13 May The Quiet Confidence of Wilderness Medicine
Photo by Tim Doyle. ©NOLS
It had been a disastrous day on Mount Rainier and night was falling. I keenly felt the loss of the sun as a chill seeped through my light down jacket and my teeth began to chatter. A few feet away, my climbing partner lay on the ground with a life-threatening chest wound that our rescuers had sealed with a nitrile glove and some tape. My own broken ankle was snugly ensconced in a makeshift splint fashioned from a backpack, various articles of clothing, and an elastic bandage. It wasn’t pretty, I thought, noting the sleeve, sock, and other bits and pieces that poked out, but it would certainly do.
“Okay, everyone. Evacuate your patients to the classroom.”
With those words from one of our instructors, a tall and not-quite-lanky Wyomingite whom I’d correctly pegged as a climber the moment I saw him, “Mount Rainier” morphed back into a University of Utah courtyard dotted with spindly trees and aluminum picnic tables. Day three of our NOLS Wilderness First Responder (WFR — pronounced “woofer”) course was winding down.
Two days earlier, brisk morning air meandered through the open windows of a University classroom. Plain brown desks that had been pushed up against the walls contrasted starkly with a rainbow of daypacks and water bottles as a motley crew of college students, firefighters, EMTs, outdoor guides, and travelers formed a closed shape that looked less like the intended circle and more like a single celled organism.
Each of us had our own reasons for taking the course. As we introduced ourselves, I spoke of time spent alone in the backcountry and other remote locations around the world, and of my wish to be prepared. I left out that I knew what it looked like when Nature wreaked havoc. And I left out that I knew the infuriating powerlessness of reaching the limits of my first aid knowledge when there were people who needed help. That last feeling, more than anything else, was why I was there.
* * *
Wild places don’t always start out wild. Driving in a sparsely populated region of eastern Colorado, four minutes was all it took. Four minutes spent with shirts pulled over our mouths and noses, trying unsuccessfully not to breathe in the chalky earth. Four minutes hearing nothing but the shrieking, piercing wind.
When the dust storm began to settle, pebbled glass glittered in the reemerging sunlight. The hood of a semi lay strewn in the roadside grass, and stretching down the highway, a chain of cars, pickups, and semis were crushed like crumpled balls of paper. We were miles from town. Emergency personnel were en route, but as the minutes ticked by, the line between urban and wilderness began to blur.
We had a first aid kit and time, but not much else. My companion was a jack-of-all-trades: a former wildland firefighter, a trained EMT, and an early responder to several natural disasters. I was none of those things. I followed his lead as we moved through the chaos, checking pulses we could reach, asking questions of people who could answer, and collecting information to pass along to emergency personnel when they arrived. The list of potential injuries seemed endless: lacerations, broken bones, internal bleeding, concussions, spinal injuries. Don’t make things worse, I thought to myself.
“Keep pressure on that wound,” I told a man who continued to bleed profusely from his head and face. “Just keep talking to me,” I implored another man trapped and contorted in his mangled car.
I had someone trained in emergency response to rely on that day. But what if I had been alone? And what if help was even farther away? What if, instead of a dust storm and a car accident, it had been a rockslide in the backcountry, or a crisis somewhere even more remote?
* * *
The goals of the WFR course were to give us exactly the skills and systems we would need in an emergency, wilderness or otherwise, but after the first few days of working through scenarios, listening to lectures, and studying into the night, I remained wary.
“What does SCTM stand for again?” I asked myself over a lunch of peanut butter and jelly tortillas. I was drowning in acronyms, abbreviations, treatment principles and evacuation guidelines: ABCDE, BSI, CSM, LOR, AVPU, PERRL, SAMPLE, OPQRST, MOI, ICP. I flipped through my spiral-bound Wilderness Medicine Handbook, already covered in the scrawl of my handwritten annotations.
Photo by Justin Alexandre. ©NOLS
“IF YOU DON’T HAVE AN AIRWAY, YOU DON’T HAVE A PATIENT,” one particularly bold note yelled in all caps. Just below, a reminder that we would also be responsible for demonstrating composure in an emergency told me to “smear calm all over the place.” Eventually I found what I was looking for:
“Right,” I said to myself. “Skin: Color. Temperature. Moisture. Normal is PWD — Pink, warm, and dry. And it’s an early changing vital sign. Don’t confuse it with CSM.”
The basics of the first days were far from being cemented, but the frequent scenarios, in which some students became the patients while the rest gained hands-on experience in assessing and treating injuries and illnesses, were becoming more complex as we covered new topics and learned new skills. On the fourth day, as we headed into a mass casualty scenario, I was still wondering when or even if things would come together.
* * *
The helicopter had gone down somewhere in the Wasatch Mountains. Beneath an azure sky, our search and rescue team approached the scene: The injured were scattered, some lying bloodied in the open, others obscured behind trees and bushes, moans and cries carrying on the soft breeze.
The pilot stumbled toward the group and a team of two rescuers split off to assess and treat him. I heard him refusing their requests, transitioning from uncooperative to belligerent. A short distance away, a passenger sat beneath a tree yelling in Russian-sounding gibberish. Again, a team of two split from the group and made their way toward him.
In an isolated corner of the accident site, beneath the shade of a mature tree, a young woman with bright red hair cradled her bloody left arm. My partner and I walked over, pausing briefly to size up the scene:
One. I’m number one. Is the scene safe for us? (“The scene looks safe.”)
Two. What happened to you? (“She was in a helicopter crash.”)
Three. Nothing on me. (We put on gloves.)
Four. Are there any more? (“Yes, but it looks like everyone is being taken care of.”)
Five. Dead or alive? (“She’s awake and looking around.”)
After introducing ourselves and obtaining consent from the woman, I knelt in the cool grass, placing a firm hand on either side of her head to stabilize her spine. My partner conducted an examination that revealed an impaled branch in her arm, but no immediately life threatening injuries. Her vital signs were normal and her patient history was unremarkable. I pushed distractions — the helicopter pilot interfering with the care of other victims, the constant stream of Russian nonsense — into the background and focused on the patient in front of me.
“I’m going to ask you some questions,” I said. “Can you tell me your name?”
“Julia.”
“And where are we right now?”
“Somewhere in the Wasatch Mountains.”
“What time of day is it?” I continued.
“It’s the afternoon – after lunch.”
“Good,” I said, “and can you tell me what happened?”
“We were on a helicopter tour of the mountains and we crashed. I’m not sure why we crashed, though.”
“That’s okay. You’re doing great,” I assured the young woman. “Have you taken any medications today? Anything over-the-counter or prescription?”
“Just an iron supplement.”
“Have you had any alcohol or taken any recreational drugs today?”
“No.”
I turned to my partner. “Patient seems to be reliable. A+O x 4,” I confirmed, using the shorthand we had learned to communicate that she was awake and oriented as to person, place, time, and event. He nodded and I turned back to Julia, placing my hands in hers.
“Can you squeeze my fingers? … Good, now wiggle your fingers for me,” I asked. Each time she complied. I gently pinched the index finger of one hand, “Can you tell me what finger I’m touching?”
“My pointer finger.”
“Excellent.” I chose a finger on her other hand, checked her pulse, then moved down to her feet and repeated the process.
“CSMs are intact times three. There is some weakness in her left hand, but that’s likely due to the injury,” I told my partner. The acronym for circulation, sensation, and motion, rolled off my tongue naturally.
“Okay,” I said once more, “We want to try to rule out a spinal injury and if we do, we can help you get a little more comfortable while we take care of that arm. Sound good?”
“Yeah.”
“I’m going to roll you onto your side to check your spine,” I explained, “I need you to give yourself a big bear hug and cross your left leg over your right.” I grabbed fistfuls of clothing at her shoulder and hip and then turned to my partner who was still holding her head in a neutral position. “On your count,” I told him.
“One. Two. Three.”
I pulled the woman towards me as my partner kept her head stable, rolling her onto her side. I began to palpitate her spine from the base of her skull to her tailbone.
“Tell me if anything hurts or if I’m off your spine,” I instructed as I moved down, checking for tenderness, and obvious deformities. “Any pain?” I asked as I reached her tailbone.
“No. None.”
“Okay. Great. We’re going to roll you back over now.” My partner once again counted to three and we rolled the patient back to her original position.
“The patient is reliable, CSMs are intact minus the injury-related weakness in her left hand and the patient denies pain upon palpitation of the spine. I’m comfortable lifting spinal precautions,” I told my partner.
“I agree,” he concurred.
I turned to Julia. “We don’t believe you have a spinal injury, so at this point, my partner is going to let go of your head and if you’d like to sit up, you can.”
Once she was seated, my partner and I moved fluidly. We knew not to try to remove the impaled object, instead rinsing the area around the branch before stabilizing it and immobilizing our patient’s arm, creating a sling and swath to keep it close to her body. We had moved smoothly and quickly, but there were others to help, so after we walked her to the evacuation point and my partner began an oral report, I looked for reassignment.
With few patients remaining, I was assigned to help evacuate a victim who had suffered an evisceration during the crash. His rescuers had already done the heavy lifting, sealing his wounds and assessing his condition. Together we carried him to the evacuation location, where a helicopter was waiting to take him to the hospital. Immediately, we went back for our final patient, and as quickly as it had begun, the mass casualty incident was over.
“Congratulations,” one of our instructors said, “that was one of the best mass casualty scenarios we’ve seen.”
* * *
Six days later, after passing the written and practical exams, I became a certified Wilderness First Responder — with a NOLS Wilderness Medicine sticker happily affixed to my Nalgene bottle.
No matter what training I have, Nature will always be in control. If I ever find myself back on that rural Colorado highway, or on a trail in the backcountry when something goes wrong, I’ll still have a voice telling me not to make things worse. But I’ll also have a voice reminding me, with quiet confidence, how to make things better.
NOLS holds frequent Wilderness First Responder courses: Check out their upcoming dates and locations here.
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