Introduction
Trip medical forms can reduce program liability and help administrators and field staff prevent injuries and illnesses. In most cases, prevention is accomplished through appropriate screening of participants and modifying the structure of a trip by adjusting the trip’s activities and routes to accommodate individual medical conditions or concerns. The type and format of a trip medical form affects the quality of information received and the ability of program administrators and field staff to prevent and treat injuries and illness in the field.

Why require medical forms for trips?

• Accident/illness prevention via screening
• Accident/illness prevention via course design/structure by program administration (preferred and requires time to prepare/adjust)
• Accident/illness prevention via individual & group management by field staff (may be necessary if discovered during the trip). If a physical disability or an ongoing medical problem are discovered during the trip, it may be necessary to assess both the group's and the individual's abilities in light of the newly discovered disability or problem as well as the proposed activity progression and environment before continuing with the trip as planned.​

How is client medical information collected?
Medical information may be collected orally from the client or via a written medical form. Collection is more effective if all involved—client, guide/instructor, healthcare provider, etc.—know why the information is important and how it will be used.
There are two basic types of written medical forms: Those completed by a health care professional (physician, PA, or nurse), and those completed by the client (self-reporting).
Medical forms completed by a health care professional—especially if they are the client's personal physician—tend to be the most accurate. Those completed by professionals with little or no previous knowledge of the client—college or university clinics, for example—can miss some conditions if the providers rely heavily on patient self-reporting.
Self-reporting may be oral or written. Oral self-reporting typically takes place the day of the trip, often as clients are ready to embark on the trip. The accuracy of oral self-reporting is questionable as it's easy for clients to forget something important or simply not mention it for fear they will not be permitted to go on the trip. Clearly written self-reporting forms are better than oral self-reports.
Written forms—regardless of whether completed by a healthcare professional or by the client—tend to be more effective when a combination of check boxes and open-ended questions are used. For example, here's a question with Yes/No checkbox followed by a series of open-ended questions asking for more information:

"Are you taking any prescription medications?" (Yes/No)

"If you answered "yes" to the above question please:

• List the medication, dose, the reason for taking it.
• Are you current with each medication?
• If you plan to carry this medication with you on the trip, are there any storage requirements we need to be aware of?

If client medical information is so important, why don't all outdoor programs collect it?

• Personal health information is protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). While there are hundreds of ways that HIPAA rules can be violated, the most common with respect to outdoor programs is an organization's failure to control access to a client's personal health information (PHI) this includes the online transmission of PHI data. While a HIPAA violation is easy to avoid by simply not requesting clients to complete a written medical form, the lack of personal health information may have significant consequences in a remote setting if clients or guides are not prepared to address an emerging medical problem. The Family Educational Rights and Privacy Act of 1974 (FERPA) prohibits student trip leaders—but not professional trip leaders—from receiving medical information of other students. In some cases, a FERPA violation can be avoided if the student contractually waives their FERPA rights for the purpose of attending a student-led outdoor trip.
• Forms completed by a healthcare provider may cost the client additional money. As such, they are typically reserved for longer, more remote trips where the medical form is part of an overall admissions process. Once received, each form is reviewed by a trained person who may contact the individual or their provider for additional information. Outward Bound and NOLS are two organizations that require prospective students to meet with their personal physician and have them complete the organization's medical form as part of their admissions process. Some colleges and universities require trip participants to go to the college or university health system to have a medical form completed.
• Simple checklist forms with a few open-ended questions are easy to complete and, as such, are often used by outfitters on day or weekend trips that will have access to 911 systems. Clients are typically asked to complete them the day of the trip or bring the completed form with them.
• More detailed forms tend to yield more usable information. Usable meaning being able to guide a potential client to the trip that best suits them or adapting an existing trip to meet their medical and/or physical needs. The earlier a medical form is received by an outfitter, the more time they have to respond.

As mentioned earlier, it is extremely important for outdoor programs and outfitters to accurately describe the trip and its associated hazards and to share how a client's Personal Health Information (PHI) will be used. Consider integrating PHI information into the program's release form to obtain permission to treat the client should it become necessary during the trip, permission to allow the program/outfitter to share and transmit PHI information with guides etc. for the protection and safety of the client during the trip, as well as release the organization from any known and unknown hazards.

With the worldwide increase in natural disasters, wilderness medicine graduates are uniquely poised to help their neighbors in the event of a local disaster. Communities in all 50 states have organized Community Emergency Response Teams (CERT). CERT members are volunteers, and teams are structured so that local managers have the flexibility to adapt the program and their training to the specific needs of their community. The concept originated with the Los Angeles City Fire Department in 1985 and went national through the Federal Emergency Management Agency (FEMA) in 1993. Contact your local fire, police, or sheriff department for more information or visit the CERT website.

Deaths in the backcountry are rare, exactly how rare is up for debate. Much depends on how you define backcountry and where you get your numbers (outside of the National Park Service, accurate statistics are hard to find). That said, a few hundred people appear to die each year while recreating in the outdoors. Given the number of people who play outside annually, statistically, death is pretty rare. While the order often changes annually, the top ten causes of death in the backcountry appear to be:

1. Falls
2. Drowning
3. Avalanche
4. Heart Attack
5. Hypothermia
6. Heat Illnesses: heat stroke, exertional rhabdomyolysis, exertional hyponatremia (low sodium)
7. Lightning
8. Infectious disease (typically transmitted by biting insects)
9. Anaphylaxis
10. Wild animal attacks

So what should I do if I'm with a person who is dying?
There is no single answer that applies to all people other than support their process to the best of your ability. For many, this means holding their hand and simply being present. For some, it may include praying with or for them. If the person is awake, it may mean taking notes to share with relatives and friends. The specifics vary from individual to individual.

How do I know when a person is dead?
They will not have any signs of life: no pulse at their carotid artery, no chest rise, and no air coming from their mouth or nose. Over time their body will cool until it reaches the ambient air temperature and rigor mortis and liver mortis will set in.
Rigor Mortis: When energy is no longer being produced, muscles contract and stiffen beginning with the small muscles of the face, neck, arms, and shoulders and gradually encompassing larger muscles until the person's body is completely stiff. Rigor is typically fully set within eight hours and remains in place for roughly eighteen hours before reversing itself to pre-rigor status, starting with the large muscles.
Liver Mortis: When a person's blood stops circulating after death, gravity causes the red blood cells to settle leaving dark "bruising" in areas of the patient's body that are in contact with the ground. The process begins roughly thirty minutes after death and is fixed after approximately six hours.

What should I do after a person is dead?
Keep in mind that your first priority is yourself and the living members of your party. Make sure everyone is safe. Then, if possible, note the GPS coordinates of the body's location and notify the local authorities via radio, cell phone, satellite phone, or other communication device and follow their instructions. If the dead person was your patient, complete a SOAP note. If they were a client or student, also complete your program's accident/incident report form. Take pictures of the site and body, especially if the mechanism was trauma, and do your best to preserve the scene for the authorities; most states prohibit moving a dead body from the scene of the accident without the authority of the coroner. Of course, some scenes cannot be preserved due to weather or terrain. If you can't contact and receive direction from local authorities and find you must leave the scene, your photos become evidence and part of any subsequent investigation. If you decide to leave the scene and the body, do your best to protect the body from scavengers and clearly mark its location both visually and on a map. Although rare, some expeditions have decided to transport the body of the deceased out of the backcountry. Treat the body with respect and be sensitive to the cultural mores of the deceased and those around you.

On a functional level, the nervous system is divided into two divisions: the voluntary (somatic) nervous system and the involuntary (autonomic) nervous system. The voluntary division of the nervous system contains both sensory and motor nerves. Sensory nerves carry input to the spinal cord and brain, while motor nerves carry messages from them. Through its nerves, the somatic nervous system controls conscious functions, principally high-level thought and striated muscle contractions. The autonomic division  maintains or restores homeostasis by regulating smooth muscle contractions and the glandular secretion of hormones. Most autonomic functions are beyond conscious control.
The autonomic division of the nervous system is subdivided into the sympathetic and the parasympathetic systems. The sympathetic system stimulates effectors (cells or organs) while the parasympathetic system inhibits them. Both systems continually transmit impulses to the same effector and act in an antagonistic manner, with the stronger impulse assuming control. Under normal conditions, the sympathetic system is responsible for waking us up and the parasympathetic system is responsible for sleep and digestion.

If the sympathetic nervous system is engaged during a stress response, the body prepares for “fight or flight”: pupils dilate to increase vision; pulse, respiration and blood pressure rates rise to meet an intense physical demand; awareness, often seen as anxiety, increases; sweating increases, while vasoconstriction leaves the skin pale, cool and moist; and endorphins are released to block pain. Over stimulation of muscle fibers often results in uncontrollable shaking. A strong sympathetic response decreases cognitive function leaving patients unable to process complex information and feeling overwhelmed and often fearful. A patient experiencing a sympathetic ASR cannot give accurate information about their injuries. In most cases, they are unaware of any physical injuries and may not exhibit abnormal signs or symptoms upon examination. Their vital sign pattern may mimic or mask volume shock.

If the parasympathetic nervous system is stimulated, the patient becomes nauseated, dizzy, and may faint. Blood pools centrally around their digestive tract and their pulse, respiratory and blood pressure rates fall. Their skin is pale and cool. Upon awakening, the patient is often confused. A parasympathetic ASR may mimic the signs and symptoms of a concussion and make accurate assessment of a traumatic head injury difficult.

A serious medical incident is often stressful to all involved: rescuers, care providers, patients, and bystanders; and, any or all involved may have both immediate and lingering effects: Post Traumatic Stress Disorders (PTSD) are common, although individual reactions vary considerably. Your actions as a rescuer or care provider can mitigate your patient's stress in both the short term and long term. And as a scene leader, the same strategies apply to working with expedition members or your rescue team and bystanders. The term "Psychological First Aid (PFA)" has been used in recent years to identify strategies that have proven to help prevent or reduce both the short (ASR) and long term (PTSD) effects of stress. While the term may be new, the strategies discussed below should not be: Psychological First Aid is—and has been—an intentional and integral part of our Patient Assessment System. The strategies below align with current PFA principles.

As much as possible, rescuers should strive to create as safe an environment as possible in the aftermath of an overwhelming event by mitigating scene threats and calming patients, bystanders, and rescuers as necessary. It's vital not to lie to patients, bystanders, or team members but to be realistic and focus on what you—and they—can do, and are doing to keep them safe. This may include removing select people from the scene or shielding them from a chaotic scene.

Remember that stress affects everyone, including rescuers and care providers. You must first reduce your sympathetic ASR (fight or flight response) before attempting to help others. Again, be truthful and focus on the present. As much as possible, radiate calm. Following the Patient Assessment System and using SOAP notes help caregivers reduce their ASR by providing an organized, step by step thought process, that also acts to calm their patients.

It's easy for both patients and rescuers to feel powerless or helpless in what they perceive as extreme situations where no clear avenue forward is visible. Care providers can empower patients by involving them in their care and evacuation decisions where appropriate, and where appropriate in the care of others. And team leaders can empower rescuers, care providers, and bystanders by assigning clear—step by step—practical, and doable tasks.

Team leaders can also build an on-scene support network by assigning a care provider to each patient and have them remain with the patient throughout their assessment, treatment, and evacuation (they do not have to be the primary care provider). The relationship between a care provider and patient provides a very real lifeline for severely stressed patients. Both team leaders and care providers can also work to extend the support lifeline beyond the scene by helping patients and bystanders connect with their friends, family, and pets as soon as possible.

ln combination with shared, relevant stories, all of the above combine to help inspire hope for the current situation.

In combination with our patient assessment system and field handbook, we use SOAP notes to help teach students how to assess and treat patients. They quickly see the benefit in a well-designed SOAP note, especially for complex problems; however, they often question if a SOAP note should be used for every patient? After all they take time to complete (and everyone hates paperwork, particularly if it's seen as unnecessary). So...what's necessary and what isn't?

Sometimes the answer is obvious: The problem is serious and/or complex and a SOAP note is necessary. But what about minor problems, for example: blisters, strains and sprains, cuts, etc.; and problems that may, or may not, develop into something more serious, like hymenoptera stings that may progress to anaphylaxis, a blow to the head that may turn out to be a mild concussion, or a drowning patient who was awake throughout their rescue but coughing, etc. These are not so obvious, usually because they don't require an evacuation at the moment...but could in the future. What about them?

There are a couple of ways to proceed; both are valid:

1. Complete a SOAP note and incident report. After all, it only takes a few minutes. While a SOAP note may ultimately turn out to be unnecessary, you've covered your bases. And, it's programmatically important to keep track of even minor incidents in case they might point to field or administrative errors that need addressing.
   
2. Write down basic information in your notebook (patient's name, presenting S/Sx, problem, and treat/monitor the patient. If developing S/Sx warrant closer attention, transfer the information to a SOAP note and continue from there. Remember to complete an incident form.

Human health is linked to the health of the environment, including its plants and animals (yes, insects are classified as animals: Kingdom Animalia > phylum Arthropoda). Infectious diseases in humans are caused by viruses, bacteria, parasites, or fungi, and transmission is via one of four routes:

1. Direct human to human transmission is often via contaminated body fluids: fecal matter, saliva, respiratory droplets, vaginal fluids, sperm, and blood (HIV/AIDS, tuberculosis, measles, STDs).
2. Direct animal to human transmission is typically via insects and mammals (rabies). Indirect, vector-borne transmission between humans and humans is usually insect- (malaria, dengue fever, yellow fever) and water-borne (cholera, Giardia).
3. Indirect water-borne infections are usually transmitted between humans via ingested contaminated drinking water or food, or through immersion (Leptospirosis, Schistosomiasis).
4. Indirect, vector-borne transmission between humans and mammals is usually via insects (bubonic plague, Lyme disease) or the urine and feces of infected rodents (Hantavirus).

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 a proliferation of many infectious diseases. While this trend—the increase in infectious diseases—is predictable, the exact type and location of an emerging disease is not. It’s likely you will be exposed to an infectious disease where there is no historical data. To this end, you should take care to protect yourself by ensuring good personal and expedition hygiene, taking precautions against insect-borne diseases (see this blog article for details), and avoiding potentially infectious animals and their habitat. Keep in mind that although the Centers for Disease Control (CDC) and the World Health Organization (WHO) are monitoring the situation worldwide, (and it is worthwhile to visit their sites to see if the area you live, or intend to visit, is endemic to a specific disease) specific outbreaks are impossible to predict. Be cautious and take precautions.

At times, the evacuation of a patient may be necessary for their further assessment, definitive treatment, and/or simply additional recovery time. All evacuations in a wilderness environment carry some inherent risk to members of the rescue party and the decision to evacuate a patient should NOT be taken lightly. The need for evacuation depends on the severity of the patient’s injury or illness and your resources. The type of evacuation depends on the mobility of the patient, the size of your party and its resources, the difficulty of terrain, the weather and the distance involved.

Any evacuation, regardless of the type—self, assisted, simple carry, litter, vehicle—should not endanger either you or your patient beyond your capacity to deal effectively with the risk presented during the evacuation. In most cases, your field treatment for minor non life-threatening injuries will be effective and rapid evacuation will not be necessary. By contrast, your field treatment for most life threatening illnesses or injuries may simply buy you and your patient some time. In these situations, focus on a quick accurate assessment and fast evacuation. The “medical window” for life-threatening problems is often specific to the particular illness or injury. If an emergency evacuation is not possible, your field treatment will usually be limited to treating the patient’s signs & symptoms and supporting their critical systems; this is often ineffective and your patient may die. In general, any problem that causes a change in the patient’s level of consciousness is very serious. If a patient reaches definitive medical care (major hospital) while they are still awake they have a reasonable chance for complete recovery. If they reach definitive care with a significantly decreased level of consciousness (voice responsive, pain responsive, or unresponsive) their chances for a complete recovery, or a recovery at all are respectively reduced.

In today’s world of rapid communication via cell or satellite phones, it may be possible to consult with medical or rescue professionals prior to initiating an evacuation. This type of consult should be encouraged and part of any emergency action plan (EAP). When in doubt, it’s always better to seek a consult sooner rather than later. A thorough patient assessment is required prior to any medical consult and the use of a detailed patient SOAP note will facilitate both accurate patient assessment and communication. At minimum, your location (GPS coordinates), party resources, and the current weather are required for a rescue consult. Conserve your batteries and set a communication schedule prior to signing off.

When you are uncertain if a evacuation is necessary and a consult is unavailable, the following general evacuation guideline may be useful: any problem that is persistent, uncomfortable, is not relieved by your treatment—or cannot be effectively treated in the field—requires an evacuation. The speed of the evacuation depends on the degree of involvement, or potential involvement, of any critical system(s). The greater the degree or potential, the faster the evacuation.

The following definitions for levels of evacuation are correlated to the severity of the patient’s injury or illness and hence the urgency and speed of their evacuation. Every effort should be made to accurately diagnose the patient’s current and anticipated problems since an incorrect diagnosis may lead to a false sense of urgency and a willingness on the part of the rescuers to accept more risk than the situation warrants. In general, rescuers should ONLY be willing to accept a level of risk they believe they can safely manage based on their skill and the foreseeable problems. Unfortunately, not all problems are foreseeable and the amount of risk any given rescuer is willing to accept tends to rise with the severity of the patient’s injury or illness. Since it is impossible to legislate judgment, rescuers, when in doubt, must base their decisions on the “worst realistic case” situation both in diagnosing the patient and evaluating the risk associated with the evacuation. That said, the risk of a minor injury or illness to a rescuer is generally present during most evacuations and unavoidable under the circumstances.

WMTC Urgent Evacuation Levels

Level 1
The patient’s injury or illness is immediately life threatening and the patient may die without rapid hospital intervention, e.g.: increased ICP, volume shock, severe respiratory distress, respiratory distress in a near drowning patient, advanced disease, moderate to severe hypothermia, HAPE/HACE etc. All VPU patients require a Level 1 Evacuation.

Level 2
The patient’s injury or illness is potentially life threatening or will result in a permanent disability; the patient may develop a life threatening problem that requires hospital intervention, e.g.: concussion that is getting worse, systemic infection, spine & cord injuries, near drowning (no respiratory distress), etc.

WMTC Non-urgent Evacuation Levels

Level 3
The patient’s injury or illness is NOT life threatening, has little or no potential to become life threatening, and may be successfully treated in the field with no permanent disability; however, the patient is unable to resume normal activity within a reasonable length of time and/or requires advanced assessment. (E.g.: concussion that is getting better, unstable injuries with good CSM, reduced shoulder (dislocation) with good CSM, etc.)

Level 4 (no evacuation)
The patient’s injury or illness is NOT life threatening, may be successfully treated in the field with no permanent disability, and the patient is able to resume normal activity within a reasonable length of time, e.g.: minor wounds, minor stable injuries, minor environmental injuries, etc.

There is typically little or no difference in the how a urgent evacuation is conducted. The difference lies in the mental preparedness and realistic expectations of the rescuers. If rescuers are not prepared for a patient death—as in a Level 1 Evacuation—research has shown that they will likely require more time to recover from post traumatic stress (PTSD) than those who recognize and accept that a patient’s death is a real possibility.

For the purpose of this document “Wilderness Protocols” are defined as any protocols outside the traditional EMS curriculum but supported by practice guidelines published by the Wilderness Medical Society (WMS), the National Association of EMS Physicians (NAEMSP), and the American Heart Association (AHA), and the Scope of Practice documents published by the Wilderness Medicine Education Collaborative (WMEC). They will likely include but are not limited to:

• Use of prescription drugs, herbs, and OTC drugs.
• Field management and clearing of spine injuries.
  
• Wound cleaning.
• Treatment of impaled objects.
• Field management and evacuation guidelines for specific environmental injuries.
• Field management and evacuation guidelines for specific traumatic injuries.
• Field management and evacuation guidelines for specific medical problems.
• CPR protocols.
• Specific treatment of preexisting conditions (e.g.: asthma, diabetes, etc.).

In conjunction with their physician advisor, each institution should establish written wilderness medicine protocols to act as guidelines for the field management of trauma, environmental, and medical problems. The protocols should define when they should be used based on the timeliness of conventional EMS response. Wilderness Medicine Protocols are usually in effect when a group is longer than one hour from definitive care (with the exception of immediately life-threatening situations: e.g.: severe asthma, anaphylaxis, etc.) Institutions should also develop a first aid kit designed to support their guidelines and staff should be trained in the use of the kit contents on a regular basis. The use of weatherproof Patient SOAP Notes for documentation is highly encouraged.

We recommend that institutions and their physician advisors review the NAEMSP position papers, WMS practice guidelines, and the WMEC Scope of Practice Documents before amending them to the needs of their program(s). Institutions should consider adopting the following general guidelines for staff trained to the Wilderness First Responder Level (WFR):

• Administer 0.3 cc 1/1000 epinephrine by SQ/IM injection (Rx) and subsequent oral H1 ± H2 antihistamine at the first sign of a anaphylaxis in an adult (standard pediatric dose is 0.15 cc or 0.01 mg/kg). Subsequent injections are indicated if: the S/Sx increase after the last injection or do not resolve within 5-15 minutes of the last injection. Oral antihistamines should be kept current for 24 hours. Consider 10-50 mg of oral prednisone—typically administered for a maximum of two doses—if evacuation to definitive care is greater than 8 hours; for those who tolerate it, it is good insurance. (Some patients may be allergic to prednisone, others, especially children and teens, may have adverse side-effects.) Clearly define evacuation guidelines.
• Clear potential spine injuries in the field using one of the following focused spine assessment (FSA) protocols: NEXUS or modified NEXUS, Canadian C-spine Rule, or WMS guideline. Clearly define how patients who fail the FSA are to be handled during their evacuation. Rigid cervical collars and full spinal immobilization are dangerous and should be avoided. Obtunded patients should be evacuated in a commercial or improvised litter with their spinal cord protected from abrupt or gross movement using a vacuum mattress or soft padding.
• Aggressively pressure flush full thickness wounds with “drinkable” water and protect with an appropriate dressing. Wounds at high risk of developing an infection may also be flushed with a antimicrobial solution depending on physician advisor preferences. Deep, highly contaminated  wounds  may  be  wet  packed  with  the  same  solution,  splinted,  and  evacuated; do NOT close high risk wounds in the field. Evacuate all wounds with underlying damage to deep structures (bone, tendons, ligaments, cartilage).
• Remove impaled objects in the field if they interfere with safe transport or are likely to cause additional damage if left in place. Removal should be easy and not cause undue additional damage. Clean the wound as described above.
• Attempt to reduce simple dislocations of the shoulder, patella, and digits (resulting from indirect trauma).
• Discontinue CPR if the patient remains pulseless for 30 minutes. CPR hypothermia protocols should be clearly spelled out.
• Treat severe asthma with 0.3 cc 1/1000 epinephrine by SQ/IM injection (Rx); repeat prn q 15-20 minutes for a total of three doses. Administer 40-60 mg oral prednisone.

Authorization should be in the form of a written document that clearly identifies:

1. The sponsoring organization (e.g.: outfitter, schools, institution, club, etc. name).
2. A brief summary of the purpose: standard EMS training is based on immediate access, assessment, and transport via 911 communications. This level of training and subsequent scope of practice does not address the special considerations required in a wilderness/remote environment where delayed  transport,  prolonged  exposure  to  severe  environments,  and  limited  medical  equipment are the norm.
3. Who is authorized to use the protocols (currently certified WEMT, WFR, WAFA, etc.).
4. Each individual protocol—acute allergic reactions, spine clearing,  etc.—should  briefly identify the problem and specify signs, symptoms, and treatment (including evacuation). Ideally the protocols should be referenced to the providers original course text, handbook, etc.
5. The medical director/consulting physician who is authorizing the treatment, their license number, and date.

The completed document should be signed and dated by the institution's medical director.

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.

Cardiopulmonary resuscitation (CPR) and cardiocerebrial resuscitation (CCR) are valuable first aid skills and we should all master them. That said, their effectiveness is severely limited in a wilderness environment. Cardiopulmonary resuscitation uses a combination of chest compressions and rescue breathing to delay brain death and extend the resuscitation window while cardiocerebral resuscitation utilizes chest compressions only; both are potentially life-saving techniques. It takes approximately 10-12 chest compressions to build enough intrathoracic pressure to start circulating blood. The same intrathoracic pressure that circulates the patient’s blood also brings in a small amount of fresh air and oxygen. If there is residual air and oxygen in the lungs—as occurs in cardiac arrest caused by a heart attack—chest compressions alone are more effective in delaying the onset of brain death than when combined with rescue breathing because they maintain a consistent intrathoracic pressure. Conversely, a combination of chest compressions and rescue breathing (CPR) is more effective than CCR for patients whose arrest stems from a primary respiratory problem and lack of available oxygen as occurs in near drowning, lightning, complete snow burial, etc. The effect of both techniques decreases rapidly over time and cannot save or prolong the life of a pulseless patient for greater than 20 minutes and neither CPR or CCR work with major trauma patients whose arrest stems from increased ICP, significant lung damage, or volume shock.

For CPR or CCR to be effective the patient’s circulatory system must be intact and their core temperature above 90º F (32º C); your chest compressions must be hard and fast (ideally at least 100 per minute) and delivered in the lower third of the patient’s sternum; your weight must be directly over the patient and the patient’s chest must be allowed to fully recoil between compressions; the recoil is as important as the compression. If rescue breathing is indicated, ventilate until the patient’s chest begins to rise; do not over-inflate—over-inflation forces air into the patient’s stomach and increases the chance or frequency of vomiting.

In settings where rapid defibrillation, advanced cardiac life support, and rapid transport to a major hospital are not possible, the overwhelming majority of patients in cardiac arrest will die. It is important that all rescuers understand the limits of CPR and CCR and when it is appropriate to start and stop.

When teaching chest compressions in our wilderness medicine courses we often tell students to compress at the rate of the beat in the Bee Gee's disco tune "Staying Alive" or Queen's "Another One Bites the Dust" depending on whether a student views the glass as half full or half empty.... (Yes, humor is important in the medical field.)

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.