Wilderness EMS Education

Wilderness EMS Education

Corey Winstead

Seth C. Hawkins


This chapter orients the reader to the present state of education in the fields of wilderness medicine (WM) and wilderness emergency medical services (WEMS). Information regarding the rich history of WEMS in the United States presented in the previous chapter will provide context for the current paradigm, and a platform for understanding the direction of the field in the coming years. By reading this chapter, care providers at all levels will gain a greater understanding of common WM and WEMS educational offerings and certifications, and will be better equipped to assess the credentials and capabilities of personnel around them in an increasingly integrated, multilevel system.

Though the purview of this text is specifically WEMS, numerous training and certification opportunities that fall outside of the current EMS structure are discussed in this chapter. WM education has largely been established and developed outside of the EMS system in this country, though the overlap between the two is often significant. Educational opportunities that are strictly offerings of the WM discipline will be defined as such, and those that stem from, and are regulated by governmental agencies within the EMS system will be distinguished. While most individuals practicing WM outside of the EMS system may not be aware of the larger field of WEMS, WEMS practitioners cannot overlook the significant group of individuals operating in parallel and often in concert with them who are not part of a currently regulated field. As discussed in our Introduction chapter, this group operating at a “first aid” level or outside the EMS system has extremely important contributions to make to WEMS operations, and the WEMS community has a large stake in ensuring they are well-educated and effective. Furthermore, as noted in Chapter 6, “having a clear understanding of the scope of practice and capabilities of all health care providers caring for a patient may act to facilitate communication.” As such, the full range of educational opportunities available will be discussed.

There is little doubt that the methods by which individuals receive instruction significantly impacts their comprehension and retention of the material. Formal medical training material is rife with references to various models of adult learning and comparisons of pedagogical approaches. Some of these models and approaches have been discussed in reference to WM education in texts such as Auerbach’s Wilderness Medicine (7th ed.), and in various articles in Wilderness & Environmental Medicine.1,2,3,4 The current trend in WM education revolves around an attempt to standardize what is included in common courses, not how it is presented. Given consensus regarding educational methodology in WM, it will not be covered in this chapter. Ultimately it is the responsibility of the consumer to thoroughly investigate educational opportunities before committing time and money to their pursuit of wilderness medical education, as methodology varies between educational organizations. The extent to which curriculum content resembles accepted standards, instructor qualification appears rigorous, certification is easily maintained, and training matches desired practice level will be important factors for the consumer to consider.


As outdoor recreation in the United States has grown over the last several decades, so too have the opportunities for wilderness medical education. These opportunities range in commitment, cost, and complexity from short half-day modules to training programs involving hundreds of hands-on and lecture hours. These educational opportunities exist on a spectrum from very basic to very advanced. Training regimens at the most basic end of the spectrum are outside the field of WEMS and are geared toward laypersons, who have an interest in outdoor activities
but who may have no other medical knowledge, and are solely interested in expanding their capacity to provide care for themselves and their companions on isolated wilderness outings. As discussed later, these are often taught at the first aid level. The middle of the spectrum is more densely populated with courses geared toward individuals who may spend significant time in the wilderness, or trip leaders who count the safety of their participants as one of their professional responsibilities. Also discussed later, this has evolved into a first responder training ground, which has grown to be distinct from the EMS conception of first responder, despite originally being attached to this EMS credential by the earliest schools such as Stonehearth Outdoor Learning Opportunities (SOLO) and precursors to Wilderness Medical Associates International (WMA). At the other end of the spectrum are courses of study geared toward medical professionals who may encounter wilderness situations as part of their occupation, or who may provide medical direction/oversight to field practitioners.

There is no universally recognized or mandated national standard for training WM providers, no widely utilized accrediting body, and no government agency oversees or regulates any of the common certifications. As such, specifically WM credentials such as Wilderness First Aid (WFA) and Wilderness First Responder (WFR) cannot be viewed in the same light as other certifications such as MD or Paramedic which conform to a widely accepted or government-mandated set of competencies, and which are universally state-regulated credentials. That said, over the years, individuals and groups of respected WM experts have worked to build consensus regarding training content.3,4,5,6,7,8 Though this effort has not been without setbacks, it has led to unprecedented communication and cooperation between major education organizations, and greater information sharing related to best practices and content delivery. Consensus-generated recommendations when available and applicable are noted in the categories below. Many other documents have been published which suggest basic guidelines for performing WM, but most leave out training guidelines. For example, the Wilderness Medical Society (WMS), which has published nonbinding practice guidelines and curriculum recommendations, has specifically avoided suggesting training protocols, noting “The WMS neither approves nor disapproves teaching methods.”1

This lack of standardization is both an opportunity and a liability.

From the standpoint of opportunity and benefit, educators have the freedom to cater and adapt their courses to the needs of the consumers as they see fit, and to draw on the strengths and experiences of their instructional staff. There are WM schools that cater to niche markets from rock climbing, to diving, to motorsports, and choosing an educator who will bring significant experience related to the environment the buyer will operate in can enhance the applicability of their training. Also, it can be recognized from the history of EMS (for example, instances in Figure 1.1) that governmental regulation potentially brings with it increased bureaucracy, slowed progress, and decisions made on considerations beyond those simply of excellence in patient care. Many physicians and others who work in hospital-based or more traditional medical care environments are often frustrated by the regulatory restrictions and obstacles overlaid on their patient care.

On the other hand, from the standpoint of risk and cost, the buyer (and the buyer’s employer) must be aware of substandard, outdated, or irrelevant instruction from rogue or inferior educational providers. The absence of widespread accreditation and regulated content and practice scopes puts the onus on the consumer to discriminate among various products and vendors, which can be quite confusing. Some educational organizations have published recommendations for “ways to choose a quality WM course”9,10 but understandably, those recommendations generally steer readers toward the characteristics of the schools producing the recommendations. This is not to say such recommendations are not correct, but the benefit of a regulated or accredited educational industry is the outsourcing of approval to an outside entity.

All this dialogue is more specifically about WM training, as EMS training does have accreditation bodies and national standards. This also means that a student must carefully understand whether the training they are receiving is intended to be used in a regulated operational environment (such as working for an EMS team that provides wilderness care under EMS protocols) or an unregulated fashion (such as volunteering on a search with a WFR credential). The reason this is important is twofold. First, an employer may require certain certification levels or accreditation standards for an educational vendor as a condition for employment. Second, in some instances, medical techniques included in WM courses may exceed those in the WEMS community. For example, a Boy Scout in North Carolina taking a WFA class approved by the Boy Scouts of America learns dislocation reductions, a skill that is outside the operational scope of practice (SOP) of a wilderness paramedic in the same state operating under state SOP rules. This creates a paradoxical situation that starts to strain the concept of regulated practice of medicine unless the Boy Scout only plans to use that skill exclusively in recreational environments. However, if a Boy Scout troop wishes to assist in a rescue as a volunteer, a confusing dynamic develops regarding their educational background and how that can be applied during actual wilderness medical care.

An important distinction is being made here between WEMS (which, as a legitimate practice of medicine, must fall under regulatory frameworks from state and federal bodies) and WM (which may substantially benefit from less regulation). The WM industry has made great progress toward internal
regulation. In parallel, there has been significant growth and sophistication in the expansion and formalization of the WEMS system. Ultimately, the lines will need to be made more clear between the unregulated, first aid practice of WM by non-EMS or pre-EMS personnel on an incident versus the deployed, regulated, professional practice of WM by WEMS providers. This is discussed in more detail in the Regulation section of Chapter 1 (WEMS Systems).


To truly understand WEMS, the reader must understand the training its practitioners, and those working outside the EMS field but potentially involved in medical care before EMS arrival, are receiving. There is no doubt that each of the categories below will be an oversimplification of the offerings, and will leave some options out. This information is in no way meant to represent an exhaustive catalogue of the WEMS training opportunities in the United States, but is meant to orient practitioners at different levels to the potential training those practicing around them have received. It may also serve as an aid for individuals attempting to choose a practice level and educational pathway to certification.

Wilderness medical education was conceived, developed, and has been maintained by wilderness enthusiasts first and foremost. Unlike nearly any other medical specialty, the education of EMS providers working in the wilderness (and of first aid caregivers providing care before EMS arrival) has happened largely outside the traditional medical academic infrastructure, via individual schools and activity-specific recreational organizations. Box 2.1 lists currently active schools for WM with a focus on WEMS.11,12,13 Note that Box 2.1 is not an exhaustive list. It is confined to American schools currently in operation and with some type of WM or survivalism programming that is relevant for WEMS providers. Readers should investigate any school listed to see if it meets their own purposes; websites are included in the Box for further reference. In the remainder of this chapter and throughout this book, we use the following nomenclature when describing programs or organizations that provide WM offerings:

Wilderness medicine school—has its own proprietary curriculum and its own instructors

Outdoor school—uses an external WM school’s curriculum, often has its own instructors (but not required), multiple WM offerings

Program Host—uses an external WM school’s curriculum, uses external instructors, few WM offerings, and WM is not its primary institutional mission

In the remainder of the chapter we will break down the most common current offerings in a dynamic and diverse field.

First Aid

As noted above, certifications and courses in this category fall outside the strict WEMS framework. That said, they account for a high percentage of all the individuals trained in WM, and many WEMS providers will find themselves taking courses from the following selections as their introduction to WM, or as continuing education in the field.

Wilderness First Aid (WFA)

WFA courses are an introduction to WM, not a thorough exploration of the topic. Within the WFA labeled offerings in the United States, there are courses of significantly varying instructional hours. A consumer wishing to take a WFA course, or an administrator attempting to choose a level of training or certification needed for their program’s trip leaders, might be overwhelmed trying to choose from the list of educational companies and offerings returned by a simple online search. Although there is no nationally accepted standard for a WFA, attempts have been made over the years to reach consensus with regard to content.2,4,14-16 The most recent attempt has been led by a group of professional educators and directors known as the Wilderness Medicine Education Collaborative (WMEC). Information on the writing group and their recommendations is found in Box 2.2.

The recommendations of this group are nonbinding, and there are numerous WFA courses offered around the country that are not presented according to the guideline. However, within the professional education providers, topics covered are fairly consistent. A significant and controversial deviation from these guidelines is the WFA curriculum promoted by the Boy Scouts of America (see www.scouting.org/filestore/pdf/680-008.pdf for additional details). This curriculum features
most prominently in WFA courses and texts presented by the Emergency Care & Safety Institute (ECSI) bearing the moniker of the WMS, the American Academy of Orthopaedic Surgeons, and the Boy Scouts of America as well as the proprietary Wilderness and Remote First Aid course offered by the American Red Cross.17,18 Among other topics, these courses are controversial for the ease by which instructors can become certified to teach this curriculum and the breadth of topics covered in a short time frame by the curriculum, characteristics which have been described as both strengths and deficits to such courses.19

SOLO has also developed a WFA variant termed Wilderness First Aid Afloat (WFAA). This unique marine-oriented course deletes certain elements of WFA such as altitude illness felt to be less relevant for marine applications and significantly expands topics applicable to the water-based environment.20

The most common training format for WFA is a 16-hour course, delivered over 2 days, though other models exist. Some companies provide a three-day WFA, some provide the WFA curriculum in 2 days and include an additional day for cardiopulmonary resuscitation (CPR). There are hybrid courses of study where 1 day worth of content must be covered by the student through online modules before arriving for a two-day course, and there are WFA courses delivered over the entirety of a college semester during shorter class meetings. Even more confusingly, some organizations offer a “basic” WFA class (at around 8 hours) in addition to a “standard” WFA class (at the more typical 16 hours), both resulting in certification in “Wilderness First Aid.” As one can imagine, given the myriad options available for receiving a certification entitled “Wilderness First Aid,” consistency in outcomes and competencies is difficult to summarize.

Individuals who enroll in WFA courses do so for myriad reasons. Everyone from the weekend warrior exploring the topic for the first time, to the Boy Scout headed off to Philmont for a summer of work, to the seasoned wilderness trip leader using the course to recertify their WFR for the tenth time, may be enrolled in a WFA course. Indeed, challenging the idea that this is not a WEMS credential, some SAR teams and wilderness response services utilize WFA or WFR as a minimum medical standard, especially those that do not purport to specifically deliver medical care as part of their rescue work (see Chapters 30 and 31 for further discussion of this).

Given the time constraints of providing such a broad curriculum in a short period of time, a WFA tends to focus heavily on prevention, and recognizing key and obvious signs and symptoms. Little time is available for anatomy and physiology, and only basic treatment of some injuries and illnesses can be covered. Though limited in scope, the WFA course is often an excellent introduction to WM, which opens students’ eyes to the complexities of providing effective patient care in a wilderness setting.


WFA certifications are generally valid for 2 years, though some companies certify for three, while some suggest recertifying every year. Since this certification is the most basic WM certification on the market, there is no abbreviated version that can be taken to recertify. WFA graduates generally retake a WFA course to maintain their certification.

Wilderness Advanced First Aid (WAFA)

The WAFA (also referred to as Advanced Wilderness First Aid [AWFA])* course usually occupies an in-between space in the list of WEMS offerings. Most schools place this credential level between WFA and WFR, as it may meet the needs of either camp or trip leaders likely to operate within reach of EMS response, or recreationists seeking more training than a WFA who do not have the time for a full WFR. Given that there have been no consensus documents generated for WAFA training, individual companies self-define the intent of their courses and SOP for graduates. These descriptions vary rather significantly. The Wilderness Medicine Training Center (WMTC) suggests that their WAFA course is
“designed for the recreational public who wish to learn more about lightning injuries, wilderness toxins, and treating spine injured patients… and for day and weekend trip leaders in college or university outdoor programs.”21 Contrast this description with the following from WMA: “[WAFA] is comprehensive medical training designed for remote professionals or wilderness leaders who venture into remote and challenging environments… We prepare students for emergency situations that involve prolonged patient care, severe environments, and improvised equipment.”22

Though companies describe their courses differently, some consistencies can be drawn regarding their offerings. WAFA or AWFA courses are longer than WFA courses, but generally shorter than WFRs. They are offered in four- and five-day formats, with some companies offering a hybrid self-directed/on-site format (see Box. 2.7). With more training hours than a WFA, several additional topics can be explored. Depending on the provider, there may be more in-depth anatomy and physiology, leadership skills, long-term patient care, greater injury/illness assessment tools, exploration of evacuation options, or further resources for treatment provided. More time is available for scenarios as well, providing the WAFA student increased simulated patient care experience, and deepening their understanding of the material.


WAFA certifications are generally valid for 2 years, though some providers allow three. Recertification varies by company. Some allow recertification by WFA course, while some require a specific recertification course. Several providers also offer bridge programs for students who would like to progress from WAFA to WFR.23,24,25

Climbing/Climber First Aid

While WFA, AWFA, and WFR are the most common courses offered within this level of WM care, one company focused on a subset of the outdoor guide and recreational population. In response to research that identified a gap in education for overuse injuries in rock climbing within the most common courses described above,26 Vertical Medicine Resources developed a unique curriculum with a focus on climbing injuries. Specifically, Climbing First Aid and Climber First Aid (two different courses with different curricula and length) cover common injuries and illnesses identified in evidenced-based literature to tailor a course to meet the needs of the growing climbing community. These courses range from 1 to 2 days, are centered on the most common traumatic and chronic injuries, and are configured to student’s interest and needs based upon a pre-course survey.

Basic Life Support

Wilderness Emergency Medical Responder

In this discussion, it is critical to mention the new nationally recognized EMS certification Emergency Medical Responder (EMR), which is replacing the EMS certification level of First Responder. For decades, the WFR course and certification shared part of its name with the nationally recognized certification of First Responder. Indeed, the WFR course as initially conceived in the late 1970s and early 1980s by industry leaders like Frank Hubbell (SOLO) and Peter Goth (WMA) was intended to be the wilderness analogue for the new front country EMS First Responder certification—a certification intended for fire, police, and lay public who would arrive first at a scene and had very little, if any, equipment (Figure 1.1). First Responder was standardized and regulated beginning in the mid-1990s by the U.S. Department of Transportation (DOT), which also regulates the terms Emergency Medical Technician (EMT) and paramedic.27 Though WFR and front country First Responder curricula and certification shared part of their name, they did not necessarily completely overlap, and over the years grew even more divergent. This was in general for good reason, as the FR curriculum (like much of EMS in the 1970s) was originally conceived around motor vehicle accident response, and later expanded to include basic techniques in urban injury stabilization. In the mid-2000s, the National Highway Transportation Safety Administration (NHTSA), a division of the DOT, and state providers began developing an expanded curriculum for the EMR certification, meant to replace First Responder, and add skills to the SOP. The NHTSA now estimates that EMR training may take approximately 48 to 60 hours to achieve competency, though places no requirements on contact time.28 As the EMR standard has been rolled out at the state and national level, WEMS providers are taking advantage of the opportunity to provide their graduates with certifications that can be recognized in both the backcountry and the front country. Several WEMS schools are now offering opportunities to add or combine an EMR certification to a WFR. At least one WEMS provider has branded their WFR course as a WEMR.29 The growing distinction between WFR and WEMR more clearly than ever delineates a difference between WM and WEMS. WEMR certification continues the theme of creating hybrid EMS and WM certifications using standards and terminology familiar to EMS regulators, with additional wilderness modular components, similar to the original early 1980s concept of WFR. Increasingly this should become a standard requisite basic certification for WEMS teams, even though WEMR is not in name a certification recognized by the NHTSA. In Chapters 24, 25, 30, and elsewhere in this book, we also endorse WEMR (or the equivalent for truly niche specialties such as lifeguarding or ski patrols) as the minimum acceptable EMS certification for a wilderness rescue team that positions itself as formal medical care providers in addition to a search or technical rescue team. Alternately, WFR is now completely divorced from any EMS certification, and is free to grow as a true WM certification without the need to match regulatory and EMS standards.

The addition of WEMR to the WEMS education offerings is a great service not only to students, but also to anyone who finds themselves in the care of a trained wilderness medical provider. The more wilderness and traditional EMS can overlap, work together, and share training modalities, the better patient care and transfer of care (as discussed in Chapter 6) will be across the board. On the other hand, there is significant clarity brought to regulatory questions, certification intent and purpose, and the difference between WEMS and WM at foundational certification levels by having separate WFR and WEMR certifications.


National Registry EMR certification has a duration of between 2 and 3 years, depending on the completion date of the applicant’s course and exam, as well as state by state regulations. Recertification can be achieved through examination or through continuing education. An individual may either schedule a computer-based exam through the NREMT, or submit documentation of 12 or more hours of continuing education (some must be in specific categories) during the duration of their certification. A National Registry certification is accepted in some states around the country, though procedures for reciprocity differ. Requirements for individual state licensure at the EMR level vary.

Wilderness First Responder

WFR certification is the level at which WM training expands significantly upon the idea of “first aid” and becomes what many consider a “professional” certification. Many wilderness trip-leading organizations require WFR certification for their trip leaders.30,31 Given the ubiquity of the model, the weight it carries in the industry, and the number of hours spent teaching this course type over the last 30+ years, it is no surprise that WFR not only has a very large number of training providers, but has also seen significant investment in defining its scope.5,7,14 The growth of the field over the last several decades has allowed a more evidence-based evaluation of likely wilderness medical injuries and illnesses as incident data are gathered by trip-leading organizations. Consistency in topic content has been in part driven by a more analytical perspective on medical situations providers may encounter. Figure 2.1 provides an example of the kind of data large wilderness trip-leading organizations can contribute to the conversation.

WFR educators are reasonably consistent in their descriptions of what the course entails. For example, Desert Mountain Medicine describes WFR as “the standard level of training expected for professional guides, outdoor educators, and search and rescue personnel.”32 Wilderness Medicine Outfitters states their WFR course is “great for the self-sufficient active back country person who hikes an hour from town or days in the wilderness. This is the required training for the professional guide in most all categories.”33 NOLS Wilderness Medicine characterizes their WFR course as “recommended for anyone who works or recreates in the outdoors or in other austere environments.”34 A more formal SOP document from the WMEC has grown from this general agreement regarding what constitutes a WFR.5 Though nonbinding, the SOP document developed by numerous wilderness medical training providers suggests that a WFR course provide a minimum of 70 hours of training, and cover a specific list of topics (Box 2.3).

As an increasing number of organizations and professions adopt WFR as the standard training model for their staff and more educational options, especially online options, have become available, new providers have entered the market and delivery methods have diversified. Some WFR courses are run over eight or more straight days, some courses take a day or more break in the middle to allow students to relax or return home, still others have adopted the distance learning model (see Box 2.7), allowing students to complete some amount of curriculum on their own, before completing the remainder of the course on-site (generally no less than 5 days.) WFR is also presented as a semester-long class at various colleges, with curriculum delivered several hours at a time, including field sessions (Box 2.4).

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Oct 16, 2018 | Posted by in EMERGENCY MEDICINE | Comments Off on Wilderness EMS Education
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