Wilderness preparedness

Background

Wilderness recreation and travel have become increasingly common in the last few decades, and with this growing popularity comes exposure to injury and sickness in environments generally far away from medical facilities. In order to avoid serious repercussions, wilderness travelers must be prepared to quickly recognize and treat common minor ailments, while also recognizing conditions that require evacuation and definitive medical care. While minor trauma and diarrhea are the most likely to affect travelers, other more severe illnesses such as cardiovascular events have been documented, as well. When paired with medical expertise, proper planning and access to appropriate supplies can help reduce morbidity and mortality associated with medical issues encountered in austere environments.

This article will provide an overview of planning for wilderness trips based on environment and activities planned, screening of potential participants, and illness and injury prevention. Medical kit preparation will be discussed including basic assembly, specialized items, and medications. Finally, there will be a brief discussion of illness/injury commonly encountered when in remote environments.

Epidemiology of Injury in the Wilderness

• During planning stage, it is important to talk to individuals with knowledge and expertise about specific environment (e.g. tour guides, local residents, colleague who has done extensive traveling in area).
• Injury secondary to minor trauma is generally more common than medical illness in the wilderness environment.
• Fatalities in remote environments are most likely to be secondary to trauma, and the three most common traumatic events are falls, blunt trauma, and drowning.
• Most life-threatening injuries leading to preventable death in the wilderness are caused by trauma that went unidentified, asphyxia, exsanguination, and untreated pneumothorax.
• Deaths that occurred in non-traumatic situations are most frequently the result of cardiovascular disease.
• Commonly-experienced nonfatal trauma: damage to soft tissue such as lacerations or sprains. Severe injuries such as fractures or dislocations are much less common.
• The lower extremities are more often injured than upper extremity, usually due to improper footwear or inadequate care for injuries such as blisters or sprains.
• Exposure to unfamiliar pathogens in the wilderness as well as limited hygiene resources commonly lead to illnesses such as upper respiratory tract infection and gastroenteritis.
• Common minor illnesses include headache, dehydration, heat-related illness, muscle ache, dermatitis, sunburn, and allergic reaction.
• Environmental causes such as altitude and temperature extremes can be be lessened or even avoided with proper research and preparation.

General Preparation

It is important to evaluate all factors of travel when preparing for a wilderness excursion. This includes weather patterns, terrain, planned activities, health of participants, trip duration, and options for rescue if needed. The goal of pre-trip planning is to be able to take into account and prevent as many potential medical problems as possible. There is no universal planning guideline due to high variability of multiple factors of travel, but some basic steps for general preparedness include:

• Plan a trip itinerary to avoid unexpected situations.
• Meet with participants well in advance of trip to outline potential risks.
• Determine if participants' physical stamina is adequate for planned activities
• Discuss immunization status of participants as it pertains to specific region of travel.
• Review past weather patterns of travel destination and plan accordingly.
• Discuss evacuation routes as part of itinerary.
• When possible, get medical insurance that included evacuation coverage.
• Provide copy of finalized itinerary to emergency contacts and necessary authorities (when possible).
• Develop knowledge and practice skills related to communication and navigation tools available to participants.
• Determine water procurement strategy with backup (e.g. filters, chemical tablets, solar disinfection), as well as mode of storage.
• Ensure participants with preexisting conditions have identification cards/jewelry/medallions as well as contact information for emergencies.
• Gather and review medical equipment and supplies (e.g. proper technique for use of equipment or expiration dates of medications).

Pre-Trip Evaluation of the Healthy Participant

• "Healthy participants" are typically considered to be those traveling who do not have any identified significant past medical history and can tolerate activity of a similar strenuousness to that required for successful participation in planned activities.
• The pre-trip evaluation in a healthy person should seek to identify potential risks or hazards to the participant, make sure travel plans include steps to minimize risks, and determine if any identified risks are acceptable to the participant and usually the leader of the trip.
• Should be conducted by participant's physician since they are most familiar with the participant's health status.
• Steps to avoid harm while traveling can include fitness endurance training, medication changes (e.g. increasing dose of medication for seasonal allergies prior to trip), diagnostic tests, or can go so far as the physician recommending the participant not take part in activities deemed to unsafe.

Screening questionnaire

Typically includes some or all of the following

1. General information (name, age, address, etc,)
2. Trip information (destination, dates, and planned activities)
3. Emergency Contact
4. Primary Care Physician information
5. Brief Medical history (Allergies to food, medication, insects, or environment; current medications and doses
6. Review of list of common illnesses
7. Explanation for any illnesses experienced in past
8. List of current medical problems and/or past surgeries/hospitalizations
9. Family history (specifically death in young age due to cardiac or unknown causes)
10. Alcohol use
11. Tobacco Use
12. Recreational Drug Use
13. Phobias that may impair ability to carry out activities required during travel
14. Evaluation of endurance (ability to run a mile or perform required level of physical activity without chest pain, shortness of breath, etc.)
15. Pregnancy status and LMP (for females)
16. Vaccination History
17. Signature of Applicant
18. Signature of Physician performing the screening

Pre-Trip Evaluation of the Participant with Preexisting Condition(s)

• Similar to screening of health participants, but special attention is given to known medical conditions and how well they are currently managed.
• In order to be cleared for wilderness travel, all medical conditions should be stable, self-managed (by patient), and discussed with physician in regards to planned trip (activities and exercise required).
• Beneficial for physician and trip leader to communicate (with participant's permission) in order to plan for potential exacerbations or relapses of medical condition.
• Participant should procure adequate amount of required medication and/or medical supplies to for period of time roughly two to three times the planned trip duration in case of travel delays or severe illness while in remote areas.
• Care should be taken to maintain normal medication schedule while traveling to minimize potential for exacerbation.
• At-risk participants should be sure to wear medical identification on their person in case of emergency situation.

Training for Physical Preparedness prior to Wilderness Adventure

• Routine exposure to wilderness settings particularly those with similar environment to planned trip is best
• Outside of wilderness, focus should be functional fitness with priority given to aerobic > anaerobic training
• All training should be tailored to preparedness for specific trip, but general guidelines are provided
• Aerobic Fitness (trains VO2 Max, lactate threshold, and efficiency of movement)

1. Walking - low risk of injury, promote weight loss, boost circulation, support joints
2. Running - excellent to boost endurance for trip, can modulate distance and intensity
3. Rucking - prepare body to cover distance carrying load
4. Other - Swimming, Rowing, Biking, and other methods to boost aerobic fitness can be equally advantageous

• Anaerobic Fitness (boosts strength, increase muscle mass, improves ability to move load)

1. Weights - primarily compound movements (squat, bench, deadlift) + functional (lunges/step-ups)
2. Calisthenics - performed using body weight and promotes greater body awareness
3. High Intensity Interval Training - 30sec sprint/15sec rest; research suggests superiority to steady state cardio

• Trip specific training (Diving, High Altitude, Hot/Cold)

General Strategy for Medical Kit and Equipment Preparation

Medical kits should be evaluated and updated for each trip taking into consideration factors such as duration, terrain to be encountered, distance to medical facility/care, diseases endemic to travel destination, as well as level of expertise of personnel on trip.

• Supplies generally divided into five categories:

1. Personal medical supplies
2. Group medical supplies
3. Devices to be used by medically-trained participant
4. Equipment specialized for particular activities and environmental hazards
5. Supplies to be stored in vehicle during trip

• avoid bringing equipment that requires a high level of skill, as misuse or mismanagement of medical condition/injury may lead to more harm than utilizing basic interventions or doing nothing at all until evacuation and transport to proper medical facility can be acquired.
• Important to label and organize kit in a way that allows for quick location of medications/tools if need for their use should arise.
• Store commonly-used items and those to be used in life-threatening situation in more easily accessible places in pack. Less frequently used items can be stored deeper in pack if necessary to optimize space.
• Type of container used depends on user preference as well as travel factors such as duration of trip and environment to be encountered.
• When determining how much of each supply (e.g. medication or bandages) to bring, take into consideration factors such as duration of trip, access to formal medical care, likelihood of illness/injury requiring use of item, maximum number of participants that may require resource at one time, to name a few.

Personal Medical Kit

A personal medical kit is a small kit kept on-person that contains essential supplies carried by each member of a trip. They are beneficial in that they provide redundancy of essential items in case another member's personal kit or parts of the group kit are damaged, lost, or stolen as well as being accessible to the individual should he/she be separated from the larger group. This kit should also include personal identification, medical identification, and any supplies or medications necessary to manage one's own personal medical conditions. While no two travelers will likely pack the same items in their personal medical kit, it would be prudent to consider carrying the following practical items no matter the type of trip planned:

• Personal prescriptions in well-labeled, waterproof lightweight container/bag
• High priority over the counter (OTC) medications such as pain relievers, anti-histamines, anti-nausea, antacids, and-diarrheals, creams/ointments, and aloe vera gel.
• Copy of personal identification documents
• notepad and writing utensil (preferably waterproof paper, and a pencil)
• sun protection (hat, sunglasses, high SPF sunscreen); bring excess of sunscreen as this will likely be shared with other participants
• topographic map and compass (and a basic knowledge of how to utilize these tools)
• multitool (e.g.Swiss Army knife, Leatherman)
• nylon cord
• small plastic zip ties
• rescue whistle and small plastic mirror for signaling
• fire starting items (lighter, wind-proof matches, flint/steel)
• rain poncho, or large thick garbage bag (preferably 4mm thickness)
• adhesive compress
• alcohol-based hand sanitizer
• alcohol preps
• bandages in different sizes
• duct tape
• brightly-colored flagging tape
• bandana
• safety pins
• granola/protein bar for quick energy
• personal hygiene products
• survival guide
• mosquito netting
• ear plugs (to maintain adequate sleep in unfamiliar environment)

Group Medical Kit

The community medical kit should contain a comprehensive supply of those items needed to manage a broad range of potential injuries and illnesses the group might encounter in the wilderness. It is generally put together and maintained by the designated medical leader for the trip. Items in the kit may be distributed to members of the group to maintain management weight distribution among the participants. When community medical supplies are distributed to members of the group, they should be labeled with large visible red crosses to signify that they are medical supplies so they can be easily located in the event of an emergency while traveling. The final list of items to be included in the comprehensive kit will be tailored to the unique needs of each trip, as deemed necessary by the medical leader. These kits often include prescription medication and medical equipment/tools that can be used to treat more sever injuries/illnesses than those items packed in a personal medical kit. A good example of a list of items to include in the group medical supply kit can be found in Box 102-4 in Chapter 102 of "Auerbach's Wilderness Medicine".

While a full gamut of diagnostic equipment is not feasible to have on hand in a wilderness excursion, the following items are generally lightweight and could be considered for adding to the community medical kit:

• Thermometer
• Blood pressure cuff
• Stethoscope
• Urine test strips
• finger pulse-oximiter
• urine pregnancy tests
• glucometer
• magnifying glass
• otoscope
• ophthalmoscope
• end-tidal carbon dioxide detector
• sam splint or other commercially available device
• long angiocatheter for needle thoracostomy

When possible, it is wise to store a fully-stocked medical kit in a locked vehicle located at the base camp for the expedition.

Special Equipment for Use by Medical Professionals Travelling

Equipment requiring a high level of training such as that for surgical airways, chest tubes, or suction, to name a few, may be included in the supply kit of there will participants with medical training. These are items that should not be used by the general public lacking medical training, as their improper use could cause further injury or exacerbation of a medical condition. These items are not limited to but may include the following:

• OP and NP airways
• bulb suction
• Bag valve mask with both adult and/or pediatric sizes available depending on age of participants
• supplemental oxygen supply
• 14 french oral and nasogastric tubing supplies
• Cricothyroid supplies
• Endotracheal tube 7.0 diameter
• LMA
• king airway
• bougie
• IV tubing with spike
• chest tube 32 french
• syringes and needles
• IV catheters
• sharps disposal container
• tourniquet
• intravenous fluid
• AED
• cervical collar
• N95 masks if concern for TB in area of travel
• surgical tools (scalpel, hemostat, forceps)

Medications

When determining which medications to pack for a trip, it is important to address the following factors: what medicines are participants and leaders trained to distribute to others, which ones are considered lifesaving, which medicines are the most likely to be needed based on itinerary and foreseeable risks, and finally, how much room is in the first aid kit.

• Include manufacturers inserts when packing medications.
• Try to purchase medications in tablet form, as these hold up the best in the rugged wilderness environment.
• Consider cost vs. effectiveness of medication when deciding whether to bring drugs in pack, or purchase them when you arrive at your destination. Many countries do not have the same standards as the U.S. FDA, therefore it is sometimes a risk to buy medications once you arrive at your destination.
• If going through customs with personal prescription medications, make sure each medicine is labeled with the patient's name, prescribing doctor's name, dosing schedule, warnings, and indications. It is also helpful to have "For use by expedition only' written on prescription bottles that are part of the group medical kit.
• Medical professionals should travel with multiple copies of their credentials in the event they are questioned at customs.

Common Medical Problems Encountered in the Remote Environment

Gastrointestinal Distress

• Be careful when ingesting locally-prepared foods and beverages when traveling in foreign environments.
• bottles and heated drinks and peeled or cooked foods are less likely to contain GI pathogens.
• Cold beverages, ice cubes, undercooked or raw foods more likely to infect traveller.
• When treating traveller's diarrhea, focus on replacing fluids lost in high volume stool.
• Those affected should increase fluids intake, and avoid sharing food or water supply with those not experiencing symptoms.
• Consider antibiotics in certain cases, and strive for symptomatic treatment.
• Consider medical care for anyone who has atypical abdominal pain or those prescribed proton pump inhibiting medication (PPI).

Fractures and/or Dislocations

• Can improvise a splint from numerous materials available at hand if no SAM splints are available.
• Use cold packs with caution to avoid chemical burns or frostbite.
• Can submerge affected extremity in cold stream.
• Monitor extremity for signs of compromised circulation, as this is a medical emergency requiring extraction and transfer to medical facility as soon as possible.

Blisters/General Foot Care

• Wear footwear that is comfortable and "broken-in" prior to trip. Avoid new footwear as shoes that have never been worn can quickly cause blisters.
• Keep socks dry and clean at all times; pack backup pair if possible.
• Prevent blisters by minimizing friction points (moleskin, bandages, petroleum jelly, for example).
• Trim toenails prior to trip.
• Can close minor skin wounds with super glue.

Wounds

• Main goals of treating wounds in the austere environment are cleanliness and hemostasis.
• Decision to close deeper wounds depends on remaining duration of trip, distance from medical facility, and risk of infection if wound is left open.
• Irrigate with sterile water is preferable, but if non is available, copious irrigation with non-sterile water is better than not irrigating a wound.
• Adhesive bandages are extremely useful in wilderness setting as they can close a wound as well as create a barrier to prevent contamination of wound.

Stings/Bites

• OTC ointments such as hydrocortisone and Benadryl cream are beneficial to keep in medical kit
• Participants with a history of insect allergy should cary epinephrine auto-injector (EpiPen) in their personal medical kit to prevent anaphylaxis in the event of a sting/bite.
• Topical corticosteroids useful for insect bites and/or contact dermatitis.

Pain

• OTC medications such as NSAID, acetaminophen, and aspirin can provide adequate analgesia for common complaints such as headache or muscle ache.
• Can consider bringing opioid analgesics in the event a more invasive procedure such as suturing or fracture splinting should be required.