Wilderness Advanced Life Support

Fifteen healthcare professionals, a diverse group of nurses, paramedics and a physicians assistants, traveled from mostly urban environments to Redwood Regional Park in Oakland, CA, this past November for an intensive 3 1/2 days of challenging themselves to learn a new way of thinking and working.

As Wilderness Advanced Life Support (WALS) providers, this was the class for people looking to help the sick and injured in the outdoors. It was not a class for those who did not want to get dirty.

“Wilderness medicine is defined as 2 hours or more from definitive care,” said David Johnson, MD, Emergency Physician at Central Maine Medical Center.

Johnson was teaching the class along with Jim Morrissey, a tactical paramedic with the FBI SWAT team out of San Francisco and Medical Health Operational Area Coordinator for Alameda County, CA. Both have written books on the topic.

Wilderness Medical Associates, the coordinator of the WALS training program, teaches several courses on medicine away from the hospital. In addition to the WALS class, which is designed for nurses, paramedics and physician’s assistants, there is also a Wilderness EMT course for BLS personnel.

In the wilderness, “whether or not you want to be or not, you’re the doctor,” Johnson said. “What you know intuitively, the others have no clue. You make decisions. You have to and that’s your job.”

PATIENT ASSESSMENT: The teams makes decisions on how to best move the patient though the woods. photo courtesy Devin Greaney

‘Minimalist Medicine’

A love for the outdoors was a common theme of the healthcare professionals, including Koala Hines, RN, of Children’s Hospital and Research Center in Oakland CA.

“I want to be able to do everything,” she said, when asked why she chose to attend the WALS training, “and I want to be able to do things when there is no one around.”

Colin Arnold, a firefighter/paramedic in East Bay, said he wanted to get out of his comfort zone.

“We are really good when we have the tools we normally have, like cardiac monitors and all sorts of fancy equipment,” he said.

“If you don’t have the equipment you feel inadequate or unprepared, so this is an opportunity to advance the assessment skills.”

During the lecture portion, Johnson expanded on what the students already knew, but got them to think of themselves in a wilderness setting.

Take frostbite, for example. Everyone knew the best thing was to put the affected area in warm water for a slow thaw.

But stop and think. Will someone have that much warm water when working a ski patrol? What if in the long transit that water became cold again?

A photo of frostbite that had been thawed and refrozen in transit drew groans even from veteran nurses and paramedics.


Wound care went beyond the direct pressure and bandaging. As advanced life support providers, they should consider prophylactic antibiotics for wound care and appendicitis.

“Five percent of wounds get infected in the emergency department,” Johnson said, adding ships and tents, places common for wilderness medicine, can be environments for MRSA.



Emergency Management Planning

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One could almost call it minimalist medicine.

“I hope what [the students] take away is the ability to do good assessments and be clear with their problem lists and not muddy up with their extraneous information,” Johnson said.

You need to have a good idea, “Is this person is sick or not sick?” he emphasized.

Yes, an injury could look bad, but Johnson showed many slides and asked the question, “Is this an emergency?”

In a situation of traveling light with few resources, such decisions may need to be made on who needs to be transported immediately and who can wait.

Later that day, the class knew, they would be making those decisions.


Into the Wilderness 

The night simulation was upon us and the scattered showers that had begun earlier in the day were becoming more and more regular.

It was time for the instructors to take a step back and let the students use the knowledge they had gained from them to make decisions on what to take when heading out into the wilderness.

Does it make sense to put the wheel on the Stokes evacuation basket before heading out or put the wheel on when would you find the patient? What drugs and equipment would be most helpful and what would just add more weight?

The healthcare professionals, their different backgrounds now with a common knowledge of outdoor medicine, were all working, thinking and providing input. “This is so exciting!” said Jessica Redford, RN, with a childlike grin and gleam in her eyes.

The most valuable pieces of equipment the class would be using would not be carried in backpacks or stretchers, but rather between their ears. “Stick to the plan. That will get you through” Johnson told the group.

At 6:30 p.m., the simulation began. The sun set some 25 minutes earlier than usual, and the overcast day gave way to an evening of steady rain.

The students were divided into two teams, “Hasty” and “Medical.”

The Hasty team traveled lightest, got to the patients first and managed immediate life threats. The Medical team carried more equipment and supplies, including equipment for evacuation.

The students were then given this scenario: A biological research team had gone into the woods to study the golden salamander. While they were out there, a flash flood swept through the valley and no one had heard from them since.

Down the trail the teams met a terrified woman saying the group had been caught in a flood and the other three were in the valley and hurt. She was walking and talking and only had a twisted ankle so the team pressed forward.

The darkness, rain, mud, plus a steep drop-off kept the rescuers mindful to not become victims.

SITUATION UNDER CONTROL: At the command center, the team prepares to take the patient inside to heat and better lighting. photo courtesy Devin Greaney

Overcoming the Elements 

At 6:48 pm the hasty team met chaos.

One man was screaming in pain down by the creek with an obvious broken tibia and hip displacement.

A woman was doing CPR on the unconscious professor and said she had been for the past hour. “Can someone help me!?” she yelled at the rescuers still assessing the scene.

Two were in the Hasty team and they had three patients. Paramedic Jenna Graham called in on the radio for the others and then began taking over CPR. Revery Barnes stayed with the injured man.

Temperatures were in the mid-50s, not terrible, but enough that wet clothes could lead to hypothermia along with the injury.

About 5 minutes later, more help arrived. The patient was given morphine; splinted and stabilized enough to move him up the hill closer to the Stokes basket.

At 7:12 p.m. the patient was loaded and ready for transport.

The decision was made to stop CPR on the professor, however, and that the woman performing CPR was OK to walk out. It was a reminder to the students tough decisions need to be made where calling for another ambulance is not an option.

Heading up the muddy trail the students were in full team mode. “Rock ahead” and “Does anyone need to change places?” was the conversation for the uphill trek by flashlight and headlamps to the command post. The best advice for walking in the mud was, “dig in!” No one fell.

At 7:33 p.m, the patient was in the building. Rain gear came off and it was time for a debriefing.

At just under an hour, the team had completed the rescue and arrived at the command post in record time, according to Johnson, who was met with cheers and applause from the team.

In the end, “team,” was the perfect word to describe this group of healthcare professionals from nursing and EMS, big cities and small towns, whom had just succeeded in thinking and working and preparing to saving lives outside of the hospital and, more importantly, outside of their comfort zones.

Devin Greaney is an EMT IV and a freelance writer and photographer in Memphis, TN.

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