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Introduction
People who live, work, travel and recreate in the outdoors have specialized medical training needs
not adequately met by traditional first aid programs. They care for patients in remote locations, inchallenging weather, with questionable communication and support, limited equipment and mayneed to make independent decisions on patient care and transport. As a result, medical andoutdoor specialists developed wilderness medicine courses to meet these needs. Initially thecontent for these courses was written independently and was opinion-based. Subsequently, thecontent has evolved based on evidence and experience. This process has led to a consensus
about content and scope of practice (SOP) amongst the leading training organizations and several
professional outdoor organizations.
Our intention is to assist the lay public, outdoor program administrators, individuals and otherconsumers of wilderness medicine courses in their choice of an appropriate course and credential
level for their programs. The SOP will describe the intended audience, the minimum guidelines forwhat graduates at each level of credential should know, what decisions they should make andwhat skills they should be able to perform. Because student and/or organizational needs can varyby location, population and experience, the SOP provides for a minimum or core requirement andacceptable elective topics and skills. Ultimately it is the responsibility of each organization
choosing medical training to understand its own individual institutional needs.
While we have strong opinions that these programs are best taught by skilled educators andexperienced outdoor and medical people using hands-on practice, case studies, and realistic
simulations as the prominent style, we are intentionally not commenting on hours per topic or
specific teaching methodologies nor are we crafting a curriculum. These should remain thediscretion of the individual program, training institution, course provider and sponsoring agency.
Likewise, this document is not intended to speak to questions of competency measurement,
organizational accreditation or instructor training or qualification. This document cannot be used to
imply any type of endorsement of content or quality for a course provider.
The signatures below reflect the respective organization’s support of this document as an
acceptable set of guidelines and scope of practice for a WFR provider. This document is notintended to create a legal duty to conform to its described minimum guidelines and scope. Neither
the Writing Group nor the approving parties are legally responsible for a loss arising from the use
or misuse of this document by a WFR provider.
Signatures of the Writing Group, July 2014
David E. Johnson MD, FACEP
President and Medical Director
Wilderness Medical Associates
Wilderness Medical Associates Canada
Tod Schimelpfenig EMT, FAWM
Curriculum Director
NOLS Wilderness Medicine InstituteFrank Hubbell, DO
Co-Founder/Medical Director SOLO
Board of Medical Directors, NH
Lee Frizzell, WEMT
Co-founder/Executive Director SOLOPaul Nicolazzo
Director
Wilderness Medicine Training CenterDavid McEvoy MS, Paramedic
Director
Aerie
Carl Weil
Director
Wilderness Medicine Outfitters
Master Fellow Academy of Wilderness Medicine
Nadia Kimmel RN WEMT
Director
Desert Mountain Medicine

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Wilderness First Responder Overview
A WFR course is primarily intended for non-medical professionals:• for whom first aid delivery is often a secondary responsibility,• who are acting as a primary care giver in a remote setting or as a second rescuer for a higher
trained person,• with the outdoor skills needed to participate in and/or lead the trip and who have an effective
emergency action plan,• who are traveling alone, with family, and/or friends,• who are employed or volunteering as wilderness guides, instructors and educators, Search andRescue (SAR) team members, ski patrol, medical personnel for adventure races/events,
missionaries, wild land firefighter medical team member.
In the context of:• multi-day to multi week domestic or international wilderness trips with unreliable communication
and/or delayed medical or rescue support,• locations where evacuations are primarily walkouts or carryout by the group with the WFR incharge, or with the assistance of local resources and where local Emergency Medical Services(EMS) or Search and Rescue (SAR) access may be delayed,• the WFR may be called upon to make independent decisions on the need for and urgency ofevacuation, and calls for outside assistance,• medical equipment is limited, communication unreliable, transport delayed and/or difficult andoften by human power, care takes place in austere or harsh environments.
Focus and Content Overview• A WFR is commonly taught as a minimum 70 hour course with an emphasis on practical skills
and drills.
• Focus is on:o performing a physical exam to identify obvious injuries or abnormalities, assessing signs,
symptoms, and vital sign patterns, along with obtaining a simple and relevant patient
history,o prevention of medical problems anticipated by the activity and environment,o treatment focused on stabilization of emergencies, initiation of specific and appropriate
medical treatments (splints, wound care, spine injury management, managing
environmental threats) and assisting patients utilizing their personal medications,o conservative decisions on the need for, urgency of and appropriate type of evacuation andfor interventions appropriate for this level of training.
o The scope of practice for a WFR is to prevent, identify, initiate reasonable and prudent fieldmanagement and identify red flag signs and symptoms necessitating evacuation forpotentially life-threatening problems.

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Patient Assessment and Basic Life Support (BLS)• Evaluate the scene and assess for safety and causes.
• Perform an Initial Assessment/Primary Survey to identify and treat life threats.
o Respiratory System- Manually open, maintain and protect an airway with standard BLS techniques and therecovery position.
- Provide adequate ventilations by mouth to mask.
- Monitor and maintain airway control and breathing for people with an impaired Level ofConscious/Level of Responsiveness (LOC/LOR).
o Circulatory System- Provide Cardiopulmonary Resuscitation (CPR )with standard BLS techniques.
- Understand start/stop considerations for CPR in the remote context.
- Control bleeding with direct pressure, pressure/hemostatic bandage or tourniquet.
o Nervous System- Assess Level of Conscious/Level of Responsiveness (LOC/LOR), identify a potential
mechanism for spine injury, protect the spine and minimize movement.
• Perform a Secondary Survey/Focused History and Physical Examo Perform a physical exam to identify obvious injuries or abnormalities.
o Measure and monitor vital signs: LOC/LOR, Heart Rate (HR), Respiratory Rate (RR), Skin
Condition.
o Obtain a patient history (SAMPLE format).
o Monitor a patient for changes over time.
o Document findings, ongoing assessments and treatments in writing.
o Deliver a concise, complete and clear verbal patient report.
• Protect and stabilize patients during prolonged evacuation.
• Decide on need and urgency of evacuation.
• Plan and conduct evacuation or access SAR/EMS.

Circulatory System
Shock• Know common wilderness causes of shock.
• Recognize signs, symptoms and vital sign patterns of shock.
• Initiate treatment
o Provide oral fluids for patients with normal mental status.
o Stabilize injuries.
o Control external bleeding.
o Protect from adverse environmental conditions.
• Decide on need and urgency of evacuation.
Acute Coronary Syndrome• Recognize signs and symptoms.
• Initiate treatment.
o Stop activity.
o Support reliable patient with their personal medications (e.g. aspirin and prescribed
nitroglycerin).
o Initiate evacuation or access SAR/EMS.

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Respiratory System• Know the common causes of respiratory distress and respiratory failure.
• Recognize signs and symptoms of respiratory distress and respiratory failure.
• Recognize signs and symptoms of hyperventilation.
• Recognize chest and lung injury.
• Initiate treatmento Maintain position which supports breathing.
o Maintain patent airway and support ventilation.
o Assist patient with their personal medications (e.g. prescribed inhaler).
o Stabilize/support the injured area.
o Seal an open chest wound.

Nervous System
Traumatic causes of abnormal mental status• Recognize signs and symptoms of traumatic brain injury.
• Initiate treatment.
o Protect the airway.
o Protect the spine.
o Protect the patient from environmental extremes.
o Monitor the patient for changes in mental status.
o Provide fluids and calories as needed.
Non-traumatic causes of abnormal mental status• Know common causes of abnormal mental status.
• Recognize abnormal mental status.
• Initiate treatment.
o Oral sugar.
o Cooling in the presence of heat stroke.
o External warming in the presence of mild hypothermia.
o Ventilation for a hypoxic patient.
o Protect the patient from environmental extremes.

TraumaSpine Injury• Recognize a high risk mechanism of injury for spine.
• Recognize signs and symptoms of possible spine injury.
• Initiate treatment.
o Stabilize the spine with hands or adjuncts (e.g. improvised or commercial c-collar).
o Use rolls, lifts and extrication as needed to facilitate patient examination and protection.
o Assess for potential spine injury via acceptable selective spine protocol.
o Stabilization/protection on a litter, vacuum splint, backboard, or protected on the ground.

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Soft Tissue Injury
Wounds• Recognize life-threatening bleeding.
• Initiate treatment.
o Control bleeding with direct pressure, pressure/!"#$%&'&()*bandage or tourniquet.
• Recognize simple versus high risk wounds.
• Initiate treatment.
o Clean wounds by removing debris, scrubbing and irrigating.
o Bandage wounds.
o Manage blisters, splinters and fishhook injuries.
o Manage impaled objects.
- Remove airway obstructions.
- Remove objects impaled from limbs only if unable to stabilize, will easily fall out, prevents
transport or unable to control bleeding because of the object.
o Manage amputations.
Infections• Recognize signs and symptoms of local versus systemic infection.
• Initiate treatment.
o For local infections apply warm compresses, promote drainage and monitor.
o For systemic infections: warm compresses, promote drainage, monitor and evacuate.
• Prevention: Methicillin-resistant Staphylococcus aureus (MRSA) and blood borne pathogen
awareness, hygiene.
Burns• Assessmento Assess depth.
o Approximate percent of body surface area involved.
o Identify high risk anatomical areas.
• Initiate treatment.
o Cool and protect with clean, non-adherent bandage.
• Prevention: sunburn and spilled hot water burns.

Musculoskeletal Injuries• Recognize signs and symptoms of musculoskeletal injury.
• Differentiate between stable and unstable injuries.
• Recognize signs and symptoms of high risk problems associated with musculoskeletal injuries.
• Initiate treatment.
o Treat stable injuries using Rest Ice Compression Elevation (RICE) and a brace/tape as
needed.
o Treat unstable injuries with:- Gentle traction into position for angulated long bones and impaired neurovascularfunction.
- Splints that provide adequate stabilization, are comfortable for extended care situations
and allow for ongoing monitoring of perfusion.
- Wound care for open fractures.
o Treat dislocations with traction into anatomical position for shoulder, patella, obvious digit
and jaw dislocations, or any dislocation with impaired neurovascular function.

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Environmental Medicine
Heat Illness• Recognize signs and symptoms of heat exhaustion, dehydration, hyponatremia and heat stroke• Initiate treatmento Heat exhaustion/dehydration.
- Stop activity and find a cooler area.
- Oral fluids to satisfy thirst and electrolytes.
- Evacuate if not improving.
o Heat stroke- Aggressive, immediate cooling.
- Evacuate.
o Hyponatremia- Consider fluid restriction and oral salt.
- Evacuate.
• Prevention: Identify predisposing environmental conditions and prevention strategies

Hypothermia• Recognize signs and symptoms of mild and severe hypothermia.
• Initiate treatment.
o Mild hypothermia- Oral fluid, calories, add heat, protect from the environment.
o Severe hypothermia- Prevent heat loss (hypothermia wrap with added heat).
- Handle gently, evacuate.
• Prevention: Identify predisposing environmental and clinical conditions and prevention
strategies.

Local Cold Injury (Frostbite and Non-Freezing Cold Injury)• Recognize signs and symptoms of frostbite and non-freezing cold injury• Initiate treatmento If not frozen, warm the injury.
o If frozen, ideally thaw in a warm water bath (99-102°F, 37°-39°C). Practically this may need
to be skin to skin. Field thaw only if there is minimal risk of refreezing.
• Prevention: identify predisposing environmental conditions and prevention strategies.

Altitude• Recognize signs and symptoms of Acute Mountain Sickness (AMS)• Recognize signs and symptoms of High Altitude Cerebral Edema (HACE) and High Altitude
Pulmonary Edema (HAPE).
• Recognize patients who need to stop ascent and acclimatize or descend/evacuate.
• Initiate treatment.
o Stop ascent if symptomatic.
o Descend if no improvement.
o Descend immediately in presence of shortness of breath (HAPE) and ataxia and/or mental
status changes (HACE).
• Understand current recommendations for medications for prevention and treatment of altitude
illness.
• Prevention: identify predisposing environmental conditions and prevention strategies.

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Lightning• Know the common mechanisms of lightning injury and common presentation of injury(cardiovascular, neurological, burns).
• Initiate treatment including prioritizing BLS for apneic and pulseless patients.
• Prevention: Recognize high risk weather conditions and prevention strategies.

Submersion - Drowning• Initiate treatmento Respiratory support.
o Spine injury potential.
o Hypothermia.
o Evacuation• Prevention: recognize high risk water conditions and prevention strategies.

Backcountry Medical Problems
The scope of practice for a WFR is prevention, initiation of reasonable and prudent fieldmanagement and identification of red flag signs and symptoms necessitating evacuation forpotentially life-threatening problems.
Flu-like illness, Nausea/Vomiting/Diarrhea, Fever, Cough, Upper Respiratory Infection• Recognize signs and symptoms of flu-like illness.
• Initiate treatmento Treat symptomatically. Support hydration.
• Prevention: Focus on camp hygiene, hand washing and water disinfection.
Abdominal Pain
• Recognize signs and symptoms.
• Initiate treatment.
• Evacuate if red flag signs and symptoms are present.
Allergy• Recognize signs and symptoms of local and mild allergic reactions• Initiate treatmento Treat local reactions with cool compresses, topical corticosteroid.
o Treat mild allergic reactions with oral antihistamine.
Anaphylaxis• Recognize signs and symptoms of anaphylaxiso Treat anaphylaxis with epinephrine, oral antihistamine and evacuation.
Genito-Urinary• Recognize signs and symptoms of vaginitis (in females), UTI, and testicular pain (in males).
• Initiateo Treat vaginitis symptomatically with non-prescription medications.
o Treat UTI with hydration. Evacuate if red flag signs and symptoms are present
o Treat testicular pain with evacuation.
• Prevention: Identify predisposing conditions and prevention strategies.

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Dental• Recognize signs and symptoms lost crown/fillings, broken teeth, avulsed teeth and dental
infections.
• Initiate treatmento Dental hygiene.
o Covering lost fillings, broken crowns.
o Attempt to preserve avulsed teeth.
Diabetes• Recognize signs and symptoms of hypoglycemia and hyperglycemia• Initiate treatmento Treat all diabetic emergencies with a change in LOC/LOR with oral sugar.
Eyes and Ears
• Recognize signs and symptoms of eye problems• Initiate treatmento Irrigation and gentle removal for objects in eye.
o Cool compresses and dark glasses for snowblindness.
o Craft improvised sunglasses for traumatic eye injury or snowblindness.
o Evacuate visual problems more than blurring, persistent irritation.
• Recognize objects in the ear, ear canal infections, symptoms of middle ear infections andchanges in ability to hear.
Poison Ivy, Oak, Sumac• Recognize signs and symptoms of contact dermatitis.
• Initiate treatment.
o Symptomatic treatment.
Sunburn• Initiate treatmento Treat as a superficial burn.
• Prevention: Understand the role of ultraviolet barriers (sunscreen and clothing).
Motion sickness• Initiate treatment.
• Prevention: Understand predisposing environmental conditions and prevention strategies.

ToxinsPoisoning• Understand general principles of ingested, inhaled and absorbed poison management and CO
poisoning• Prevention.
• Initiate treatment:o Ingested Poisons: Supportive care and evacuation.
o Inhaled Poisons: (commonly CO, occasionally other gasses e.g. volcanic fumes) Scene
safety. Remove from exposure. Administer O2, if available.
o Absorbed Poisons: remove contaminated clothing. Flush area with water and wash withsoap.

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Snake bite
• Initiate treatmento Immobilize the limb.
o Compression wraps if dictated by local protocol.
o Transport to a physician/hospital.
o Monitor for signs and symptoms of envenomation.
• Prevention: identify common human behaviors that are factors in snakebite incidents.
Arthropods (insects, arachnids e.g. scorpions, spiders)• Initiate Treatmento Symptomatic treatment including wound care.
o Tick removal.
• Prevention: Understand the role of clothing, netting, repellents, insecticides in prevention of
disease transmission.

Medical Legal• Understand the following legal concepts as they apply to wilderness medicineo Duty to Act and Good Samaritan Laws
o Scope of practice and standards of practiceo Consent and confidentiality
o Certification, licensure, and protocols• Understand the purpose of written medical protocols and guidance from a medical advisor.
• Medication Administrationo Understand the legal aspects of medication administration by laypeople in a remotecontext.
o Understand the concepts of right drug, reason, route, dose, and patient.
o A WFR should not be making decisions on whether a patient should or should not take theirpersonal prescription medications (unless it’s an obvious situation of abuse or harm). A
WFR may assist trip participants in the administration of personal prescription and nonprescription medications. The WFR should follow state and employer rules/protocol
on offering non-prescription medications for adults.
o The possession and administration of epinephrine by laypeople is a complex issue.
Support for laypeople using epinephrine for anaphylaxis amongst jurisdictions, includingfrom country to country, varies considerably. The WFR should become familiar with any
specific local regulations and implication in this regard. Organizations should seek advice
from a lawyer and/or guidance from a person acting as a medical advisor before deciding toinitiate a policy that includes the emergency use of injectable epinephrine.

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Electives
Electives are skills and knowledge within the WFR Scope of practice that can be included or
excluded at the discretion of the provider and course sponsor to meet specific needs of the student
or program and the context in which they will use their WFR.

Elective Topics
SAR Fundamentals• Understand fundamental concepts of search and rescue, Incident Command System(ICS), andevacuation plans.

SCUBA Diving Injury• Know the physiology of Self-Contained Underwater Breathing Apparatus (SCUBA) andbreathing a gas under pressure.
• Know basic pathophysiology of pulmonary over pressure problems and decompression
sickness.
• Recognize the common signs and symptoms.
• Initiate treatment to include:o Stabilization of critical system problems.
o Provide supplement high flow oxygen when available.
o Use of resources such as the Divers Alert Network.

Mental Health• Recognize and manage a possible mental health issue.
• Recognize, manage signs of stress in participants and colleagues.

Marine Toxins• Initiate treatmento Treat Nematocysts (jelly fish, corals, anemones)- Hot water immersion. Vinegar for box jellyfish (Class Cubosa).
o Treat Marine Spine Injury:- Soak in hot water until pain relieved or 30-90 minutes, standard wound care.

Elective Skills• Blood Pressure (BP) with sphygmomanometer and stethoscope• Pulse Oximetry• AED (automatic external defibrillator)• Assessment of lung sounds with stethoscope.
• Medical oxygen delivery devices e.g., cannula or mask; airway management devices e.g. OPA,
NPA, and PPV; and Mouth-to-mouth, mouth-to-mask or Bag Valve Mask (BVM) ventilation asneeded.)• Improvised litters or stretchers• Traction splints, improvised or commercial, for femur fractures.
• Circumferential pelvic wrap for suspected pelvic fractures.

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