title: "Field Medicine and Wilderness First Aid" subtitle: "Assessment, Intervention, and Evacuation When Help Is Hours Away" author: "Nored Farms" date: "2026"

Content Extraction Summary

Hook Options

1. Most first aid training assumes an ambulance arrives in eight minutes. Remove that assumption and nearly everything you were taught changes — from the order you assess injuries to how long you maintain interventions. 2. Tourniquets were demonized for decades in civilian first aid courses. The TCCC data from 2005–2015 showed tourniquet application within minutes of extremity hemorrhage reduced mortality from 24% to 6%. The myth cost lives. 3. The biggest killer in remote trauma is not the injury — it is the delay between injury and definitive care. Field medicine exists to extend that window.

Key Mechanism

Field medicine bridges the gap between point-of-injury first aid and hospital-level definitive care. Standard first aid assumes rapid EMS response (8–14 minutes in urban settings). In wilderness, rural, or disaster environments, that response time stretches to hours or days. Field medicine adds prolonged patient care, improvised interventions, and evacuation decision-making to the basic first aid skillset. The MARCH protocol (Massive hemorrhage, Airway, Respiration, Circulation, Hypothermia/Head injury) replaces the civilian ABC sequence because hemorrhage — not airway — is the leading preventable cause of death in trauma.

Misconception to Correct

"Call 911 and keep them comfortable" is the default response trained into most people. This works when EMS is minutes away. In a backcountry, offshore, or grid-down scenario, that advice produces a bystander who watches someone die of treatable hemorrhage or hypothermia. Field medicine training closes the gap by teaching interventions that were previously restricted to paramedic and combat medic curricula — wound packing, tourniquet use, chest seal application, traction splinting — and placing them in the hands of the first person on scene.

Practical Application

A layered medical kit (pocket, day, extended) combined with 16–80 hours of structured wilderness medicine training allows a non-medical professional to manage hemorrhage, maintain airways, splint fractures, treat environmental emergencies, and make sound evacuation decisions in remote settings. The training path from Wilderness First Aid (16 hours) to Wilderness First Responder (80 hours) is accessible, affordable, and directly applicable to anyone who works, travels, or lives more than one hour from a hospital.

Citation-Ready Claims

  • Tourniquet use in combat reduced extremity hemorrhage mortality from 23.7% to 5.8% (Kragh et al., 2009, *Journal of Trauma*, 66(4), S38–S50)
  • MARCH protocol adopted by TCCC as standard prehospital trauma assessment (Butler et al., 2015, *Journal of Special Operations Medicine*, 15(4), 86–100)
  • Hypothermia present in 66% of trauma fatalities; active rewarming improves survival (Tsuei & Kearney, 2004, *Current Surgery*, 61(5), 479–486)
  • Wound packing with hemostatic gauze controls junctional hemorrhage in 79% of cases within 3 minutes (Kheirabadi et al., 2009, *Journal of Trauma*, 66(2), 316–328)
  • Tension pneumothorax accounts for 3–4% of combat deaths; chest seal application is the standard field intervention (Leigh-Smith & Harris, 2005, *Journal of the Royal Army Medical Corps*, 151(3), 170–176)
  • Wilderness First Responder certification (80 hours) is the minimum standard for professional wilderness guides in the US (Wilderness Medical Society Position Statement, 2014)
  • Golden Hour concept: mortality increases significantly when definitive care is delayed beyond 60 minutes post-injury (Lerner & Moscati, 2001, *Prehospital Emergency Care*, 5(4), 381–390)

**This document is education and training guidance, not medical advice. Nothing here replaces formal wilderness medicine training, certification, or professional medical judgment. Practice these skills under qualified instruction before relying on them in the field.**

1. Introduction — The Gap Between First Aid and Field Medicine

Standard first aid assumes one thing: help is coming. Every Red Cross course, every workplace AED training, every CPR card builds on the assumption that someone will call 911, an ambulance will arrive in under fifteen minutes, and a paramedic will take over. Remove that assumption and the entire framework collapses.

Field medicine exists in the gap. It is what you do when definitive care — a surgeon, a hospital, blood products, imaging — is not eight minutes away but eight hours. Or eighty. The skills overlap with first aid at the front end (stop bleeding, open airways) but diverge sharply at every decision point after the first five minutes.

**The golden hour.** The concept originated in trauma surgery: patients who reach an operating room within sixty minutes of injury have significantly better outcomes than those who do not (Lerner & Moscati, 2001). In urban EMS systems, the golden hour is a logistical problem — traffic, dispatch delays, triage errors. In wilderness settings, it is often a physical impossibility. A fractured femur on a ridgeline three hours from a trailhead means the golden hour expired before anyone started walking out.

This changes everything about priorities. In urban first aid, you stabilize and wait. In field medicine, you stabilize and then manage. You monitor vital signs over hours. You make evacuation decisions with incomplete information. You treat pain, prevent hypothermia, manage hydration, and reassess continuously — because nobody else is going to do it.

**Who needs this.** Anyone who spends time more than one hour from a hospital. Ranchers, backcountry hikers, offshore sailors, rural homesteaders, hunting guides, international travelers, disaster preparedness teams. The common thread is not a desire to play doctor — it is recognition that geography and circumstances can make you the only medical resource available.

**What this document covers.** Assessment protocols, hemorrhage control, airway management, breathing emergencies, fractures and splinting, environmental emergencies, medical kit design, evacuation decision-making, and training pathways. Every section is structured around what to do when you cannot hand the patient to someone with more training.

2. Assessment — Find the Killing Problems First

Assessment is the single most undertrained skill in first aid. Most people rush to the visible injury — the blood, the deformity, the screaming — and miss the problem that will actually kill the patient. Field assessment follows a rigid sequence because human attention under stress is unreliable. The sequence catches lethal problems in order of lethality.

Scene Safety

Before touching the patient, stop. Look at what caused the injury and determine whether it can cause the same injury to you. Rockfall. Electrical hazard. Unstable vehicle. Aggressive animal. Avalanche terrain. Swift water. A dead rescuer helps nobody. If the scene is not safe, make it safe or do not enter. This is not optional. It is the first and most frequently skipped step.

Check: How many patients? One casualty from a falling tree is a rescue. Four casualties from a structural collapse is a mass casualty incident with different protocols.

Primary Survey — MARCH

The MARCH protocol replaced the traditional ABC (Airway, Breathing, Circulation) sequence in tactical and wilderness medicine because data from combat casualties showed that extremity hemorrhage — not airway obstruction — was the leading cause of preventable death (Butler et al., 2015). MARCH addresses threats in order of how quickly they kill.

**M — Massive Hemorrhage**

  • Look for arterial bleeding: bright red, spurting, or rapidly pooling blood
  • Check all four extremities, the groin (junctional), the neck, and the axillae (armpits)
  • Apply tourniquet to extremity hemorrhage immediately — do not waste time with direct pressure on arterial bleeds from limbs
  • Pack junctional wounds (groin, neck, axilla) with hemostatic gauze and hold direct pressure
  • Time limit to address: seconds to minutes. Arterial bleed from a femoral artery can produce class IV hemorrhage (>40% blood volume loss) in under three minutes

**A — Airway**

  • Is the patient talking? If yes, the airway is open. Move on.
  • If unconscious: head tilt/chin lift (trauma: jaw thrust only if spinal injury suspected)
  • Look in the mouth for obstructions: blood, vomit, broken teeth, foreign objects
  • If the patient is breathing but unconscious, place in recovery position to prevent aspiration
  • If you cannot open the airway with positioning, insert a nasopharyngeal airway (NPA)

**R — Respiration**

  • Expose the chest. Look for asymmetric rise, wounds, bruising, flail segments
  • Listen for breath sounds on both sides (ear to chest wall if no stethoscope)
  • Seal any open chest wound with a vented chest seal or improvised occlusive dressing (taped on three sides)
  • Watch for tension pneumothorax signs: worsening respiratory distress, tracheal deviation, distended neck veins, absent breath sounds on one side

**C — Circulation**

  • Check radial pulse (wrist). Present = systolic BP likely above 80 mmHg. Absent = check carotid
  • Assess skin color, temperature, and moisture. Cool, pale, clammy skin = shock
  • Control remaining non-massive bleeding with direct pressure and bandaging
  • If shock signs present: lay patient flat, elevate legs if no spinal injury suspected, insulate from ground, prevent further heat loss

**H — Hypothermia / Head Injury**

  • Hypothermia kills trauma patients. Even in warm environments, a bleeding patient loses heat rapidly. Wet clothing, wind, ground contact, and blood loss all accelerate cooling
  • Remove wet clothing. Insulate from the ground (this matters more than covering from above). Wrap in anything available — sleeping bags, tarps, emergency blankets, dry clothing
  • Assess neurological status: AVPU scale (Alert, responds to Voice, responds to Pain, Unresponsive)
  • Check pupils: equal and reactive is normal. Unequal pupils after head trauma suggest intracranial bleeding — this patient needs evacuation immediately

Secondary Survey — Head to Toe

Only after MARCH is complete and all life threats are addressed, perform a systematic head-to-toe examination. This finds injuries the primary survey missed.

  • **Head:** Run fingers through hair feeling for lacerations, depressions, fluid from ears or nose (CSF leak = skull fracture)
  • **Neck:** Palpate cervical spine for tenderness, check for tracheal deviation, distended jugular veins
  • **Chest:** Palpate each rib for crepitus (grinding) or instability, check sternum
  • **Abdomen:** Press gently in all four quadrants. Rigidity, guarding, or distension suggests internal bleeding
  • **Pelvis:** Compress iliac crests gently once. Instability or crepitus = pelvic fracture. Do not repeat this test — an unstable pelvis can hemorrhage catastrophically
  • **Extremities:** Check each limb for deformity, swelling, tenderness, circulation (pulse distal to injury), sensation, and movement (CSMs)
  • **Back:** Log-roll the patient and inspect/palpate the entire spine

Patient Documentation — SOAP Notes

In field settings, written documentation serves two purposes: it tracks changes over time (critical for prolonged care), and it provides handoff information when the patient reaches higher care. Use the SOAP format:

  • **S — Subjective:** What the patient tells you. Chief complaint, pain description (location, severity on 0–10 scale, character), medical history, medications, allergies (use SAMPLE: Signs/Symptoms, Allergies, Medications, Past medical history, Last oral intake, Events leading to injury)
  • **O — Objective:** What you observe and measure. Vital signs (pulse rate, respiratory rate, skin color/temp/moisture, pupil response, AVPU level, blood pressure if you have a cuff), physical exam findings
  • **A — Assessment:** Your best determination of what is wrong. "Suspected closed femur fracture, left leg" or "Controlled hemorrhage from right forearm laceration, possible shock"
  • **P — Plan:** What you are going to do. Treatment steps, reassessment schedule, evacuation plan

Record vital signs every 15 minutes for unstable patients, every 30 minutes for stable patients. Trending is more useful than any single reading. A pulse rising from 80 to 100 to 120 tells you the patient is compensating for blood loss even if each individual reading looks acceptable.

3. Hemorrhage Control — The Skill That Saves the Most Lives

Uncontrolled hemorrhage is the number one cause of preventable death in trauma — in combat, in the backcountry, and on the highway (Eastridge et al., 2012, *Journal of Trauma and Acute Care Surgery*, 73(6), S431–S437). It is also the most trainable skill. A person with four hours of hemorrhage control training and a $30 tourniquet can prevent deaths that would otherwise be inevitable.

Direct Pressure

For wounds that are not arterial and not on extremities, direct pressure remains the first intervention. Use a gauze pad or the cleanest available material. Press directly on the wound — not next to it, not above it, on it. Maintain steady pressure for a minimum of three minutes before checking. Lifting the dressing to look resets the clotting process.

Pressure works by compressing the severed vessel against underlying tissue, slowing flow enough for the coagulation cascade to form a stable clot. It fails when the vessel is too large, the bleeding site is too deep, or the anatomy does not provide a backstop (junctional areas).

Wound Packing

When direct pressure alone is insufficient — deep wounds, junctional hemorrhage, wounds with tissue disruption — wound packing is the next step. This is the single most uncomfortable skill to learn and the one that saves the most lives outside of tourniquet application.

**Technique:** 1. Open the wound with gloved fingers to identify the bleeding source 2. Feed gauze (plain or hemostatic) directly into the wound, packing tightly against the bleeder 3. Continue packing until the wound cavity is completely filled — the gauze itself becomes the pressure 4. Apply direct pressure on top of the packed wound for a minimum of three minutes (ten minutes for hemostatic gauze per manufacturer instructions) 5. Secure with a pressure dressing (Israeli bandage, ACE wrap, or improvised equivalent)

**Hemostatic agents.** Combat Gauze (kaolin-impregnated) and Celox (chitosan-based) accelerate clotting at the wound surface. Kheirabadi et al. (2009) demonstrated that hemostatic gauze controlled junctional hemorrhage in 79% of cases within three minutes. These agents work by concentrating clotting factors at the wound site and providing a matrix for platelet aggregation. They are not magic — they still require proper packing technique and direct pressure to work.

Tourniquet Application

The tourniquet is the single most effective hemorrhage control device for extremity bleeding. The data is unambiguous: Kragh et al. (2009) documented mortality reduction from 23.7% to 5.8% when tourniquets were applied before the onset of shock in combat casualties.

**The tourniquet myth — debunked.** For decades, civilian first aid taught that tourniquets cause limb loss and should be used only as a "last resort." This was based on anecdotal reports from prolonged wartime applications (hours to days) and was never supported by controlled evidence. Modern data shows:

  • Tourniquet application times under six hours carry negligible risk of limb loss (Kragh et al., 2009)
  • The risk of death from uncontrolled hemorrhage vastly exceeds the risk of limb damage from tourniquet application
  • In field settings where evacuation to surgery is possible within six hours, tourniquet use is unambiguously life-saving

**Recommended tourniquets:**

  • **CAT (Combat Application Tourniquet):** One-handed application, proven in combat, the most widely used device. Windlass design.
  • **SOFTT-W (Special Operations Forces Tactical Tourniquet - Wide):** Metal windlass, slightly more durable, requires two hands for optimal application. Better for prolonged use.

**Application technique (CAT):** 1. Place the tourniquet 2–3 inches above the wound (never on a joint) 2. Pull the free end of the band through the buckle and tighten as much as possible by hand 3. Twist the windlass rod until bleeding stops completely — not reduces, stops 4. Secure the windlass in the clip 5. Write the time of application on the tourniquet (or on the patient's forehead with a marker) 6. Do not loosen or remove the tourniquet in the field. This is a hospital decision.

**When to tourniquet immediately vs. attempt other methods:**

  • Arterial extremity bleed (bright red, spurting): tourniquet first, no delay
  • Amputation or near-amputation: tourniquet first
  • Multiple casualties with limited rescuers: tourniquet all extremity bleeds to buy time
  • Non-arterial extremity bleed where you have time and hands: try direct pressure and wound packing first, escalate to tourniquet if control is not achieved in 60 seconds

4. Airway Management — Keep It Open, Keep It Clear

An obstructed airway kills in minutes. In conscious patients, the airway usually self-manages — coughing, gagging, and positioning reflexes keep it clear. In unconscious patients, the tongue relaxes backward and occludes the pharynx. This is the most common airway obstruction in trauma and the easiest to fix.

Head Tilt / Chin Lift

The standard opening maneuver for any unconscious patient without suspected spinal injury. One hand on the forehead tilts the head back. Two fingers under the bony part of the chin lift it forward. This mechanically pulls the tongue off the posterior pharynx and opens the airway. Takes two seconds. Works in the majority of cases.

Jaw Thrust

For patients with suspected cervical spine injury (falls from height, diving injuries, high-speed impacts, any mechanism that could load the neck). Kneel behind the patient's head. Place fingers behind the angles of the jaw (the bony points below the ears). Push the jaw forward without moving the neck. This opens the airway while maintaining cervical alignment.

Recovery Position

An unconscious patient with a patent airway who is breathing adequately should be placed in the recovery position: on their side, mouth angled toward the ground, top leg bent forward for stability. This position prevents aspiration if the patient vomits — a common and lethal complication in unconscious patients.

Nasopharyngeal Airway (NPA)

When positioning alone does not maintain the airway — common in patients with facial trauma, heavy bleeding into the airway, or deep unconsciousness — an NPA provides a mechanical bypass.

**Insertion technique:** 1. Select the appropriate size: measure from the patient's nostril to the earlobe 2. Lubricate with water-based lubricant or clean water 3. Insert into the right nostril (larger passage in most people), bevel facing the septum 4. Advance straight back (not upward) along the floor of the nasal passage 5. Insert until the flange rests against the nostril

**When NOT to clear an airway:** If you suspect a basilar skull fracture (raccoon eyes, Battle's sign behind the ears, clear fluid from nose or ears), do NOT insert an NPA — it can enter the cranial vault. Use jaw thrust and positioning only.

5. Breathing Emergencies — Beyond Airway Obstruction

An open airway does not guarantee adequate ventilation. The chest wall, pleural space, and diaphragm must all function for gas exchange to occur. Field-treatable breathing emergencies include tension pneumothorax, open pneumothorax, and anaphylaxis.

Tension Pneumothorax

Air enters the pleural space (through a chest wound or a ruptured bleb) and cannot escape. Each breath pumps more air into the space. The affected lung collapses. Pressure builds. The mediastinum shifts, compressing the opposite lung and the heart. Untreated, it kills by cardiac arrest from reduced venous return.

**Recognition:**

  • Increasing respiratory distress despite open airway
  • Absent or diminished breath sounds on the affected side
  • Tracheal deviation toward the unaffected side (late sign — do not wait for this)
  • Distended neck veins
  • Hypotension and tachycardia

**Field treatment:** Needle decompression is the definitive field intervention but requires specific training and equipment (14-gauge, 3.25-inch needle/catheter). For the scope of wilderness first aid, recognition and rapid evacuation are the priorities. If you carry the equipment and have the training, insert the needle in the second intercostal space, midclavicular line, just above the rib (the neurovascular bundle runs below each rib).

Chest Seals

An open chest wound ("sucking chest wound") allows air to enter the pleural space through the wound rather than through the trachea. You will hear air moving through the wound with each breath. Cover immediately.

**Application:** 1. Expose the wound 2. Apply a vented chest seal (HyFin, SAM, or equivalent) directly over the wound 3. If no commercial seal: use plastic (bag, wrapper, credit card) taped on three sides. The open side acts as a flutter valve — air escapes on exhalation but cannot re-enter on inhalation 4. Monitor for tension pneumothorax development (the wound seal may trap air if the lung itself is also leaking) 5. Check for an exit wound on the back. Seal both wounds.

Anaphylaxis

Severe allergic reaction causing airway swelling, bronchospasm, and cardiovascular collapse. In the field, this kills faster than most trauma because the timeline is minutes.

**Treatment:** 1. Epinephrine auto-injector (EpiPen): 0.3 mg IM, outer thigh, through clothing if necessary 2. Position: sitting upright if breathing is the primary problem, flat with legs elevated if hypotension dominates 3. Second dose of epinephrine at 5–15 minutes if no improvement 4. Diphenhydramine (Benadryl) 50 mg oral if the patient can swallow — this is adjunct, not primary treatment 5. Evacuate. Anaphylaxis can recur (biphasic reaction) 4–8 hours after initial resolution

Asthma

Severe bronchospasm without the allergic cascade. Field management: patient's own rescue inhaler (albuterol), seated upright position, calm coaching on slow exhalation. If the patient has no inhaler and is in severe distress, epinephrine 0.3 mg IM is an alternative — it is a bronchodilator as well as a vasopressor.

6. Fractures and Splinting — Stabilize, Do Not Fix

Field splinting has one goal: prevent further injury during transport. You are not setting bones. You are not reducing fractures (with specific exceptions). You are immobilizing the injury to reduce pain, prevent further soft tissue damage, and maintain distal circulation.

General Splinting Principles

  • Splint in the position found unless distal pulses are absent (then gentle realignment to restore circulation)
  • Immobilize the joint above and below the fracture
  • Pad all bony prominences
  • Check circulation, sensation, and movement (CSMs) before and after splinting
  • Reassess CSMs every 15–30 minutes — swelling under the splint can compromise circulation

Traction Splints — Femur Fractures

A midshaft femur fracture is a life-threatening emergency. The thigh muscles spasm and override, shortening the limb and creating a space that can hold 1–2 liters of blood internally. Traction splinting counteracts the muscle spasm, reduces pain dramatically, and decreases internal hemorrhage.

**Commercial traction splints** (Kendrick Traction Device, Sager, Hare) are purpose-built. They apply mechanical traction to the ankle while bracing against the pelvis.

**Improvised traction:** Two rigid poles (ski poles, trekking poles, branches) longer than the leg, padded at the groin and ankle. Traction is applied by pulling the ankle away from the body and securing it to the poles with cravats or cordage. This requires two rescuers and should only be attempted by those trained in the technique.

**Do not apply traction to:** fractures near the knee, fractures near the hip, open femur fractures with bone protruding, suspected pelvic fractures.

SAM Splints

The SAM splint is a padded aluminum strip that bends to conform to any anatomy. It becomes rigid when bent into a curve (structural engineering — a flat strip is flexible, a C-shaped channel is rigid). One SAM splint and two rolls of tape can splint any extremity fracture.

**Common configurations:**

  • Wrist/forearm: fold into a gutter splint, secure with tape or wrap
  • Ankle: bend into a stirrup shape around the foot and lower leg
  • Finger: cut a strip and bend into a finger splint
  • Neck (improvised cervical collar): bend into a wide U-shape, pad heavily, secure with tape

Improvised Splints

Anything rigid works: sticks, tent poles, trekking poles, rolled magazines, cardboard, SAM splints fashioned from aluminum flashing. Buddy-taping a broken finger to the adjacent finger is an improvised splint. Tying a broken arm to the torso with a sling and swathe is an improvised splint. The materials matter less than the principles: immobilize above and below, pad, check CSMs.

When to Reduce a Dislocation in the Field

Most dislocations should be splinted in the position found and evacuated. Two exceptions exist where field reduction is appropriate:

1. **Anterior shoulder dislocation** — when evacuation will take hours and the patient has no pulses in the affected arm. Technique: External rotation method. Patient supine, elbow bent 90 degrees, slowly rotate the forearm outward (like opening a door). The humeral head often relocates with gentle traction and rotation. Stop if resistance or pain prevents completion.

2. **Patella dislocation** — the kneecap has visibly shifted laterally. Straighten the leg slowly while pushing the patella medially. This often reduces spontaneously with leg extension.

Never attempt field reduction of hip, elbow, or spinal dislocations. The risk of neurovascular damage exceeds the risk of delayed reduction.

7. Environmental Emergencies — The Threats Nobody Packed For

Environmental injuries are preventable in theory and common in practice. They kill through mechanisms that have nothing to do with trauma, and they require different treatment logic.

Hypothermia

Body core temperature below 35°C (95°F). The most insidious environmental emergency because it impairs judgment before it impairs function — hypothermic patients make bad decisions about their own condition.

**Stages:**

  • **Mild (35–32°C / 95–90°F):** Shivering, impaired coordination, poor judgment. The patient can still rewarm themselves with shelter, dry clothing, and caloric intake.
  • **Moderate (32–28°C / 90–82°F):** Shivering stops (this is worse, not better — the body has exhausted its warming mechanism). Confusion, slurred speech, paradoxical undressing. Cardiac irritability begins.
  • **Severe (<28°C / <82°F):** Unconsciousness, rigid muscles, barely detectable pulse and breathing. The heart is electrically unstable — rough handling can trigger ventricular fibrillation.

**Treatment principles:** 1. Remove from the cold environment. Shelter, insulate from the ground (ground conduction is the primary heat loss pathway for a supine patient) 2. Remove wet clothing. Replace with dry insulation 3. Mild hypothermia: warm fluids (not hot — warm), high-calorie food, physical activity if possible, heat packs to the core (neck, armpits, groin) 4. Moderate to severe: handle gently. No rough movement. No upright positioning. Wrap in vapor barrier (plastic sheet inside insulating layers to trap body heat). External heat sources to the core only — do not warm the extremities first

**The afterdrop phenomenon.** When a severely hypothermic patient is rewarmed, cold blood pooled in the extremities returns to the core, temporarily dropping core temperature further. This can trigger cardiac arrest even as external warming succeeds. This is why severe hypothermia patients must be rewarmed core-first, handled gently, and monitored continuously. Peripheral warming (warm water on hands and feet) is dangerous in severe hypothermia because it accelerates afterdrop.

**Practical rule:** Nobody is dead until they are warm and dead. Severely hypothermic patients with no detectable pulse should receive gentle CPR and rewarming efforts until they reach a hospital. Cold is neuroprotective — survival with full neurological recovery has been documented after core temperatures below 18°C (Wanscher et al., 2012, *Resuscitation*, 83(9), 1078–1083).

Heat Stroke vs. Heat Exhaustion

These are not the same condition on a spectrum. They are different physiological events.

**Heat exhaustion:** Volume depletion. The body is overheated but the thermoregulatory system is still working. Symptoms: heavy sweating, weakness, nausea, headache, dizziness. Skin is cool and clammy. Core temp is elevated but typically below 40°C. Treatment: move to shade, remove excess clothing, cool with wet cloths, oral rehydration with electrolytes, rest. Recovery is usually rapid.

**Heat stroke:** Thermoregulatory failure. The hypothalamus has stopped regulating temperature. Core temp exceeds 40°C (104°F). Symptoms: altered mental status (confusion, combativeness, seizures, unconsciousness), hot dry skin (though sweating may still be present in exertional heat stroke), tachycardia, hypotension. This is a medical emergency with >10% mortality even with treatment.

**Field treatment for heat stroke:** 1. Cool aggressively and immediately. Immerse in cold water if possible (stream, lake, tarp filled with water and ice) 2. If immersion is not available: soak clothing, fan the patient, apply ice packs to neck, armpits, and groin 3. Do not give oral fluids to patients with altered mental status (aspiration risk) 4. Evacuate immediately — this patient needs IV fluids and monitoring

Drowning

Remove from water (rescuer safety first — reach, throw, row, go, in that order of preference). Check for breathing. If not breathing, begin rescue breaths immediately — drowning deaths are primarily respiratory, not cardiac. Five initial rescue breaths, then standard CPR if no pulse. Do not attempt to drain water from the lungs (the Heimlich maneuver does not work for drowning and wastes time). Hypothermia protocols apply to cold-water drowning — these patients may survive prolonged submersion.

Lightning

Lightning injuries are not the same as electrical burns from power lines. Lightning produces a massive brief current over the body surface (flashover effect) rather than sustained internal current flow. Cardiac arrest is the primary killing mechanism — a direct strike can cause both respiratory arrest and cardiac arrest simultaneously.

Triage reversal applies: in a multi-casualty lightning strike, treat the apparently dead first. Patients who are moving and groaning will likely survive. Patients in cardiac arrest may respond to CPR because the heart often restarts spontaneously if you can maintain respirations through the initial arrest period.

8. Medical Kit — Layered by Mission and Duration

The most common medical kit failure is having a $200 bag in your truck when you needed a $15 kit in your pocket. Kit design follows the layered principle: what you carry on your body, what you carry in your daypack, and what you carry in your base camp or vehicle.

Pocket Kit (Always On Your Person)

  • 1x CAT tourniquet
  • 1x chest seal (HyFin Twin Pack — two seals for entry and exit wounds)
  • 2x pairs nitrile gloves
  • 1x compressed gauze (z-folded, vacuum sealed)
  • 1x emergency blanket (SOL brand, not dollar-store mylar)
  • 1x permanent marker (for tourniquet time, triage marks)
  • 1x small flashlight

This kit fits in a cargo pocket. It addresses the two most time-critical emergencies: hemorrhage and tension pneumothorax/open chest wound.

Day Kit (Daypack or Belt Pouch)

Everything in the pocket kit, plus:

  • 2x additional compressed gauze
  • 1x hemostatic gauze (Combat Gauze or Celox)
  • 1x Israeli bandage (6-inch)
  • 1x SAM splint (36-inch)
  • 2x cravats (triangular bandages)
  • 1x NPA (28 Fr with lubricant)
  • 1x roll 2-inch medical tape
  • 1x irrigation syringe (20cc or 60cc)
  • 1x wound closure strips (Steri-Strips)
  • 1x EMT shears
  • 1x CPR pocket mask
  • 1x oral thermometer
  • Medical documentation card and pencil

**Medications (day kit):**

  • Ibuprofen 200 mg (anti-inflammatory, pain) — dose: 400–800 mg every 6–8 hours with food
  • Acetaminophen 500 mg (pain, fever) — dose: 500–1000 mg every 6 hours, max 3000 mg/day
  • Diphenhydramine 25 mg (allergic reactions, sleep aid) — dose: 25–50 mg every 6 hours
  • Loperamide 2 mg (diarrhea) — dose: 4 mg initially, then 2 mg after each loose stool, max 16 mg/day
  • Epinephrine auto-injector (0.3 mg) if anyone in the group has known severe allergies
  • Aspirin 325 mg (chest pain protocol — chew 1 tablet if cardiac event suspected)
  • Glucose tablets or gel (hypoglycemia)

Extended Kit (Base Camp, Vehicle, or Multi-Day Expedition)

Everything in the day kit, plus:

  • 1x traction splint (KTD or Sager)
  • Additional SAM splints (2–3)
  • 1x blood pressure cuff and stethoscope
  • Pulse oximeter
  • Additional hemostatic gauze (2–3 packs)
  • Wound irrigation supplies (1L clean water in squeeze bottle, povidone-iodine for dilution)
  • Suture kit or skin stapler (only if trained)
  • Oral rehydration salts
  • Additional bandaging: roller gauze, elastic wraps, adhesive bandages
  • Duct tape (structural repairs, blister prevention, improvised splinting)
  • Safety pins (sling fixation, drainage)
  • Hypothermia wrap (heavy-duty vapor barrier)
  • Foil blankets (additional)
  • SOAP note documentation forms (waterproof paper)

**Extended medication list:**

  • Ciprofloxacin 500 mg (broad-spectrum antibiotic for GI/urinary infections) — dose: 500 mg every 12 hours. Prescription required.
  • Amoxicillin/clavulanate 875 mg (skin and soft tissue infections) — dose: 875 mg every 12 hours. Prescription required.
  • Ondansetron 4 mg ODT (anti-nausea, orally disintegrating) — dose: 4–8 mg every 8 hours. Prescription required.
  • Prednisone 20 mg (severe allergic reactions, asthma exacerbation) — dose: 40–60 mg once, then taper. Prescription required.
  • Acetazolamide 250 mg (altitude sickness prevention) — dose: 125–250 mg every 12 hours, starting 24 hours before ascent. Prescription required.
  • Albuterol inhaler (bronchospasm) — dose: 2 puffs every 4–6 hours as needed. Prescription required.

**Consult a physician to obtain prescription medications for your kit. Carry prescriptions or a letter from the prescribing physician.**

Improvised Supplies

When your kit is inadequate or inaccessible:

  • Tourniquet: belt, triangular bandage with a stick windlass, webbing strap. Must be at least 1.5 inches wide — paracord and wire cut into tissue before achieving occlusion
  • Pressure dressing: t-shirt, sock, any absorbent fabric plus direct pressure
  • Splint: sticks, trekking poles, rolled sleeping pad, packed clothing
  • Chest seal: plastic bag, food wrapper, credit card — anything non-porous, taped on three sides
  • Irrigation: clean water bottle with a hole poked in the cap. Pressure irrigation is more important than sterile irrigation — high-pressure tap water outperforms low-pressure saline for wound cleaning (Fernandez & Griffiths, 2012, *Cochrane Database of Systematic Reviews*)
  • Litter: two poles threaded through jacket sleeves (zip the jackets closed, button or zip them, thread poles through the sleeves)

9. Evacuation Decision — Stay or Move

The evacuation decision is the most consequential judgment call in field medicine. Move a patient who should not be moved, and you worsen their injuries. Stay when you should evacuate, and they die waiting.

When to Evacuate Immediately

  • Uncontrolled hemorrhage despite interventions
  • Signs of internal bleeding (abdominal rigidity, pelvic instability, worsening shock without external cause)
  • Head injury with altered or declining mental status
  • Chest injury with respiratory distress
  • Spinal cord symptoms (numbness, tingling, weakness, paralysis below the injury)
  • Heat stroke
  • Severe hypothermia
  • Anaphylaxis (even after successful epinephrine — biphasic reactions occur)
  • Any condition that is worsening despite your treatment

When It May Be Safe to Stay

  • Isolated extremity fracture, stable, with intact CSMs and adequate splinting
  • Controlled minor hemorrhage
  • Mild hypothermia responding to rewarming
  • Minor allergic reaction responding to antihistamines
  • The patient is improving, conditions will worsen with movement (nightfall, weather, terrain), and you have shelter and supplies

Improvised Litter Construction

**Pole-and-jacket litter:** Two rigid poles 7–8 feet long. Two or three jackets zipped closed and buttoned. Thread the poles through the jacket sleeves. The closed jacket bodies form the bed.

**Blanket wrap:** Lay a blanket or tarp flat. Place one pole at the center. Fold half the blanket over the pole. Place the second pole on the folded blanket about 24 inches from the first. Fold the remaining blanket back over the second pole. The patient's weight locks the folds.

**Rope litter:** Requires 40–50 feet of rope and two poles. Clove-hitch the rope to alternating poles in a zigzag pattern, spacing hitches 6–8 inches apart. Pad with clothing, sleeping pads, or pine boughs.

Carries

**Fireman's carry:** One rescuer, conscious patient who cannot walk. Drape the patient across the rescuer's shoulders in a shoulder carry. Effective but exhausting. Limited to short distances.

**Two-person carry:** Rescuers face each other, each gripping the other's wrists to form a seat. Patient sits on the wrist seat and holds the rescuers' shoulders. Moderate distances.

**Four-person litter carry:** One rescuer at each corner of the litter. Most stable option. Rotate positions every 15–20 minutes. On steep terrain, the litter travels feet-first downhill (so the patient's head is uphill) unless the injury dictates otherwise.

Communication and Rescue Signaling

  • **Cell phone:** Always try. Even without signal, 911 may connect through any available tower. Text messages use less bandwidth than voice and may go through when calls fail.
  • **Satellite communicators:** InReach, SPOT, Zoleo. Two-way messaging and SOS capability. If you operate in remote areas regularly, this is not optional equipment.
  • **Signal mirror:** Effective in daylight to 10+ miles. Aim by sighting through the hole and sweeping the reflection across the target area.
  • **Whistle:** Three blasts is the universal distress signal. Carries further than shouting and does not deplete the signaler.
  • **Ground signals:** Use contrasting materials (rocks on snow, dark fabric on light ground). SOS in large letters. Straight lines and right angles do not occur naturally — they attract attention from aircraft.

10. Training Path — Certificates That Actually Teach You Something

Reading this document is not training. Field medicine skills require hands-on practice under stress with feedback from experienced instructors. Simulated scenarios with fake blood, moulage wounds, and timed assessments are how these skills transfer from knowledge to capability.

Wilderness First Aid (WFA) — 16 Hours

The entry point. Two days of classroom and hands-on instruction covering primary assessment, basic hemorrhage control, splinting, litter improvisation, and evacuation decision-making. Appropriate for recreational hikers, hunters, ranch workers, and anyone who wants baseline competency beyond standard first aid.

**Providers:** NOLS Wilderness Medicine, SOLO, Wilderness Medical Associates International (WMAI), Remote Medical International.

**Cost:** $200–$350. Certifications valid for 2–3 years.

Wilderness First Responder (WFR) — 70–80 Hours

The professional standard. Eight to ten days of intensive training covering everything in WFA plus: advanced patient assessment, medication administration, wound management, environmental emergencies, improvised rescue techniques, and multi-day simulated scenarios. Required by most professional outfitter and guiding organizations.

**Providers:** NOLS Wilderness Medicine, WMAI, SOLO, Aerie Backcountry Medicine.

**Cost:** $750–$1,200. Certifications valid for 2–3 years. Recertification courses available (typically 16–24 hours).

Wilderness EMT (WEMT)

Combines the National Registry EMT-Basic curriculum with wilderness medicine protocols. Typically 200+ hours. For those who want both the urban EMS certification and the extended-care wilderness skillset. Several providers offer a bridge course for existing EMTs to add the wilderness component.

Tactical Combat Casualty Care (TCCC)

Military-origin hemorrhage control and trauma management. Emphasizes the MARCH protocol, tourniquet application, and care under fire. Civilian versions are available and are the source for much of the hemorrhage control content in this document. NAEMT offers the civilian TCCC course (TECC — Tactical Emergency Casualty Care).

Continuing Practice

Certification is the beginning, not the end. Skills degrade without practice. Recommendations:

  • Practice tourniquet self-application monthly until you can do it one-handed in under 30 seconds
  • Review MARCH assessment quarterly
  • Replenish and inspect medical kit contents every six months (check medication expiration dates)
  • Take a refresher course or recertification on schedule — do not let certifications lapse and restart from zero

11. Sources

1. Butler, F. K., et al. (2015). Tactical Combat Casualty Care 2015: Management Recommendations for the Treatment of Bleeding. *Journal of Special Operations Medicine*, 15(4), 86–100. 2. Eastridge, B. J., et al. (2012). Death on the battlefield (2001–2011): Implications for the future of combat casualty care. *Journal of Trauma and Acute Care Surgery*, 73(6), S431–S437. 3. Fernandez, R., & Griffiths, R. (2012). Water for wound cleansing. *Cochrane Database of Systematic Reviews*, (2), CD003861. 4. Forgey, W. W. (2017). *Wilderness Medicine: Beyond First Aid*. 7th ed. Globe Pequot Press. 5. Kheirabadi, B. S., et al. (2009). Hemostatic agents in traumatic wound management. *Journal of Trauma*, 66(2), 316–328. 6. Kragh, J. F., et al. (2009). Survival with emergency tourniquet use to stop bleeding in major limb trauma. *Journal of Trauma*, 66(4), S38–S50. 7. Leigh-Smith, S., & Harris, T. (2005). Tension pneumothorax — time for a re-think? *Journal of the Royal Army Medical Corps*, 151(3), 170–176. 8. Lerner, E. B., & Moscati, R. M. (2001). The Golden Hour: Scientific fact or medical urban legend? *Prehospital Emergency Care*, 5(4), 381–390. 9. National Association of EMS Physicians (NAEMSP). (2014). Position Statement on Wilderness EMS. 10. NOLS Wilderness Medicine. Curriculum Standards for WFA, WFR, and WEMT. https://www.nols.edu/en/wilderness-medicine/ 11. Tsuei, B. J., & Kearney, P. A. (2004). Hypothermia in the trauma patient. *Current Surgery*, 61(5), 479–486. 12. Wanscher, M., et al. (2012). Outcome of accidental hypothermia with or without circulatory arrest. *Resuscitation*, 83(9), 1078–1083. 13. Wilderness Medical Associates International (WMAI). Curriculum and Certification Standards. https://www.wildmed.com/ 14. Wilderness Medical Society. (2014). Practice Guidelines for Wilderness Emergency Care. 6th ed.

`[practical-skills]` `[advanced]`