Introduction
Numerous articles, podcasts, and letters have recently argued for regulating wilderness medicine certifications. At its root, regulation is about control—someone always benefits, and there are always associated costs. This article discusses the various forms of regulation that apply to wilderness medicine certifications and attempts to identify who benefits and at what cost. Once they are known, we can run a cost/benefit analysis and see where it leads us in the near and distant future. Three types of regulation apply to wilderness medicine: economic regulation, government regulation, and self-regulation. 
Economic Regulation
Economics currently regulates the field of wilderness medicine; it's a problematic market-driven, buyer-beware scenario. The Boy Scouts of America, the American Camping Association, and numerous college recreation programs require tripping staff to be certified in Wilderness First Aid. And the outdoor industry recognizes Wilderness First Responder certification as the industry standard for guides and outdoor instructors. Interestingly, course curricula, hours, format, delivery strategies, instructor training, and student assessment and evaluation for both courses vary greatly depending on the provider. Without industry-wide certification standards, potential students, sponsors, employers, and land management agencies have no easy or reliable way to evaluate course curricula or quality. 
Beneficiaries 

• Low-quality wilderness medicine schools or training companies.

Costs

• There are no industry-wide certification standards for wilderness medicine. Economic regulation does not work for government agencies tasked with protecting the recreational public, employers seeking well-trained staff, and students seeking a quality education.

Government Regulation
Governments enact laws (policies) to control the practice of medicine. In the United States, the Emergency Medical Services (EMS) act of 1973—part of the Public Health Service Act—allocated funds to develop regional EMS systems. States are responsible for training and licensing four levels of first responders: Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), Advanced Emergency Medical Technician (AEMT), and Paramedic. Other countries have similar, but not identical, EMS systems. While numerous schools teach Wilderness EMT (WEMT) or Wilderness EMS (WEMS) courses, wilderness EMS is essentially unregulated on a national or international level. If a country regulated wilderness medicine certifications, it would likely roll the curricula and standards into its existing EMS system. 
Beneficiaries 

• The general public and state EMS agencies would benefit from an expanded scope of practice, and licensure is enforceable.
• EMS practitioners would benefit from a nationally recognized wilderness medicine certification.

Costs

• Innovation would slow down due to increased bureaucracy.
• Governments would likely approve some wilderness medicine schools as training centers so they could teach the WEMS curricula and standards.

Rendering First Aid versus Practicing Medicine
Good Samaritan laws protect people who provide first aid at the scene of an accident, act in good faith for the patient's benefit, within their training, and do not receive payment for their services. First aid training addresses the specific needs of a workplace, and the course curriculum tends to vary with the organization; sometimes, this requires advanced training. Graduates of WFA, WAFA, and WFR courses work in remote environments, under challenging conditions, with minimal resources, and in places where traditional EMS is not readily available. Depending on the country and region, some treatment skills taught in wilderness medicine courses may not be considered first aid by local authorities, but practicing medicine and, as such, require a license. Again, depending on the region, a licensed medical advisor with prescribing authority may—or may not—be able to authorize trained staff to administer prescription medications or follow advanced protocols.
Self-regulation
Two potential self-regulatory options exist—accreditation or industry acceptance of scope of practice documents that set standards for WFA, WAFA, and WFR certifications.
Accreditation
Accreditation is typically the form of self-regulation that initially jumps to mind. If a wilderness medicine school is accredited, an external body has reviewed and approved its curricula, delivery strategies, topics, scope of practice, assessment requirements, instructor hiring, and instructor training guidelines according to a previously agreed-upon set of standards. Accreditation is not a panacea; it does not guarantee quality but indicates an organization has gone through an evaluation process that may improve its operations. Seeking accreditation is voluntary, and the process generally requires a rigorous, often costly, evaluation of the organization's pedagogy with a focus on educational quality. The accrediting body is typically a non-profit organization comprised of widely recognized experts in the field. At present, there is no accrediting body for wilderness medicine schools. 
Beneficiaries 

• The general public and the outdoor industry would benefit from consistent WFA, WAFA, and WFR certification standards should accreditation be widely accepted.

Costs

• Establishing an accrediting body would be expensive and time-consuming and likely encounter serious resistance from the established schools. Wilderness medicine schools would have to adopt the certification standards created by the accrediting body. In today's environment, it's unlikely that the major schools would be willing to abandon their curricula, instructor training standards, copyrighted material, etc., in favor of accreditation.
• The bureaucracy and cost associated with accreditation would create barriers to establishing new wilderness medicine schools and slow innovation.

Scope of Practice Documents
Voluntary adherence to scope of practice documents is another form of self-regulation and a reasonable alternative to accreditation. Medically, scope of practice (SOP) documents define the assessment and treatment skills graduates can perform, while curriculum refers to content, delivery, and assessment strategies. Scope of practice, curricula, and certification are related and often overlap. For example, a scope of practice document may require graduates to be able to recognize and treat _______ As a result, _______ becomes part of the course curriculum; however, the SOP generally will not specify how a school must teach _______. While SOPs may specify the minimum hours required to teach core material and in-person skill labs and simulations, they typically leave the curriculum details, delivery methods, and assessment strategies to the individual school.
The Wilderness Medicine Education Collaborative (WMEC) formed in 2010 to provide a forum for discussing trends and issues in wilderness medicine and to develop consensus-driven scope of practice documents for WFA, WAFA, and WFR certifications. In 2022, they expanded their work to include related white papers and position statements. Collectively, the WMEC schools* have over two hundred years of experience teaching wilderness medicine and have trained over 750,000 students in the past four decades. 
Decisions regarding the content of the WMEC SOPs and papers are made based on emerging research and technology, peer-reviewed articles, and best practices. The WMEC SOP documents provide a basis for certification and curriculum development and are available for public use on the WMEC website. For the WMEC SOP documents to solve the wilderness medicine regulatory problem, international outdoor education and recreation associations must formally recognize them as the industry standard. Examples of industry-wide associations include the Association of Outdoor Recreation and Education (AORE), the Association of Experiential Education (AEE), and the Wilderness Education Association (WEA). 
Beneficiaries 

• The general public and the outdoor industry would benefit from consistent WFA, WAFA, and WFR certification standards.
• Curriculum and delivery innovation remain with the provider and will increase compliance.
• Management costs are significantly lower than accreditation.
• Adopting certification standards would avoid government intervention.

Costs

• Compliance relies on signatory schools to honor their commitment to adhere to the SOPs.
• Enforcement relies on the strength of industry standards to leverage buy-in.
• Since curriculum and delivery details, student assessment, instructor qualifications, and training remain within the provider's purview, these standards will vary. 

Conclusion
The United States EMS system will likely develop a Wilderness EMS (WEMS) certification in the coming years; however, licensing WFA, WAFA, and WFR certifications appear unlikely. That said, there is the possibility that state regulators may push for standardized exams, and if that occurs, the exams will have the potential to impact WFA, WAFA, and WFR course curricula. Creating an accreditation body also seems unlikely due to the expense and resistance from established WFA, WAFA, and WFR schools. At this juncture, adopting the WMEC SOP documents as certification standards seems the most likely outcome, assuming AORE, AEE, and WEA, among others, are willing to endorse them as industry standards. The WMEC released an updated WFR SOP and numerous white papers October 2022 and is on track to release updated WFA and WAFA SOPs in the coming months.

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:

• Help program managers identify predisposing terrain, environmental, and clinical conditions that may contribute to program-related accidents, injuries, and illnesses and suggest strategies to prevent them.
• Write standing orders authorizing your staff to administer medications or follow treatment protocols in the event of an injury or illness. 
• Assist in reviewing your trip participants' health information.
• Provide advice during an incident.
• Annually, review the program's accidents and incidents.
• Help train staff.

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:

• Online protocols require verbal permission from a medical advisor to implement.
• Offline protocols do not require verbal permission from a medical advisor to implement and rely on the judgment of the field provider.

Many states or governing bodies have laws and rules regarding the use of "standing orders" or "protocols" for non-prescribers. Local laws may prohibit unlicensed persons from using techniques and treatments listed in the Wilderness Medicine Education Collaborative (WMEC) scope of practice documents and taught in WFA, WAFA, WFR, or WEMS courses.
Best Practices
Standing orders and protocols should:

• Be written in clear, easily understood language.
• Be accessible to all who need to follow them.
• Be carefully chosen so they have little potential to cause patient harm.
• Be based on evidence-based guidelines and recommendations.
• Clearly define who is authorized to use the protocol. Standing orders imply training and certification. [Does the protocol apply to all currently certified staff—WFA, WAFA, WFR, WEMS—or only to graduates holding a WFR or WEMS certification?]
• Clearly define when—under what conditions—staff may use the protocol.
• Clearly define if the protocol is offline or online. In other words, may staff exercise their judgment, or must they obtain verbal permission from the medical advisor—or their appointee—before proceeding?
• Be periodically reviewed and revised; annual reviews are common.
• Be signed and dated by the medical advisor authorizing the order(s) and include their license number.

We recommend medical advisors review the WMS practice guidelines, the WMEC scope of practice documents, and all applicable laws before writing standing orders for an organization. It is critical that organizations train their staff to follow their standing orders and protocols.
Examples
Examples of standing orders written for an outdoor program or guide service by their medical advisor include:

• Authorizing staff to administer prescription or over-the-counter medications to clients.
• How to clean and debride wounds.
• How to treat impaled objects.
• When to start and stop cardiopulmonary resuscitation (CPR) in both normothermic and hypothermic patients.
• How to rule out a potential spine injury in a person involved in a traumatic incident.
• How to reduce a specific joint dislocation.
• How to treat persons who test positive for COVID in the field.

Examples of standing orders written for an individual by their personal physician or an organization's medical advisor include:

• Developing a sick day plan for an individual with Type 1 diabetes.
• The administration of prescribed medication for an underage individual.
• The on-going field treatment of an individual with a chronic condition.

All outdoor trips incur risk. Trip planners must balance the severity of a potential injury or illness with the expedition members' outdoor skills, equipment choices, and the availability of outside assistance. The planner must accurately assess each member's skills and other factors with:

• the risks inherent in the activity: rock climbing, mountaineering, trekking, whitewater, skiing, caving, ocean touring, etc.
• the potential for and the severity of a hazardous weather event: flash floods, lightning, wind events, storm surges, mudslides, high water and flooding events, and wildfires
• infectious disease outbreaks
• evacuation-associated injuries should an injury or illness occur.

Program managers and trip planners often require a deeper understanding of preventative wilderness medicine strategies than most WFR or WEMT graduates possess. A medical advisor who is intimately familiar with the program or trip can recognize clinical conditions for specific medical problems and aid in developing effective mitigation strategies.
Let's take a closer look at each risk category:

​Hazardous Weather Events
Due to global warming, hazardous weather events are increasing worldwide, making a trip-related prediction of potential weather-related injuries challenging. In addition to injuries directly associated with weather events, changing microclimates are expanding disease and fauna boundaries, often increasing the range of infectious diseases and venomous creatures.
Managers and trip leaders need to:

• focus on identifying emerging weather patterns within their expedition areas and modify their routes and activities accordingly
• ensure reliable two-way field communication and increase weather check-ins
• review, field test, and update their emergency action plans
• ensure pre-season or pre-trip training that focuses on early field recognition of potentially hazardous weather events and their subsequent avoidance and mitigation strategies
• work with a medical advisor to ensure effective pre-trip screening to identify pre-disposing risk factors for environmental injuries and illnesses and develop management guidelines to mitigate them

Inherent Activity- and Terrain-associated Risks
Most activity- and terrain-associated hazards are well known within the outdoor industry. Nationally and internationally recognized professional organizations offer training and certification in numerous outdoor pursuits designed to promote best practices within the industry. Both professionals and non-professionals can benefit from these courses and certifications. Training in activity-specific rescue techniques and wilderness medicine, especially Wilderness First Responder, helps expedition members understand potential consequences should things go wrong and imbibe a conservative approach to risk and site management.

Infectious Disease Outbreaks​
Each pathogen, animal vector, and host has an optimal climate in which they thrive, with warm, moist temperate, subtropical, and tropical environments being the best. Global warming has increased and will continue to increase, both temperature and precipitation worldwide, leading to the proliferation of many infectious diseases. While this trend is predictable, the exact type and location of an emerging disease are not, and exposure to and contracting an infectious disease in an area without historical data is increasingly common. To this end, expedition members should protect themselves by treating their water, ensuring good personal and expedition hygiene, taking aggressive precautions against insect-borne diseases, and avoiding potentially infectious animals and their habitat. Avoidance equals prevention, and there are no reliable field treatments for most infectious diseases.
Do your research:

• Information about prevention, vaccines, drug prophylaxis, and treatment is available from the Department of State, the Centers for Disease Control (CDC), the World Health Organization (WHO), and the International Association of Medical Assistance to Travelers (IAMAT). NOTE: the above sources may not have current information on remote regions; confirm or update your findings with local medical professionals immediately upon arrival. 
• Common insect carriers are fleas, mosquitoes, sand flies, lice, chiggers, ticks, & assassin bugs, and proteins in an insect's saliva may cause allergic reactions. Use protective netting, clothing, and insect repellent. The most effective repellents are those with 20% DEET, picaridin, or IR3535; use them on exposed skin. Treat clothing & equipment with products that contain 0.5 percent permethrin, an insecticide.

​Evacuation-associated Injuries
​The ability—or lack thereof—to rapidly evacuate an injured or ill expedition member to definitive care may directly affect their outcome. Since the inherent risk of injury to rescue party members tends to increase with the severity of the patient's injury or illness, it is critical to diagnose the patient's current and anticipated problems accurately. In some cases, an accurate assessment may require more medical experience than expedition members possess, and a physician consult may be necessary. Any evacuation, regardless of the type or urgency, should not endanger members of the evacuation team or the patient beyond the team's capacity to manage the risk effectively.

Stress is inherent in outdoor trips and activities. People can often adapt to mild stress and return to their baseline relatively quickly; however, chronic, moderate, or severe stress may overwhelm an individual’s coping mechanisms and result in a mental health problem. S/Sx include increasing inability to cope with the challenges of the trip, activity, or group. The graphic below depicts the different levels of distress and their associated evacuation levels with respect to a mental health even

To help avoid a mental health crisis on expeditions or trips, it is critical to identify and evaluate an individual’s distress early. Check in with the group or individuals daily or after potentially stressful events as part of the expedition culture and stress management. Consider using colors as a tool to help group members self-identify their current stress level.

Green = no distress
Yellow = distressed and actively compensating or coping
Orange = overwhelmed having difficulty compensating or coping
Red = severely overwhelmed and no longer compensating or coping

People who self-identify as distressed, overwhelmed, or severely overwhelmed need support and should be encouraged to seek out and speak with staff or the trip leaders privately. Similarly, if staff or trip leaders observe behaviors that indicate a participant may be in distress or crisis, they should speak privately with the individual. Depending on the participant’s story and presenting S/Sx, they may  elect to support them in the field or begin an evacuation.   

S/Sx of Potential Behavioral & Psychological Distress

• Does not participate in group discussions or decision making.
  
• Has little or no interest in maintaining friendships or participating in daily activities.
  
• Withdrawn, seeks solitude whenever possible.
  
• Shunned by group members.
  
• Constantly fidgets, appears anxious or afraid.
  
• Appears easily annoyed, irritable, or unusually critical.
  
• Appears distracted, speaks unusually slowly, or rambles.
  
• Appears sad or unhappy, exhibits episodes of crying.
  
• Poor appetite or overeating.
  
• Shares beliefs that other group members find unusual or bizarre.
  
• Sudden or noticeable change in daily functioning.
  
• Exhibits disruptive behavior.
  
• Unusually emotional.
  
• Exhibits on-going conflict with group members or staff.
  
• Exhibits on-going irrational behavior.
  
• Complains of numerous unexplained physical ailments.
  
• Exhibits an inability to cope with daily problems and activities.
  
• Self-identifies as distressed (yellow), overwhelmed (orange) or severely overwhelmed (red).
  

Support Guidelines
Participants who are in distress but actively compensating (yellow) may remain in the field if supported and their daily functioning monitored. Support participants by:

• Creating a calm, safe environment
  
• Carefully listening to their story and concerns
  
• Involving them in problem-solving and self-care
  
• Helping them build stronger relationships with staff or trip leaders and group members
  
• Working with them to create practical step-by-step solutions with measurable (visible) outcomes
  

Evacuation Guidelines
If any of the following conditions are met, the participant should be evacuated and seen by a mental health professional; closely monitor them during evacuation.

• Field staff—or those providing patient care­—are uncomfortable with the situation.
  
• Patient exhibits an on-going or growing inability to cope despite interventions and support.
  
• Patient’s behavior negatively affects other trip members’ experience.
  
• Patient is prescribed Rx meds for a mental health condition and is not taking them.
  
• Patient appears to have the potential to harm themselves or others.
  
• Patient wishes they were dead or expresses suicidal thoughts.
  

Prevention and proper hydration is key to avoiding all heat-related illnesses, and the cornerstone of prevention is to allow your body enough time to acclimatize to a new heat challenge. With that said, the drugs listed below can predispose outdoor adventurers to a variety of heat illnesses and heat-related problems. Check to see if your friends, clients, or students are taking any of them before venturing into the outdoors this summer when it's hot outside. (A printed drug guide, app, or website will help you understand the side effects, contraindications, and administration guidelines for most drugs.)  If you find that they are taking a drug that predisposes them to a heat illness:

1. Avoid outdoor trips that will expose them to a significant heat challenge.
2. If you decide to go on the trip in the face of a moderate heat challenge—as many people do—make sure to allow time for them to acclimate to current and new heat challenges, carry enough water to ensure adequate hydration (and to cool them should it become necessary), minimize exercise (especially during the hottest time of day), carry reliable communication, and have an emergency evacuation plan in place.

Anticholinergics
Anticholinergic drugs block the transmission of the neurotransmitter acetylcholine in the central and peripheral nervous system responsible for the autonomic control of the smooth muscles primarily in the gastrointestinal (GI) tract, the genitourinary tract, and the lungs. They are used to treat:

• vertigo and motion sickness
• peptic ulcers, diarrhea, diverticulitis, ulcerative colitis, nausea and vomiting (GI problems)
• cystitis, urethritis, and prostatitis (GU problems)
• asthma, chronic bronchitis, COPD (respiratory problems)
• slow heart rate due to a hypersensitive vagus nerve. 

Anticholinergics inhibit sweating—and therefore cooling—and predispose people to both heat exhaustion and heat stroke.

Antihistamines 
Antihistamines block histamine receptor sites in mast cells and basophils, smooth muscle, the lining of lymph and blood vessels, and histamine-releasing neurons in the brain. There are two subcategories of antihistamines: H1 and H2; both are used to treat allergies. H2 antihistamines, because they bind to histamine receptors in the gut, are also used to treat peptic ulcers and acid reflux and H1 antihistamines, because they cross the blood-brain barrier and bind to histamine receptors in the hypothalamus, may be used to treat insomnia in adults and motion sickness. Similar to anticholinergic drugs, antihistamines inhibit sweating and predispose people to both heat exhaustion and heat stroke.

Opioids
Opioids—including their semi-synthetic and synthetic derivatives—are used to manage both acute and, to a lesser extent, chronic pain; strong opioids are highly addictive. Codeine, a weak opioid, is commonly used in over-the-counter (OTC) pain medications and cough suppressants. Loperamide, an  opioid that cannot cross the blood-brain barrier acts on the large intestine to suppress diarrhea. All opioids decrease blood flow to the skin and predispose people to heat stroke.

Pseudoephedrine
Pseudoephedrine is a stimulant that acts on the smooth muscle lining the blood vessels and bronchi causing them to constrict; it is used to treat sinus and nasal congestion and promote drainage of the sinuses and the Eustachian tubes. Because it's a vasoconstrictor, pseudoephedrine decreases blood flow to the skin and predisposes people to heat exhaustion and heat stroke.

Diuretics
Prescription diuretics are first-line drugs used to treat high blood pressure. Along with caffeine, prescription diuretics promote dehydration via excessive urination and, through that route, predispose people to heat exhaustion, heat stroke, and—because they deplete the body of sodium—hyponatremia. ​

Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRIs are a class of drugs primarily used to treat depression and anxiety disorders but may also be used to treat post traumatic stress disorders (PTSD). The exact therapeutic mechanism is unknown and the side effects of SSRIs may outweigh their benefit. All SSRIs can cause dehydration, which, in turn, can lead to more serious heat illnesses.

Ibuprofen & Naproxen 
Both ibuprofen & naproxen belong to a family of drugs called non-steroidal anti-inflammatory drugs (NSAID) that are commonly carried in first aid kits to treat pain or reduce a fever. While neither drug predisposes people to a heat illness, CAUTION is advised as they can cause kidney damage in the presence of dehydration.

Antipsychotics
Antipsychotics block receptor sites in the brain's dopamine pathways and are used to treat schizophrenia and bipolar disorders, and combined with antidepressants to treat depression in the short term. Unfortunately, they can inhibit the body’s ability to regulate temperature and predispose people to heat stroke.

Beta Blockers
Beta receptors are found in the smooth muscle cells of arteries, bronchi, kidneys, and the heart. When stimulated by epinephrine and other stress hormones, they cause a sympathetic stress response that, among other things, increases heart rate and blood pressure. Beta blockers weaken the stress response and are primarily used to manage abnormal heart rhythms and prevent a second heart attack. (They may also be used to treat high blood pressure but are not as effective as diuretics.) They reduce blood flow to the skin and and predispose people to heat stroke.

Calcium Channel Blockers
Calcium channel blockers disrupt the movement of calcium through cell membranes and are used to treat high blood pressure. They help increase the elasticity of the wall of large blood vessels allowing them to stretch and expand. In this way they also reduce chest pain caused by angina pectoris. They are more effective than beta blockers but have more side effects. Similar to beta blockers, they also reduce blood flow to the skin and predispose people to heat stroke.

Ephedrine, Amphetamines, & Cocaine 
Ephedrine, amphetamines, and cocaine are central nervous system stimulants. Ephedrine is used as a stimulant, appetite suppressant (currently banned in the United States), concentration aid, and decongestant; it works by increasing the activity of norepinephrine. Amphetamines are used to treat attention deficit hyperactivity disorder (ADHD) and narcolepsy. Cocaine is made from the leaves of the coca shrub with no current medicinal use; it is primarily used as a recreational drug...as are many amphetamines. ​Ephedrine, amphetamines, and cocaine increase internal body temperature, constrict blood vessels, and predispose people to heat exhaustion and heat stroke.

Tricyclic Antidepressants
Tricyclic Antidepressants (TCAs), as the name implies, are primarily used in the treatment of mood disorders; they are also used to treat chronic neuropathic pain and as migraine prophylaxis (but will not treat a migraine attack). TCAs also decrease sweating and inhibit the body’s ability to regulate temperature and predispose people to heat exhaustion and heat stroke. ​

ACE Inhibitors
ACE inhibitors are primarily used to treat heart and kidney problems. They block the production of enzymes that cause vasoconstriction and permit blood vessels to relax (dilate) reducing both blood and kidney pressure. ACE inhibitors may cause increased sweating in some patients, which may quickly lead to dehydration in a heat challenge, and by that route predispose people to heat exhaustion and heat stroke.

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