Lightning StrikeEven though summer is coming to an end, lightning remains an ongoing risk. that between 1997 and 2000, there were 104,294 strikes in the canyons. Before embarking on your adventure, it is important to prepare yourself to avoid such risk. Below are some key things to note to prevent the risk of lightning strike.

  1. Know your local weather patterns. Seek a low-risk area for shelter when you see lightning or hear thunder. Lightning can strike whenever the time from the lightning flash to the thunder crash is less than 30 seconds
  2. Remember lightning can strike even when it is not raining and when there are no clouds visible in the sky
  3. Avoid exposed areas during potential storms, such as creeks, cracks, crevices, ridges, towers/high places, open water, isolated tall objects, and opening of caves or buildings
  4. Get low and sit or squat in a way that will decrease your ground-contact footprint.  Although its effectiveness questionable, sitting on an insulator like ensolite, a rope or other padding can’t hurt.
  5. The risk of a strike increases as the time interval shortens. Estimating the distance from lightning by dividing the time interval bin seconds from the flash and crash (by 5 for m & 3 for km) is simple but not terribly accurate. The National Lightning Safety Institute’s 30/30 rule is often an impractical guideline for backcountry use.
  6. Spread the group out but maintain visual contact if possible to avoid a multiple-casualty strike
  7. If you can get to an area of lower risk, keep moving toward it. Inside your vehicle is safest.


Treatment of Lightning Injury

Scene size-up is particularly important when responding to lightning injury. Hilltops or cliff faces may be especially dangerous to approach. Look for other patients as 10% of lightning injuries involve two or more people. 25% of survivors develop long-term physical or psychological problems, such as chronic pain or depression.

  • Initiate immediate basic/advanced life support
  • Treat what you see:
    • Cardiopulmonary arrest – Lightning can induce cardiac arrest. Pulse often returns spontaneously if heart damage is minimal. If it does not, immediate cardiopulmonary resuscitation (CPR) and positive pressure ventilation (PPV) can be life-saving
    • Blunt or penetrating trauma – Rare but possible, the force of a direct strike or near miss may cause significant blunt trauma including ruptured organs and broken bones
    • Neurological impairment – Many patients experience loss of consciousness, amnesia, numbness, tingling and weakness
    • Burns – Most burns are superficial. Less than 5% of patients experience more serious, deep burns


Bonus: What states experience the most fatalities from lightning strikes?

According to , Florida has by far experienced the most fatalities in the U.S. with 345 deaths between 1959-1994 in Storm Data. Here are the other 9  states with the most deaths by lightning strike.


Number of Deaths

1 Florida 345
2 North Carolina 165
3 Texas 164
4 New York 128
5 Tennessee 124
6 Louisiana 116
7 Maryland 116
8 Ohio 115
9 Arkansas 110
10 Pennsylvania 109


Much of this information comes from the . The recently revised textbook, printed on water and tear-resistant paper, serves as a great reference guide for those well-versed in wilderness medical emergencies.

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I am not sure that there is a consensus about their use but here is my opinion about tourniquets in remote and hostile environments.

In brief:

1.  Learn how to use one and practice with it.

2.  Apply to stop bleeding not controlled by well-aimed direct pressure.

3.  Use something wide and firm (but not hard) that can apply circumferential pressure.  The pressure should be sufficient to stop bleeding.  Make sure that it is in good shape and not a knock-off.

4.  Place proximally (upstream) and as close to the wound as possible.

5.  Don’t release in the field if the patient is in shock, has an an amputated limb, or has a wound site that cannot be monitored for re-bleeding.

6.  For a long evacuation, wait an hour before trying to release it.  If bleeding starts again, re-secure.  Note the time and leave it in place until definitive care is reached or arrives.

7.  Under dangerous circumstances, one may be applied before a thorough evaluation is possible.  These should be applied to the proximal thigh or arm if there is any question about the location and/or number of wounds.  Carefully check the wound when it is safe and feasible. As indicated, leave, reposition, or release it or add a second one proximally.

The following is an explanation of my above opinion.  None of this should be misconstrued as a blanket endorsement to buy and carry one on all trips.

Tourniquets have a checkered history and hyperbolic .  Past and current combat experience in the SW Asian theaters has because injuries to limbs have been a major source of life-threatening bleeding. There, .  In the later case, they are applied before a proper assessment is possible e.g., multiple casualties, continued live fire.  The tourniquets used are relatively cheap and can be lifesaving if used properly.  As with anything in medicine, nothing works 100% of the time.

In civilian practice, it is relatively for death from limb bleeding to occur because applied, well-aimed direct pressure failed. Still, tourniquets have their use outside of theater (e.g., mass casualty), so knowing how to use one is important. The relevant questions include what, where and for how long.

What: ought to be soft (but not mushy) and wide.  Within limits, wider is better. To be effective, the circumferential pressure needs to be sufficient to stop bleeding. A sphygmomanometer (BP cuff) might be ideal except that they usually will not maintain adequate pressure for a long enough period of time. They and are also bulky and fragile. The gauges break easily and the fabric, bladder and tubes are vulnerable to sharp objects. Cordage, like a rope or 550 cord (parachute), is not a good choice either because of the potential for direct skin and neurovascular injury.

There are a variety of more serviceable versions. Two of them, the CAT (combat application tourniquet) and SOFTT (special operations forces tactical tourniquet), have worked reasonably well in combat. They are compact, inexpensive and easily applied, even by the patient.  Their advantages are a for .

One needs to have enough remaining limb to hold the tourniquet. I have heard intelligent people argue that they should never be applied to forearms and legs (lower).  Generally, I disagree and would seem to bear that opinion out.  They should be applied as close to the wound as possible.  When circumstances prevent a proper assessment for location and number of wounds, some recommend using only the proximal arm (upper) and/or  thigh as default positions.

If limb bleeding will not stop, especially with a , , proximally, may help. Stay off joints.  Controlling junctional (e.g., in the groin) bleeding remains problematic.

How long:
People fear tourniquets because prolonged use can lead to neurovascular damage and tissue death. We know that tissue death from impaired circulation can occur in as little as two hours. We also know that .

Releasing a tourniquet has its own risks and there are circumstances where removal never makes sense.  These later would include limb amputation, shock, the inability to monitor the wound or continued bleeding.  Intermittently releasing them to temporarily restore circulation has been .   On a long evacuation, if the conditions seem otherwise safe, waiting 1 hour before attempting a removal seems like a reasonable time interval.  If bleeding starts again, resecure,  note the time and leave it in place.

Improper application is an important cause of failure.  They can  or from poor construction (e.g., older version knockoff).  Always check your equipment before heading out and replace anything questionable.  Practice with any tool before you need it for a real emergency.

There are plenty of good resources online that cover step-by-step application and the identification of knockoffs (e.g., date printed on webbing, red tip on the end of webbing).



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Walking through the first aid aisle at your local outfitter store can be overwhelming. While there are many excellent prepared kits on the market, often enthusiasts choose to create and specialize their own.  Your kit will be different based on where you are camping and hiking. Trips at altitude, near marine environments or canyoning, and desert trekking each have unique needs that would require you augment your kit accordingly.

Below is a “basic kit list,” to which you can add on as your number of adventurers, length of trip, level of training, or destination dictate. An asterisk marks items that you might include for your week-long trip. For your overnight, you can feel comfortable paring down the quantities.

Personal Protection:

  • Gloves (Nitrile) – Vinyl is too porous, and latex is a common allergen.  Bring a few more pair than you think you need. You use one pair of gloves each time you clean a wound, and gloves aren’t designed to be re-used. If your gloves have been in your kit for a long time, check them to make sure they didn’t degrade in heat or cold. Have these easily accessible so that you are inclined to use them when needed.
  • CPR mask and airway management- you can get a quality mask with a filter for around $12. “Keychain” masks are better than nothing, but have a short life span when put to use. If you have been trained to use airway adjuncts, include some—they are a little bit of weight for a lot of good.
  • Wound care (probably the most common supplies I use on trips):
  • 1” athletic tape- one roll per person per week for hiking/skiing/climbing trips (really). It’s good for blister prevention, blister covering, ankle taping, and much more.
  • Gauze/ dressings (4-6) – different sizes and a few nonadherent (great for burns or abrasions).
  • Adhesive bandages (8)- various styles.
  • Roller gauze or vet wrap (2)- something to keep the gauze next to the wound that won’t cut off circulation. Vet wrap lasts longer than roller gauze.
  • Waterproof/ breathable (occlusive) wound dressings (2-3)*- an invaluable addition to wound care if you will be out for a few days. On a clean wound, this can create an environment conducive to healing that lasts a couple days. These are generally 2” x 3” or larger.
  • Tweezers- invest in a good pair (sharp and pointy), which will only cost a couple dollars more than a cheap pair.
  • Small magnifier- for wound cleaning. Be sure you have a reliably bright light source for wound exploration.
  • Wound cleaning*- a 60cc syringe (check the local feed store) with an irrigation tip is cheap and lightweight and gives better pressure than anything we could improvise.
  • Trauma shears (1)- there are some cool tiny ones (4”) on the market that only cost a few dollars and work great.
  • Blister care- Moleskin, foam, gel pads, or whatever your flavor. Duct tape should not be used on open blisters.


Musculoskeletal injuries:

  • Compression wrap(s)- 3” works great for supporting ankles or knees.
  •  Aluminum foam splint (1)
  • Triangular bandages (2)- these are multi-functional.


Over the counter medications:

  • Pain management- ibuprofen and acetaminophen work in different ways. Bring what you prefer, and pack a few grains of rice if you have bottles of tablets. It keeps the tablets from becoming a paste in moist conditions.
  • Gastrointestinal meds*- antacids such as calcium carbonate, anti-diarrheal such as loperamide, or whatever works for you.
  • Antihistamines- diphenhydramine for allergic reactions. Epinephrine injectors are prescription only and should be carried by those who require them.
  • Topical antibiotic cream*- good for small, shallow wounds. No need to get a huge tube, and beware of antibiotic allergies among your group.


Random other things and debatable items:

  • Your
  • Timepiece
  • Extra waterproof zip bags- these can be packaged with your SOAP note, pencil, and local emergency numbers.
  • Stethoscope*- If you are comfortable listening to lung sounds, I would recommend this for aquatic or altitude trips.
  • Oral glucose gel*- If you have honey in your camp kitchen, it will suffice. Many coffee shops have honey packets available as condiments- perhaps pick up a few with your purchase.
  • Temporary dental filling*- maybe not for a week-long trip, but it’s small, cheap, easy to find in the store, and can turn a trip around to the good easily.
  • Antifungal cream*- miconazole or clotrimazole would be good for a longer trip.


Comfort care to be carried by individuals, depending on the environment:

  • Aloe*
  • Throat lozenges*
  • Lip balm
  • Sunscreen
  • Insect repellant
  • Contact care
  • Personal medications- asthma inhalers, etc.


Much of this can be bought at local pharmacies, “feed and seed” stores, grocery stores, or through online retailers.

Pick your vessel. You might be inclined to choose a zippered nylon clamshell with organizer pouches or see-through dividers. Or, if you are an ultralight hiker, you may choose waterproof zip-top bags. For paddling trips, dry bags or dry cases may be preferred if you can keep the inside dry (but I wouldn’t want to haul a dry box on a mountaineering trip!) Regardless of your outside package, it is worth the extra few minutes to compartmentalize your contents by thought- something that makes sense to you, like: big wounds; little wounds and blisters; common pills (like ibuprofen); uncommon pills (like GI meds); etc. I use a vacuum sealer when I am more worried about water seepage or risk management (this makes it inevitable to see if something’s been used, and then program managers know to seek out an incident report or replace stock).

Have a great trip!

*This assumes your survival gear (the rest of the ten essentials) is packaged elsewhere.

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A medical advisor can and should be an integral part of your risk management team, not just the person who writes prescriptions for epinephrine. Functions could include review and advice on policies that have to do with safety, medical management and treatment protocols. If you do any screening, an adviser can also give some guidance and insight on a potential client’s underlying medical issues and how to work toward making meaningful accommodations to your program. In addition, this person should be involved in all incident reviews (e.g., treatment, evacuations, near misses).

If you use any medications, an advisor could be part of the entire process from prescription, purchase, storage, and development of any protocols and policies regarding use, expiration, and disposal. Especially with epinephrine, an advisor could also be part of a yearly training refresher beyond any certification and training provided by an outside organization. If you supply medications for your staff to use in the field, make sure that both of you understand state rules, regulations, limitations, and risks regarding prescribing medications to non-licensed providers

People with a wider range of medical experience provide the best guidance. Emergency medicine, family medicine, and depending on the age, pediatrics or internal medicine are areas of practice that best fill that bill. Look for someone who is local. Even better, try to find someone with outdoor interests who knows your program. Selecting a family member of your staff or of a prior participant has lead to successful matches in the past. Then, if you find someone who is interested, invite that person to come out with you on a trip or a day of one of your planned activities. Who knows, maybe you will find a new staff member.

In the end, you want someone who likes the outdoors and understands and believes in what you are doing. It is important for that person to feel part of what you do, not just the provider of prescriptions.

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WildER Med logo

There are a number of wilderness medicine conferences that happen yearly both in North America and abroad that focus on general medical issues in the outdoors as well as more specific themes such as altitude, environmental emergencies, and disasters. The Wilderness Medical Society has done an admirable job of offering and supporting many of these.

There are also a number of smaller, local conferences on wilderness medicine hosted by medical school, outdoor and rescue groups. Some of these “home-grown” and grassroots type conferences can provide a different approach  on wilderness medicine and healthcare in remote communities through local cultural interactions, specific experiences and social perspectives.

One such conference is called and occurs September 28 to 30, 2012 on in Ontario, Canada. Manitoulin Island sits between Lake Huron and Georgian Bay on their northern shores. The conference is quite inclusive and designed to focus on remote medical issues that affect everyone from hospital based physicians to first responders to wilderness guides. A major theme of the conference is interdisciplinary communication and teamwork amongst these groups for successful patient care in the wilderness. While based on local experiences and insight, there is value in this theme for anyone dealing with wilderness emergencies.

Another unique aspect of this conference includes the use of an aboriginal theater group called the Debajehmujig Storytellers. One of the evening activities includes an interactive “wilderness med” theater experience.

With a maximum of 30 participants allowed for the conference, expect an intimate and unique experience.



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Wilderness Medical Elective
July 16-24 2012
Highland Plantation, ME
Claybrook Mountain Lodge

Wilderness Medical Associates (WMA) International has teamed up with University of New England to offer the Wilderness Medical Elective. Unlike traditional medical courses, WMA International provides a practical approach when environments are hostile and equipment and personnel are limited. The elective is tailored to medical students opting to gain knowledge of managing patients in these remote and low-resource settings; providing them with the confidence to think critically during medical emergencies. The Wilderness Medical Elective has prepared students for diverse medical work such as medical rescue, expedition doctors, Medicine Sans Frontier, remote medical clinics, disaster relief, rural practices, and the military.

The Wilderness Medical Elective offers medical students an opportunity to expand their academic knowledge and clinical experience. Our core pedagogical components instill the best practices of medical school education, including didactic sessions, case study discussions, a variety of simulated patient encounters, practical skills lab, and evidence-based medicine reviews. Emphasis is given to assessing patients, formulating problem lists, and carrying out student-planned treatments (including evacuations) in relatively low-tech environments. The goal is for students to actively investigate and articulate these best practices through a hands-on curriculum that is engaging, practical, and proven.

The course will be led by of . WMA International trains over 8,000 students annually and has instructed courses on all seven continents. The organization is compromised of hundreds of instructors with medical expertise balanced with a passion for the outdoors and a commitment to first class education. WMA International offers this specialized training because they understand the need. Recreationally and professionally, there is a large audience that faces unique medical risks. Proper training brings you home.

Justin Childs

51 Baxter Boulevard, Portland, ME 04101


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(WMA International President and Medical Director) and (WMA International Executive Director) meet with executive members of both the Chinese Mountaineering Association and Chinese Olympic Committee in May 2012 in Toronto, Canada. The meeting was an opportunity to discuss how WMA can support outdoor sport and recreation within China in an official capacity. WMA courses run regularly on mainland China and frequently in Hong Kong and Taiwan. Complete translation of WMA materials into Chinese is expected by the end 2012.


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The following was posted at the FDA :

“American Regent Initiates Nationwide Voluntary Recall of Epinephrine
Injection, USP, 1:1000, 1mL Ampules Lot #1395 Due to Discoloration and
Small Visible. Regent is conducting a nationwide voluntary recall to the
Retail/Hospital level of the following product: Epinephrine Injection, USP,
1:1000, 1 mL Ampules NDC #0517-1071-25 Lot #1395, Exp Date: July 2012”

If you are using ampules check the dates and lot numbers listed above.

This is just another reminder that epinephrine shoud be visually inspected before use.  It should be clear with no dislcoloration and free of any particulates.  The manufacturer’s recommended storage temperatures are between 15° and 25° C (59º and 77º F) with no freezing (Lexicomp database).  There is literature to suggest that those can be pushed and that expiration dates are not set in .  and then thawing is not a good idea for liquids in general but I could find nothing specific about epinphrine.  Storing out of direct sunlight is also felt to be a good idea. 


Use epinephrine that is up-to-date, clear without color, and free of particulates.  Storing in a hot glove compartment for hours or a few days is most likely okay as long as the prior conditions are met.  Freeze/thaw is not so clear.  An expirated EpiPen will be degraded but still helpful if clear/colorless and particulate free.

If you take any medications into the field, consider the following:

1.  Store them properly

2.  Check expiration dates and replace expired medications with fresh replacements before leaving

3.  Periodically check the condition of  medications and their packaging. 


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We are pleased to announce the publication of the newly revised, spiral-bound Field Guide of Wilderness & Rescue Medicine and the fold-out Wilderness First Aid (WFA) Guide. Each reflects our understanding of current advances in the medicine utilized in wilderness and low-resource settings; while both retain their simplicity and practical utility.

We use the orange version for all our courses except the WFA.  This comprehensive yet concise guide covers a wide array of topics. They include: basic first aid, as well as spine and musculoskeletal management; environmental medical topics; selected prescription medications; helicopter safety; and mass casualty incidents. The WFA Guide is intended for our WFA students and for those looking for a brief, light summary that will apply almost anywhere. Additional topics such as dislocations, spine evaluation, patient packaging, and medications are not included.

For these current versions, we have made minor adjustments to the layout, font size, and colors for consistency and to ease readability.  Wherever possible, we have edited the texts so that the wording in both is either identical or close to one another.  The index of each guide has been expanded and reorganized for accuracy and ease of navigation.

Listed below are some of the notable changes.

Wilderness First Aid Fold-Out Guide

  • For the first time, it will include text and charts briefly summarizing spine injuries, volume shock, traumatic brain injury, and acute stress reaction.
  • The text for topics like thermoregulation, submersion, lightning, and musculoskeletal has been condensed from the Orange Field Guide.



The Field Guide of Wilderness & Rescue Medicine

  • Rick Lipke has provided us with several new color graphics that illustrate pelvic binding, femur stabilization without a traction splint, and side stabilization on a litter and vacuum mattress. Each is accompanied by new summarizing text.
  • The Primary Assessment triangles of the PAS have been updated to spell out the details of each step.
  • Newly revised SOAP Note.
  • Musculoskeletal tables have been simplified and consolidated.
  • The acronym STOPEATS has been spelled out in multiple locations including the pages on PAS, Respiratory, Neuro, and the Glossary.
  • All of the topics have been updated or modified to reflect current thinking.
  • And in spite of all these additions and updates, it remains 102 only pages.



These guides continue to be produced in-house to allow for annual revisions. Some of our best feedback and critique has come from our students and purchasers of these guides. We encourage you to contact us if you have suggestions or criticisms about clarity or regarding new topics.

We are anticipating Japanese and updated Spanish versions sometime before the end of the year. We also have plans for Portuguese and Mandarin editions.

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Want to be Notified of New Courses?

is a service dedicated to notifying students when courses are added to You choose the criteria: Type of course, the distance you are willing to travel, and dates that work with your schedule. This is a useful tool if you want to know when viable recertification options become available. Course Subscriber may also be used if you are a WAFA (or AWFA) student looking for Bridge courses to further your training.

How to Access Course Subscriber

and complete a quick registration form. It’s that simple! You will receive notification as courses are added that meet your parameters.

We encourage you to continue educational pursuits in wilderness medical training. We are always receptive to your feedback, as it’s integral to our progress. If you have suggestions on how we can improve our services to you, please .

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