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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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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. You are on a three-week canoe expedition in the boundary waters. One of your students, Ximena, approaches you before breakfast complaining of pain and swelling in her ankles; she thinks it's a reaction to the black fly bites she received a couple of days ago when she forgot to reapply DEET after swimming. Yesterday the bite sites were slightly red and itchy. This morning, upon awakening, both her ankles are swollen with red streaks moving up her lower legs. She is tired and feels sick. Her core temperature is 101º F (38.3º C). It's day 14. What is wrong with Ximena 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 a Forest Service wildland firefighter supervisor and trainer. You have a strenuous field exercise planned for tomorrow for a new cadre. Unfortunately, an unseasonable heat wave is in place and the high temperature predicted for the day is in excess of 110 degrees F. What are your concerns and how should you address them? 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 and your partner are planning a two or three day backpacking trip near your home in Boone, NC with your seven year-old daughter and six year-old son. They have been car camping with you for the past three years, taken short day hikes, and enjoyed both. Your daughter is severely allergic to wasps and poison oak; she was hospitalized at four after being stung by a yellow jacket in your backyard. How should you plan your trip? 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 part of a hotshot crew responding to a wildfire in northern California. Temperatures are well into the triple digits close to the handline they were tasked with holding. James, one of the crew members, is complaining of the heat and it's difficult to keep him cool. During your patient assessment, you find that he has recently started taking Benadryl® for a newly developed allergy to juniper pollen. What do your think is wrong with James 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. |
