds, cleansing a high-risk wound bed, or saturating a gauze dressing to treat or prevent a local infection. [we carry 10% povidone iodine solution in a variety of Nalgene® bottles to prevent leakage while in your first aid kit. Medical Honey Medical honey has proven more effective than antibacterial ointments in preventing infection and promoting healing. It can be used to fill a deep wound, applied to the wound’s surface, or impregnated into a gauze dressing. It can be left in or on a wound for up to seven days.
Medical honey [we carry Medihoney®] is recommended for the prevention of local infections and the treatment of biofilms.
Antibacterial Ointments & Creams Antibacterial ointments & creams — e.g., Bacitracin, Neosporin, Polysporin, or mupirocin — to prevent wound infection are controversial.
Antimicrobial ointments and creames are NOT RECOMMENDED for treating or preventing local infection infections in an expedition setting because medical honey is more effective and versatile in promoting healing and does not lead to allergic dermatitis or bacterial resistance.
Refer to the graphic on the below for a summary of wound care guidelines throughout the healing process. Download a pdf copy
Click graphic to download as a pdf file
Bottom Line
There's a ton of information in this post. Bottom line, here's what you need to know:
Severe bleeding is rare in an expedition environment; partial- and full-thickness wounds are not. Barring a life-threatening bleed, you need to be able to clean, dress, bandage, and care for a wound until it heals or you have successfully evacuated the patient to more advanced care. If you are working with or around machinery, chainsaws, axes, other cutting tools, etc., we recommend carrying:
To clean a wound, we recommend carrying:
To dress a clean, low to moderate risk wound during the inflammatory phase:
To pack and dress a deep wound, we recommend carrying:
If you are on an afternoon, day, weekend, or even a long-weekend trip and get a partial or full-thickness wound, you're not out long enough to get past the inflammatory phase of wound healing, and will not need to carry a foam dressing; for longer trips you will. To dress a wound with low to moderate exudate, a wound at risk of infection, or a wound with increasing slough in the proliferation and epithelialization phases, we recommend carrying: To protect a wound in a wet expedition environment, we recommend carrying:
Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
While mountain biking down a steep single track your friend catches his front wheel and is thrown forward with his bike. During the fall the handlebars smash into the left side of his chest. Asa has difficulty sitting up and catching his breath, and appears to have injured his left wrist. After assisting him to a sitting position and coaching him to breathe with his abdomen, his respiratory distress appears to resolve. During your physical exam, he reports a sharp pain (7) in the ribs on his lower left chest when he tries to take a deep breath. While his left wrist hurts (4) and has a slightly decreased ROM with good distal CSM, it appears weak: Asa is unable to easily hold and lift a full 1-liter water bottle. His helmet is cracked, he reports feeling a bit woozy, and has a headache (4); the remainder of his physical exam is unremarkable. With abdominal breathing, the pain in his ribs is manageable (3). 20 minutes after his accident his pulse is 94 and regular and his respiratory rate is 22 and remarkably easy; he reports his normal pulse rate is in the mid-60's and he doesn't know his normal respiratory rate. While awake, he still feels a bit "out of it." A focused spine assessment reveals cervical pain and tenderness at C-7 with no shooting pain and normal motor and sensory exams. What is wrong with Asa and what should you do? Click here to find out. Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.
Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available. You are on a multi-day backpacking trip in the southwestern canyons with a friend and her partner. You haven't seen your friend Janey for a number of years, and this is the first time you spent any time with her partner, Jon. The temperatures on the trip have been in the mid 70s until today when they unexpectedly climbed to over 90º F by noon. You are in a fairly open part of the canyon and exposed to the direct sun. Everyone is sweating heavily and looking forward to reaching camp and water. By mid-afternoon Jon is noticeably tired and feeling nauseated. You are almost out of water, but camp is within a half mile. You stop, pull out a SOAP note and complete a full patient assessment. During your SAMPLE history, Jon tells you he just started taking lithium for a mild bipolar disorder; the last time he urinated was before lunch. The remainder of his history is unremarkable; however, both his pulse and respiratory rates are a little higher than normal. What do you think is wrong with Jon and what should you do? Click here to find out. Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.
Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available. |
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