The Benefits of a Medical Advisor

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.

Interested in learnig 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.