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Blog

California & Washington State Epinephrine Laws and WMTC Epinephrine Certification

10/1/2019

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Washington State Epinephrine Law
WMTC is recognized by Washington State Department of Health as an authorized Epinephrine Auto-injector & Anaphylaxis Training Provider. The law permits healthcare providers to prescribe epinephrine auto-injectors to certified lay providers and REQUIRES the lay provider to report the use of epinephrine within five days of an incident via the departments Epinephrine Auto-injector Incident Reporting Survey online at https://fortress.wa.gov/doh/opinio/s?s=EpinephrineAutoinjector

California State Epinephrine Law

WMTC is an approved California state epinephrine auto-injector training program. WMTC students issued a WMTC Epinephrine card after April 29, 2019, may apply for a California epinephrine auto-injector certification card and should visit https://emsa.ca.gov/epinephrine_auto_injector/ for information and an application form.
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Applicants must include a WMTC epinephrine certificate with their application; the certificate is different from the WMTC epinephrine card issued at their course. To obtain a WMTC epinephrine certificate for the State of California application please email office@wildmedcenter.com. Put CA State Epi Certification in the subject line. In the body of the email include:
  1. The type of WMTC course taken: WFA, WAFA, WFR, WEMT, or Recert­.
  2. Student's name as it appeared in the course registration.
  3. The location of the course.
  4. The course sponsor.
  5. The dates of the course.
  6. The name of the instructor.

​Upon receipt of the email, our office will verify the student's WMTC epi certification using the above information and send them a pdf file of the certificate for them to print and include in the application for California State Epinephrine Certification; this service is fee of charge to all WMTC graduates. We will also send each student a pdf file summary of our auto-injector curriculum and CA Auto-injector laws. NOTE: California Epinephrine Certificates expire two years from the date a student graduated from their WMTC course.

Businesses and other organizations may obtain a prescription and stock epinephrine auto-injectors if they employ or utilize a volunteer that is an EMSA-certified lay rescuer. To receive the epinephrine auto-injector(s), the business must take the EMSA certification card to a physician to receive a prescription. The prescription can then be filled by a pharmacy. A business that stocks epinephrine auto-injectors is required to keep records, create and maintain an operations plan, and report to EMSA when an epinephrine auto-injector is used.
Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
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Community Emergency Response Teams

9/3/2019

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(What are they and should I join one?)
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.

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Wilderness Medicine Case Study 74

8/6/2019

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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.
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Death in the Field

7/2/2019

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(What to do when someone dies in the backcountry.)
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.

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Wilderness Medicine Case Study 73

6/4/2019

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You are leading a three-week summer backpacking trip for 18-21 year-old college students. While on a day hike to a local summit on day 13 of the trip, one of your students, Geoff, falls and cuts his leg on a sharp rock. There is not much bleeding and he can bear weight and walk with minimal pain. You are roughly a mile from your campsite with two days left until your next resupply.

What should you do? Click here to find out.

Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.

Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
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Wilderness Medicine Case Study 72

4/22/2019

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You are on a 6-day preseason guide training trip for a commercial river company operating on the Colorado River in the Grand Canyon. There is a party on the 3rd evening of the trip and many of the guides are drinking. When you head for bed around 10 pm there are still a few souls by the fire. An hour and a half later you are awakened by a drunken guide and asked to examine a 28 year-old male trainee who they cannot arouse.

You find Jim lying on his side on a sleeping pad near the fire. He is unresponsive with slow, irregular breathing; his pulse rate is 36 and regular, his skin is pale and his nail beds are blue-tinged. The night is slightly cool, likely in the mid-60s °F but it's warm by the fire where Jim is lying. You remember seeing Jim with a beer in hand but no one can remember how much he drank or if he had some of the whisky that had been passed around. Going through Jim's personal belongings reveals a bottle with a number of unidentified tablets.


What is wrong with Jim and what should you do? Click here to find out.
Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.

Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
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Wilderness Medicine Case Study 71

3/18/2019

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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.
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Wilderness Medicine Case Study 70

3/4/2019

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You are leading for a week-long rafting trip for a drug addiction program in Costa Rica. It's 6 PM and one of your students, Amalia, does not respond to your call for dinner. A quick search finds her lying in her shelter on her sleeping bag apparently asleep. She does not fully awaken when you call her name and lightly shake her. Her breathing is slow and easy, at 8 breaths per minute and her pulse rate is 46 and regular. Her medical form shows her normal resting pulse is 78 and regular and her normal respiratory rate is 16 and easy. She is in your program for opioid abuse after getting injured in an automobile accident a year ago.

What is wrong with Amalia and what should you do? Click here to find out.

Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.

Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
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Wilderness Medicine Case Study 69

2/18/2019

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Picture
You are en route to a backcountry lean-to managed by the forest service in the summer. Although the current temperature is in the low single digits after a cold front moved in early this afternoon, the weather yesterday was warm, above freezing, with bouts of hard rain. The snow is crusty and heavy on the forest road leading to the hut. You are two days from your car and it will take another day to reach the lean-to. You are carrying two weeks of supplies and hoping for new snow and fresh tracks after you reach the lean-to.
When you arrive at the forest service campground two of the shelters are occupied by a high school group who have been touring in the park the past week leaving an older, half-buried one for you and your friend. After setting up camp and eating dinner, you wander over to the high school group to say "Hi." They are starting to eat dinner when you arrive. The leader, one of the school's teachers, tells you much of their gear is frozen from yesterday's rain. You notice that a student is huddled in their sleeping bag in one of the shelters, everyone else is eating dinner. The group leader tells you the student, a 15-year-old female, was very cold when they arrived, immediately went to bed, and said she wasn't interested in dinner. While your gear is dry, you can see that many of the students' sleeping bags are frozen. The group leader is concerned about the drop in temperature and unsure how to keep the students warm at night.

What can you do to help? Click here to find out.

Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.

Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.

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Preventing Deaths from Opioid Overdoses in the Backcountry (Should I carry Naloxone?)

2/4/2019

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Deaths due to opioid overdoses continue to rise. Opioid abuse knows no age, race, or economic barriers; and, abuse is often hidden, making it difficult to know who is at risk for an overdose. In April 2018 U.S. Surgeon General, Dr. Jerome Adams, issued a public health advisory urging more Americans to learn to use and carry naloxone. Most states have approved Narcan® Nasal Spray for over the counter sales and publicly encourage addicts, family, and friends to carry it. Communities provide training and naloxone to police and place naloxone in public places with AEDs; some public health agencies provide it for free. Colleges and universities provide training and naloxone to staff and students. While still uncommon, opioid overdoses have occurred in wilderness settings. This begs the following questions:
  1. Should I carry naloxone in my wilderness first aid kit? Answer: Maybe. It makes sense to carry naloxone if you use high dose opioids, or if you are a friend, family member, or person who comes into contact with people at risk for an opioid overdose. Theoretically, the list could include almost everyone; that said, the risk of encountering an opioid overdose is likely higher for ski patrollers, outdoor therapy/substance abuse staff, park rangers, campground hosts, etc. and anyone who attends a party where alcohol and drugs are likely to be present.
  2. If so, how should I administer it? Answer: Narcan® Nasal Spray. While one ml vials and ampoules of naloxone are slightly less expensive than  Narcan® Nasal Spray, they require a prescription and take more training to use.

What are Opioids?
Heroin, morphine, codeine, and thebaine are naturally occurring opioids made from the resin of poppy plants; hydromorphone, hydrocodone, and oxycodone are derived from resin in a lab setting. Fentanyl, pethidine, levorphanol, methadone, tramadol, and dextropropoxyphene are synthetic. All opioids depress the central nervous system (CNS) and cause feelings of euphoria; when used correctly, for short periods of time, they are effective pain medicines. All are physiologically addictive. Chronic opioid users develop a tolerance for the drug and require increasingly higher doses to achieve the same level of pain control or well-being. (Note: Opioids are often mixed with other drugs for recreational purposes.) Withdrawal signs and symptoms are the result of excessive stimulus of the sympathetic nervous system and include: increased pulse rate and blood pressure, restlessness, tremors, sleeplessness, muscle and bone pain, abdominal pain, diarrhea, vomiting, sweating, and shivering; patients in acute withdrawal may become combative. As opioid tolerance increases so does dependence…and the severity of withdrawal S/Sx.


An opioid overdose typically occurs when someone takes a large amount of an opioid or a drug containing an opioid, mixes opioids with alcohol, or had a recent change in their level of tolerance. Life-threatening signs and symptoms of an opioid overdose include:
  • decreased level of consciousness from drowsiness to unresponsiveness
  • decreased pulse rate
  • slow, irregular, or no respirations
  • low blood pressure
  • the person’s skin is often pale or cyanotic (blue-tinged) from the lack of oxygen in their blood
Death due to an opioid overdose is usually due to respiratory arrest and the subsequent lack of oxygen to vital organs as the central nervous system shuts down.

What is Naloxone?
Naloxone is an opioid antagonist; it binds with and blocks opioid receptor sites in the brain, reversing the signs and symptoms of an overdose. In order to be effective, naloxone must be given before the patient goes into cardiac arrest. Except in extremely rare cases when someone is allergic to naloxone, administering naloxone to a patient who is not suffering from an oipoid overdoese does no harm. Naloxone will not prevent deaths caused by other drugs: alcohol, speed, cocaine, or sedatives (e.g.: benzodiazepines like Xananx®, Valium®, etc.).


While there are numerous delivery methods only two are conducive to using in a remote setting: intranasal spray and intramuscular (IM) or subcutaneous (SQ) injection. Of the two, only Narcon® nasal spray is available over the counter in most states, making the choice easy for lay people, outdoor educators, and guides.

Naloxone delivered as a nasal spray or injection takes roughly 3-5 minutes to act. If there is no response after five minutes, give another dose. Naloxone is metabolized in the liver within 30-90 minutes and its metabolites excreted in the urine over the next 3-4 days. Because naloxone is metabolized faster than most opioids—especially long-acting opioids like methadone or sustained-release pain compounds—it’s vital to carry more than one dose. Patients should be monitored for 2-3 hours as further doses may be necessary to treat a relapse. Acute withdrawal symptoms are possible but rare with intranasal administration of naloxone but cause for concern should they occur as the the patient may become combative and a danger to themselves and others.  
Naloxone slowly loses its potency over time or if it is exposed to too much heat, cold, or sunlight. That said, using expired naloxone will not cause harm but you may need more doses to reverse the S/Sx of an opioid overdose. Ideally you should replace expired all expired drugs, and store naloxone in a dark and dry place between 80°F (25°C) and 40°F (5°C)...you want to make sure that it is easily accessible should you need it.

When should I administer naloxone?
  • Give naloxone at as early as possible when an opioid overdose is suspected.
  • If no response after five minutes, give another dose.
  • If the patient’s breathing is slow, and they are cyanotic and obtunded (VPU), assist their breathing and give naloxone.
  • If the patient is in respiratory arrest, begin rescue breathing and give naloxone.
  • If the patient has no pulse and appears to be in cardiac arrest, begin CPR. Detecting a pulse in opioid overdose patients can be difficult and it may be reasonable to give naloxone based on the possibility that the patient is not in cardiac arrest (2015 AHA guidelines); note that naloxone alone will not reverse cardiac arrest.
Directions for administering Narcan® Nasal Spray
  1. Hold the spray with your thumb on the bottom and your first and middle fingers on either side of the device.
  2. Gently insert the nozzle into one nostril until your fingers on either side of the nozzle are against the bottom of the person’s nose.
  3. Once in place, you press the plunger firmly to spray the entire dose of Narcan® nasal spray into one nostril. There is no need to spray into both nostrils.
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Directions for administering an intramuscular injection of naloxone
Carry naloxone in a 1 ml snap-top vial (they are easier to use than a 1 ml ampoule); dose is 0.4 mg/ml. Consider carry a vial and syringe in a capped PVC pipe container; use the capped pipe as a sharps container to safely carry the used needle and syringe out of the backcountry for disposal.
Use a 21 to 23 gauge needle 1 to 1.5 inches long for an adult.


  1. With the vial sitting upright, inject air into the top of the vial; this increases the pressure inside the vial and will allow you to withdraw the medication.
  2. Turn the vial upside-down and withdraw the full contents (1 ml) of the vial.
  3. Hold the needle vertically and tap to move the bubbles to the top of the syringe.
  4. Gently depress the plunger to clear the air from the syringe; tiny air bubbles in the syringe won’t hurt anyone.
  5. Injections sites are deltoid or quadriceps muscles; you may go through clothing. Fully depress the plunger and wait 10 seconds before removing the needle.
  6. Place the used needle and syringe in a hard protective container; seal and clearly mark the container for disposal.

Interested in learning more about wilderness medicine? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.

Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
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