Advanced Wilderness Life Support Course
This past weekend my wife and I completed the Advanced Wilderness Life Support Class sponsored by the Wilderness Medical Society and hosted by Ben and Jenni Mattingly of Wild Med Adventures (http://www.wildmedadventures.com/). It was held in New York at Camp Little Notch, a former Girl Scouts camp that was recently reopened as a camp for girls with memberships available for camping and other adventures (more info available here http://www.friendsofcln.org/history/).
During the drive, the roads were gradually enveloped by beautiful deciduous forests and ridges of the Adirondacks and just prior to arrival, cell signal disappeared – an awesome addition to the feeling of austerity. We arrived the evening of September 8th, and slowly drove through camp to a building that would serve as the lecture hall.
There we met Ben and Jenni and were given the AWLS course textbook and a Wild Med Adventures shirt, then spent the next hour meeting classmates and unpacking our gear into the platform tents encircling a small clearing punctuated by a large firepit. The class of 25 comprised diverse medical backgrounds including Paramedics, Physician Assistants, Nurses and Nurse Practitioners, and Physicians from all different specialties. The instructor staff was just as diverse with each instructor having significant wilderness medicine experience.
After settling, we reconvened for dinner at the cafeteria down the camp path where we were served three meals a day for the remainder of the course. Afterward, Ben gave an introductory “Why Wilderness Medicine?” lecture and explained how we could encounter austere medicine really anywhere where definitive medical care was not immediately available. Next, he reviewed patient assessments utilizing the MARCH protocol that is common in the TCCC world. MARCH emphasizes first quickly addressing life threatening massive hemorrhage and then moving on to airway and respirations, etc. To conclude the evening, the instructors each displayed and explained their medical kits while the class rummaged through each bag. With the first evening of education finished, we all met down by the fire pit and laughed and talked into the night…a tradition that would continue throughout the course.
After breakfast, we learned about lightning injuries and the importance of reverse triage in these patients. Lectures on wilderness management of HEENT injuries, dermatology disorders, and water safety and drowning followed. A water treatment lecture introduced the common pathogens in wilderness water sources and multiple means of disinfection and the positives and negatives of each method. After lunch, we were randomly divided into five teams of five for the “2nd Annual Wild Med Adventures” wilderness medicine team competition that would span the next few days and culminate with the top team leaving with pride and most importantly winning Wild Med Adventures swag. Each team was provided a backpack with a tarp, a sleeping bag, a sleeping mat, a rope, and a medical kit that would be utilized in future scenarios.
Next, we practiced patient carry techniques and then raced with our fallen comrades uphill to the lecture hall to establish a team winner. We then improvised a hypothermia wrap incorporating gear from our team bags that would likely be present in most group expeditions: a rope, a tarp, sticks for spinal immobilization, a sleeping bag, a sleeping mat for padding, and a backpack with lumbar straps that served surprisingly well as a cervical spine immobilization device. The patient was then wrapped tightly and made ready for evacuation. Having just come from a mountain medicine course where we used a SKEDCO litter exclusively, I found this hypothermic wrap to be a phenomenal improvised litter system and probably one of the the most valuable skills learned at the course. While utilizing this method for short evacuation sprints afterward, the litter proved its durability and would likely survive a prolonged extrication with few adjustments.
After lunch and a period of free time for swimming and hiking, the teams regrouped for practical labs demonstrating how to correctly apply SAM splints for various upper and lower extremity fractures, the proper application of extremity tourniquets, various improvised cervical spine immobilization techniques and a C-spine roll for injured prone patients, water disinfection techniques, and application of small portable and improvised femur traction splints. It was fascinating to see that with just a little brainpower and ingenuity one could create a traction splint from some cordage, a coffee mug, and a ski pole. We then broke for dinner and again ended up around the firepit, but this time we discussed a few medical scenarios before someone broke out a guitar and alcohol, which then evolved into singing and laughter, and again lasted late into the evening.
Day three was epic! It started in the lecture hall again with wound management, common wilderness musculoskeletal injuries, and animal bites and stings. After lecture, the class divided into two groups and hiked to the Iron Ore Furnace – an old iron mine and smelting furnace that was operational during the civil war and likely provided iron for the USS Monitor, the Union’s first ironclad ship.
Along the way, each group encountered instructor mediated medical scenarios and responded with a team leader and team support to care for each patient appropriately. The scenarios included two lightning strike victims requiring reverse triage, a mountain biking accident with a splenic injury and cervical immobilization considerations, and a skiing accident where the patient was significantly injured and was developing hypothermia requiring a hypothermic wrap.
Each scenario was fantastic in that it incorporated previously learned material, and the instructors acted the part well and even utilized make-up and props to add reality. The class then ate lunch at the Iron Ore Furnace and posed for class pictures before making the trek back to camp.
Later, we returned to the lecture hall for presentations on altitude illness, avalanche rescue, and environmental illnesses and injuries: hypothermia, hyperthermia, frostbite, etc. After lecture, we broke into our groups again for more scenarios spread throughout the woods: a mountain climber at altitude experiencing HAPE-like symptoms with possible concomitant HACE, an intoxicated hunter who accidentally shot himself in the leg causing an arterial injury that required scene safety considerations and application of a tourniquet, a teenager who fell off a rope swing onto a cement wall causing a spinal injury but who was also in cold water inducing hypothermia, and a confused boater experiencing hypothermia.
While the initial assessment should always be similar with scene safety, PPE, MARCH, SAMPLE history etc., the instructors managed to add a level of complexity to each scenario that stimulated the improvisation side of our brains. Our team stared at the quadriplegic patient hanging over the cement wall and draped in the water for a few minutes before we figured out how to get him out of that scenario and into our hypothermia wrap safely. Several of us flagged ourselves with the drunk hunter’s rifle before removing it from the scene, a mistake that could easily lead to unnecessary and unexpected injury in the wilderness. An additional pro tip learned was that when engaging with an altered patient to look through their gear and pictures for information on their medical history or other possible patients not yet discovered. After the scenarios, we dispersed for another period of free time. A large group hiked around the lake while others explored the surroundings in canoes, and one rockstar student training for a triathlon jumped into the lake for a 2+ mile swim.
After dinner, an instructor discussed the basics of diving medicine in the lecture hall before the night festivities began. One of the budding traditions with Wild Med Adventures is a final night “wilderness medicine dance off,” one of the highlights of the course. Each team was required to invent a group dance that somehow pertained to wilderness medicine and then dance in front of the other teams and instructors for evaluation. Watching the various teams compete and then interpreting their dances was hilarious. Most referenced some hypothermic shiver or outhouse shuffle, and greatness ensued. And then to top it off, the instructor staff showed us wilderness medicine dance moves from previous classes and then the entire group joined in for a group dance party with music blaring and moves mimicking a backwards kayak, or forward canoe, or stirring beans, or casting a line, etc. I never thought you could make such sweet dance moves out of ordinary life experiences, it was altogether hilarious, and ridiculous, and awesome, and epic. Once we had worked up a sweat and were all danced out, we headed back to the firepit for another late night of guitar playing, singing, laughing, and all kinds of nonsense…without anyone staring at their phones or Facebook. It was perfect.
The morning began with the last lecture which was really more of a group scenario discussion in the lecture hall covering infectious disease in the wilderness setting. Following this lecture was another highlight of the course: the dissection of an Epi-pen. Ben took an expired Epi-pen and showed the class how to inject the initial dose, but then how to cut off the back half of the cartridge to gain access to the syringe which contains two to three extra doses of epinephrine. In the austere setting with hours of evacuation likely, this skill could be life saving with severe anaphylaxis. We also discussed theories on why there would be multiple extra doses that are inaccessible to the general population, but did not reach any definitive conclusions.
After lecture, we took the course final written exam and then assembled back outside for a few more group scenarios. One patient required initial C-spine immobilization and fracture splinting and slinging of his arm. Another interesting tidbit that I learned: after splinting a fractured upper extremity, if you do not have a sling, you can wrap the injured arm in the patient’s fleece or sweatshirt or shirt with a safety pin securing it in place. A different patient experienced anaphylaxis requiring treatment with an Epi-pen, and another was experiencing crushing, substernal, exertional chest pain while climbing a mountain – a scenario that emphasized the conundrum of medical evacuations.
Evacuation considerations are huge in the wilderness due to limited medical capabilities and the often remote locations. Medical evacuation can be very difficult or nearly impossible depending on the number of patients, the severity of injury, the number of rescuers, the distance to be traveled to further evacuation or definitive care, and the manifestation or progression of injury or illness. Deciding when or how to evacuate a patient from the wilderness was probably the most important point of this course, and a point that was emphasized excellently by the instructor staff.
After the scenarios, we ate our last lunch as a class and each team had one last competition playing corn hole. After determining the winning team, we all sat around the firepit for final discussions, handing out AWLS cards, and Wild Med Adventures swag going to the winning team – hats and beanies and stickers, etc. After final goodbyes, we all dispersed, packed our gear, and headed our separate directions. It was an incredible weekend of learning and meeting new professional friends.
The venue was perfect in the Adirondacks surrounded by a lake and the wilderness and living in tents away from the world with meals provided by camp staff and without access to the internet. It allowed the class to focus on each other, learning the material, and experiencing the wilderness in a way that would never be possible in an urban setting and a conference room.
The instructor staff was phenomenal. Ben recruited a world class team of experienced, professional instructors each with their own niche in the wilderness. But the best part was that each instructor was a normal person, informal in their approach, and willing to guide and teach and learn along with the students.
The lectures were an ideal balance of bird’s eye view but with appropriate details emphasized. This was important with such widely diverse student backgrounds. The practical labs and patient scenarios likely provided the best learning of the entire course since they covered material just learned in the classroom and again emphasized the important aspects of each subject. Additionally, this was a certificate course that is valid for four years and pluses up the resume for those pursuing wilderness medicine opportunities. It also provides 20.5 hours of continuing medical education credits for medical professionals needing CMEs, and it’s a blast. Additionally, this is incredibly valuable information if you are an adventurer and go to remote places frequently, do yourself a favor and take this course, it may save your life or the lives of your loved ones.
Wild Med Adventures is a great company that is growing daily and offers many other opportunities for learning and CME. Ben and Jenni really set the tone for their company with their professionalism but informality and flexibility that is necessary for enjoyable hosting. Check out their website and strongly consider attending a course with them in the future.