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On a bright January morning out for a day trip on snowshoes, you and two friends, Anna and Jason, traversed a snow slope beneath Shadow Peak in the Tetons. The air was clear, the snow glittered with 14 inches of new snow, and the mountain felt calm. Midway across the bowl, the slope fractured above them with a deep thump. In seconds, all three are engulfed in a four-foot wave of snow that knocks everyone off their feet and carries them to the bottom of the bowl. When the avalanche settled, Anna was half-buried near the surface. Shaken, she quickly freed herself from the surrounding snow. Below her, and to her right, she could see you doing the same thing. She watched as you awkwardly attempted to stand. It quickly became apparent that, although possible, you have difficulty fully supporting your weight on your left leg. Jason was nowhere in sight. Turning our beacons to search mode, the signal led farther downslope and to the left. Sliding down the slope on our butts, you and Anna probed through the debris until she struck something solid. Digging diagonally from the side, Jason’s head and body slowly emerged from the hole nearly two meters beneath the surface. He was unresponsive and not breathing, with snow packed into his mouth and nose. What's wrong with Jason, and what should you do? Interested in learning 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 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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It’s a cool, breezy morning in November. You and a friend are cutting standing dead trees for firewood. You have a Forest Service permit. Your truck is close by, but you are five hours from the nearest hospital, some of that on gravel roads. Your friend, Tom Jensen, is cutting the tree. He is not wearing chaps. Tom stumbles when the saw kicks sideways, and the chain bites into his right upper thigh before he kills the throttle. Tom swears loudly and drops to one knee. The cut is deep and bleeding fast; blood is pooling on the ground. He clamps both hands over the wound. When you reach him seconds later with the first aid kit, his face is pale. You can feel the urgency in Tom’s voice when he clearly states, "I’m dizzy.” What's wrong with Tom, and what should you do about it? Interested in learning 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 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.  It’s late summer in Icicle Creek: the air is dry, a light breeze flows through the canyon, and the shaded gray granite feels cool to the touch. You and your partner, Beth Sanson, are halfway up a three-pitch 5.9 crack climb. Beth is leading. On the second pitch, Beth places a small cam in a shallow, flared crack, steps up, but slips on dusty crystals. The next piece holds, but she drops about twenty feet, swinging violently into the wall. Her right hip hits the wall first, followed almost immediately by her head. She is wearing a helmet. Beth is initially unresponsive as you lower her to your belay. She regains consciousness at the belay before being lowered to the ground. Once on the ground, you help Beth sit down. She is favoring her right leg, but talking and breathing normally. Her helmet is chipped above the left temple. She says she feels a bit dazed. She is slightly pale and complains of pain in her right hip. A bruise is forming high on her right thigh with some swelling. When she tries to stand, her face tightens, and she quickly sits back down. She keeps one hand over her right hip as you help her settle into a jacket for padding. When asked, Beth says she is starting to feel cold and has a headache. She also mentions feeling a bit nauseous. What’s wrong with Beth, and what should you do? Interested in learning 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 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.  It’s a hot Saturday in July on the Lower Yough, the seven-plus mile Class III/III+ drop-and-pool run below Ohiopyle Falls. The river is crowded with rental rafts and commercial trips. At the entrance to Dimple Rapid, the raft caught a strong eddy line, and the bow dove. Two of the guests lose their balance, stop paddling, and fall into the water. One swimmer—Elena Márquez—flushes toward Dimple Rock’s undercut. She disappears in the aerated water, then surfaces coughing and gasping. A guide’s throw bag reaches her, and she is pulled to shore. You eddy out on river right. Elena sits upright on a riverside boulder, soaked and shivering. She coughs repeatedly, bringing up small amounts of river water. Her breathing is fast, and she pauses between sentences to catch her breath. She says it feels hard to take a deep breath. Her skin is cool and damp, and she leans forward, resting her forearms on her knees. There are scrapes on her right shoulder and forearm. She says she did not hit her head and remembers everything. Her chest discomfort is mild at rest but increases when she tries to take a deeper breath. What’s wrong with Elena, and what should you do? Interested in learning 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 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. Applying concepts: A real-life example of a SAR incident in the Narrows of Zion National Park8/14/2025  In this second installment of our 3-part series exploring Search and Rescue, I’ll tell the story of a complex SAR incident in the Narrows of Zion National Park. Using what you’ve learned in part one "Foundations: What is Search & Rescue?" see if you can tease out the different stages of a SAR response throughout this story. Furthermore, consider what could have made this response go more smoothly, better mitigate risk, or require fewer resources. Then, we’ll “debrief” the callout in the final part of the series: “Lessons learned: Reflecting on the Narrows incident,” and discuss some strategies that could have improved the response.
I spent the summer of 2022 working in Zion National Park as an EMT on the park’s ambulance and on their search and rescue (SAR) team. The EMS/SAR staff for the park was small and scrappy; we had two full-time EMTs (including myself) and two full-time Paramedics, a handful of park law enforcement officers with EMT and AEMT certs, and a bunch of excited SAR volunteers from other park departments and local guide companies to help with transports. It’s an ideal place to learn by getting thrown into the action, and I loved it. It’s also a place where, given our limited resources and complex terrain, we had to get creative, try out new strategies, and continually reflect and learn from each call to make the next one better. Let’s start at the beginning of the incident: the call. Our dispatcher received word that someone was hurt in the Narrows, “about a mile or two up from the main trailhead” around 4pm in the afternoon. The Narrows is an incredibly popular, aptly named section of the Virgin River canyon where day hikers walk up the river bed between stunning, sheer walls of sandstone only as wide as the water. Most of the hike is in ankle to knee deep water, more like walking up a babbling stream than what we imagine as a rushing river, but there are some sections with swift currents and surprisingly deep pools that require careful route-finding. Some folks choose to hike the entirety of the Narrows “top-down,” starting at a trailhead outside of the park and hiking a total of 14 miles in the river to the main trailhead in the park, which can be done as an overnight trip or a single, long day hike. The injured party apparently was attempting the latter, before injuring their lower leg, according to the reporting party. Unfortunately, the report came from a passerby, and they had no other information about the patient, who they were with, or what resources the injured person had at their disposal. Furthermore, there is no cell service in the Narrows, and even satellite devices sometimes struggle to get messages out from the depths of the canyon; our dispatch was unable to get any further reports or information about the patient. At Zion, one of the law enforcement park rangers always took the role of Incident Commander (IC) - usually it was whomever was on duty and available at or near the dispatch center when a call came in. For the Narrows incident, the IC decided to send five rescuers as the hasty team: two medical rescuers (myself and a paramedic), one park ranger to serve as team leader, and two additional SAR volunteers solely for carrying gear. Since the initial report was unclear, IC cautioned us to prepare for a long, and possibly overnight, rescue and to pack accordingly. Packing for calls like this is difficult: Would we be out for a few hours, or well into the following day? What items were going to be essential, and where could we cut down? Our basic first aid kit was essential, of course. We also chose to pack an IV kit, a bag of fluids, and IV pain meds in the event of a severe injury paired with a long evacuation. We packed light on bulky splinting materials, only carrying a few SAM splints and mentally preparing to improvise from there if necessary. The rest of our packs were stuffed with overnight gear, both for ourselves and for the patient and possible companions. This included sleeping bags and pads, as well as additional dry layers since we’d be walking mostly in the river in the Narrows. Then there was food and water to haul, and we’d need enough for the five of us, plus the patient and companions, to get through the night and into the following day if necessary. In the backcountry, when supplies are carried on backs and patients may be miles from vehicle access, these decisions can be critical. We want to carry just the right amount – too much and the team will be bogged down and inefficient; too little and we might be missing essential gear that could greatly improve patient, and team, outcomes. Once we cleared the first hurdle and our team was assembled and packed about two hours later, we headed up the Narrows as the day waned. We moved against the flow of traffic as most people were hiking out, downriver, for the day. Our patient had been on a through-hike of the Narrows, starting 14 miles up the canyon at a trailhead outside the park, and planned to exit at the main Narrows trailhead within the park. We hoped the report was true and she was only a couple miles out from the trailhead, but we all knew we might end up walking in the dark. Once night falls, the somewhat whimsical river walking becomes difficult to navigate, and requires good knowledge of the canyon, knowing where to avoid the deepest pockets and swiftest currents. It was an arduous and complex way to travel with heavy packs and methodically searching each bank of the river so we didn’t miss the patient. Sure enough, the miles began to tick by with no sign of the injured party, the sun sank behind the cavernous walls, and we picked our way up the canyon in deep darkness. As we walked, it was a constant negotiation between making forward progress and managing our team’s risk. At some points, people had to scout ahead for obstacles like log jams or rocks to find clear ways around them in the dark. At others, we had to pass packs through tight squeezes past boulders, or spot each other through deep pools. And at each of these stages, we also had to consider: keep going, or pull back and reassess? Is the risk still acceptable for the mission at hand? Finally, at about midnight, we found our patient. She was situated on a gravel bar at the confluence of the Virgin River and Deep Creek. We were perfectly in the middle: seven miles from the trailhead we came in from and also seven miles from the trailhead at the top of the Narrows. She had one companion, uninjured but unprepared to spend a night out, who had managed to build a small fire. Some other hikers had left them with a few jackets. The night was cool, and their hiking clothes (and ours) were wet from walking in the river. The patient’s ankle was obviously deformed and very swollen. They both were hungry, thirsty, and getting cold. The paramedic, Tim, and I quickly got to work assessing the patient, taking vitals, and asking questions about medical history. We started working to get them both warm, dry, fed, and hydrated. It was clear we’d need to improvise a splint for the ankle using the SAM splints we had packed. It was also clear the patient was in a lot of pain. Tim decided he’d like to start IV pain meds - Fentanyl - to ease her pain levels so she could hopefully sleep. Starting IV pain meds in the backcountry on a gravel bar is tricky: you have to be exceedingly careful to keep everything clean. You also need to monitor the patient carefully, especially with opiates, because they can suppress respiratory drive if the dose is too high. We were the sole medical care for this patient until she reached a hospital, which likely wouldn’t be until the next day at this rate, so we were in it for the long haul. Tim and I set up a sleep shift schedule, one hour on, one hour off, so we could try to rest while also keeping an eye on the patient’s pain and vitals through the night. Meanwhile, our team lead, Erin, was in contact with IC, notifying them of our location and the patient’s condition. We had already discussed as a team that evacuating at night would be too risky both for us and the patient, so Erin notified IC that we wanted to hunker down for the night and wait for IC to organize an evacuation in the morning. The options for evacuation were either a seven-mile litter float back down the Narrows, in which we strap the patient into a litter, which we rig onto a small raft, that we then walk down the river by hand; or a possible helicopter hoist, if the canyon walls proved to be wide enough at our location. The litter float was a common evacuation procedure in the Narrows for shorter distances, but a seven-mile float would likely take a team of at least 15 additional rescuers, probably more, and it risked taking so long that we could get benighted again the following night, which would render the rest of the float to be quite dangerous. The helicopter wasn’t an easy shot either though, since the canyon walls were so narrow that we weren’t sure if a helicopter could even access the patient. Our IC decided to begin mobilizing both in the morning, and organized a helicopter recon flight as well as a team to start packing for a possible float out. While we waited for evacuation the next morning, our task was to move the patient to the widest, most accessible spot on the sand bar for a possible helicopter hoist. We had sleeping bags and pads as well as a few hiking poles, so we improvised a stretcher. All five of us had to help move the patient onto the stretcher, and then carry her down the gravel bar. We only had to carry her 100 yards or so, but it’s amazing how tricky that can be over uneven terrain! Eventually, the helicopter flew by and the pilot decided they would attempt a hoist. The helicopter hovered, rotors spinning only a couple yards away from the canyon walls, as we all watched in total awe. Cool as cucumbers, they dropped one of their crew members down to start rigging the patient. For the patient, the story was nearly over. The helicopter was not medically equipped, but they quickly flew her to an ambulance rendezvous where she was then transported to the nearest hospital. She was admitted for ankle surgery within hours. But for us, we had a long day ahead. We were still seven miles from any trailhead, with loads of gear to haul and the clock ticking for when we’d run out of food or water. Time to move! We decided it would be easier walking, less hazardous, and faster, to continue upstream where the river was shallower and slower-moving rather than return the way we came. Finally, after about three more hours of river trudging, we reached the trailhead, tired but accomplished. Fellow team members picked us up, with a pile of burritos at the ready, and hauled us back to headquarters for clean up and debrief. This story is an example of how a real-life SAR incident unfurled. Referring back to the first installment in the series, “Foundations: What is Search and Rescue?” see if you can identify all the parts of the incident following the P-LAST acronym. Which parts seemed the most challenging during the story? Which parts were the simplest? Furthermore, consider what information, planning, or actions might have improved the response. In the final installment of this mini SAR series, “Lessons learned: Reflecting on the Narrows incident” we’ll debrief the story and discuss what would make a smoother response for next time. 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! 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! 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 learning 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 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! |
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