Other Things I Learned at Wilderness First Aid

I expected to learn first aid in the Wilderness First Aid course, but I did not expect to learn so much about planning and teamwork.

I first took Wilderness First Aid (WFA) in 2009 and I’ve taken the course again three times since then to recertify. The material hasn’t changed much, but I always learn or re-learn something.

Our WFA class uses a lot of practical scenarios. All of them require teamwork, and they are planned to stretch your skills. That means that you kill the patient most of the time. We learn a lot more from failure than from success.

A lot of our older Scouts have taken WFA. They are high-achieving youth and are not used to failing, so killing the patient every time was really unsettling for them. It made them think and made them more aware about risks in the backcountry.

WFA taught me that you can always evac. If you don’t like the situation, pack up and walk out, even in the middle of the night. We’ve aborted a few outings, for example at Sky Camp in Point Reyes, an exposed location on the side of Mount Wittenberg. It was planned as a two-night outing with a hike to the summit. A storm came in during the night with 40º temps and 40 mph winds. The lighthouse recorded an 80 mph gust. We had trail food for breakfast, packed up, and headed home. Afterwards, I put a dozen patches on my Walrus Aero Tarp 150 because it had pulled out stakes and banged against the charcoal grill all night.

WFA in the field uses incident command skills—organized decision-making and teamwork in a high-stakes situation. A back-country emergency often means choosing the best among several bad options. Open communication can save lives, another important message.

A good WFA course is a great team-building course. Half of our 2010 Philmont crew was WFA-trained and it was the best shakedown we had.

I practice incident command skills in other areas. I volunteer in amateur radio emergency communication (ARES/RACES), where we are always part of an incident command structure. The Incident Command System (ICS) was developed in response to failures fighting California wildfires. It is now a national system for responding to any emergency, whether there are three or three thousand responders. Learn more with the online FEMA ICS-100 course. Hint: The person wearing the white hat is the Incident Commander.

What happens when there is an earthquake and you are at work? ICS is a good first step.

I’ve learned confidence. On a 50-mile Sierra trek, one of our Scouts had a neck injury. They’d tied a rock to a rope, thrown it into a tree for bear-bagging, and the rock got stuck. When they pulled it loose, it slammed into the neck of one Scout. The other Scout ran to me, panicked. I took time to grab the first aid kit, hustled over there without running, determined that it was a soft tissue injury (a bad bruise), and started treating for shock. I deputized the Scout’s tent-mate to watch over him while he recovered in his sleeping bag. I checked on him every 15 minutes.

This could have been a lot worse if the rock had hit somewhere else on his neck or head. Even so, we had a shocky Scout for the evening and he couldn’t turn his head for a couple of days. Later, the injured Scout (now a Philmont Ranger) told me how impressed he was with my calm response. Of course, I had been full of adrenaline, but I had practiced what to do, so I could go down the checklist.

The scariest part about the first course was being retroactively terrified at how unprepared I had been for previous outings. Please, take WFA as soon as possible to spare yourself this grief.

Any time that I did the right thing, I owe it to the course. We usually don’t perform up to our potential, but rather down to our training. Get trained.

Hand Sanitizer is not Enough

I’m seeing more and more backcountry books that suggest using hand sanitizer by itself. That does not work. Soap and water is necessary, sanitizer is optional.

The Scouts Backpacking Cookbook is one of those with that bad advice. The BSA Handbook gets it right. Wash your hands with soap and water.

Clean hands are important in the backcountry. People who know, like Tod Schimelpfenig, Curriculum Director at the Wilderness Medicine Institute of the National Outdoor Leadership School, believe that dirty hands are a bigger health risk than dirty water.

The Centers for Disease Control (CDC) say that hand sanitizer does not work on dirty hands. Natural oils and dirt on your hands create a barrier to the sanitizing action. The CDC procedure is to wash off visible dirt first, then sanitize. Here is a clear PDF handout about clean hands from the Connecticut Department of Public Health. This is a good thing to distribute to your troop.

How do you wash your hands well? Wash with soap and water, scrubbing for the time it takes to sing the Happy Birthday song twice (20 seconds), then rinse. That’s it.

Soap is also lighter than hand sanitizer. An ounce of concentrated soap will last for a couple of years of backpacking. I carry a basin cut from the bottom of a milk carton (33g, 1 oz.) and a small bottle of biodegradable soap (25g, 1 oz.). Again, that is a lot of soap.

If you do want to follow up with hand sanitizer, there are a few options.

Alcohol hand sanitizer: This is the most common kind. It must be 60% alcohol or more to be effective. It can dry out your hands and increase the chance of skin cracks on a long trip. Bacteria hide in skin cracks.

There is enough alcohol in hand sanitizer to make it flammable. I haven’t seen boys figure this out yet, but they will. One could make a good argument that alcohol hand sanitizer is a chemical fuel and should be handled according to the Guide to Safe Scouting rules on chemical fuels. When I teach Introduction to Outdoor Leader Skills to Scoutmasters, I demonstrate alcohol hand sanitizer on toilet paper as an emergency fire starter.

Amk sanitizer mdBenzalkonium chloride (BAK): Non-alcohol sanitizers use BAK, the same thing used in Bactine (which also has lidocaine, an anesthetic). BAK is effective and also useful as part of a first aid kit. Adventure Medical makes a nice 0.5 ounce spray bottle of non-alcohol sanitizer. That is what I carry.

Herbal sanitizers: Or, ineffective hand sanitizers. Concoctions like lavender oil may kill some bacteria, but they are not a reliable sanitizer. They are also “smellables”, and go up in the bear or raccoon bag, along with anything they have been spread on. If you want to keep your Scouts in their tents rather than in the bear bag, stick with an alcohol or BAK hand sanitizer.

If you are up for a longer article on this, with references, read Ryan Jordan on hand sanitizers.

BSA Incident Reporting

I’m excited about the incident reporting that the BSA requires now, but there may be a few kinks to work out.

How are they going to handle the volume with paper reporting? Using the back of a virtual envelope, we have 40,000 troops and five reports/year from each one. That is 200,000 reports. They’ll be lucky to get a few thousand this year, but on-line reporting is a must.

Any “first aid” is a Marginal incident, which must be reported within five days. That means a report for every blister. With about 900,000 Scouts and Venturers, 100% reporting could mean a million reports per year.

Obviously, there will be massive under-reporting, so the BSA should do something to estimate the true rates. Perhaps a sampling survey, or at least a re-charter checkbox on whether you are participating in the incident reporting program.

Many of these reports are going to be injuries or illnesses (property damage is also reported), and that is personal medical information. I’m not a HIPAA expert, but I doubt that leaving names out of a report is sufficient anonymization to protect health information. The BSA needs to provide some guidance on this. Perhaps they could update the release on the annual health form to cover incident reporting.

A quarterly or yearly report would be wonderful. I’m sure that would give the PR department the willies, but it has to be better than the current ostrich approach.

This is a gold mine for outdoor safety studies. It might become the largest database of such data. NOLS Wilderness Medicine Institute has done some great work with their stats, so the BSA should partner with them.

Is this being piloted at Philmont? I’m sure the staff reports incidents that they know about, but I don’t see anything about crew reporting in the Council and Unit Planning Guide or the Guidebook to Adventure for the 2014 season.

New Checklists and Reporting Requirements in Guide to Safe Scouting

The quarterly update of the Guide to Safe Scouting includes two new checklists in the appendix.

The Campout Safety Checklist (PDF) is two pages long with 35 items, and a big improvement in BSA risk management. Some of the checklist items:

  • Have weather conditions been checked and communicated?
  • Has an adult been assigned to help Scouts with taking meds?
  • Is a mechanism in place for contacting a camp ranger or camp office (e.g., walkie-talkie, mobile phone, etc.)?
  • Has the location of the nearest hospital/ER been identified and announced to all adults?
  • Is the unit first-aid kit in a conspicuous location and readily available?
  • Have any incidents been recorded and reported, if necessary, to BSA professionals?
  • Have the adult and youth leaders captured any lessons learned from the campout?

There is a similar Event Safety Checklist (PDF) for non-camping activities.

Units are now required to report all incidents and near misses. I’m not sure when this was added, but this is the first time I’ve noticed it. These reports make more paperwork for adults, but are key to improving our risk management. The Incident Descriptions and Reporting Instructions (PDF) sheet establishes incident levels and reporting requirements. Here is a overview with some of the incident types, but read the original, it is a single page with another page of definitions.

  • Catastrophic: fatality or life-critical hospitalization, allegation of sexual abuse, major multi-vehicle accident, national publicity — report as soon as possible (after 911 or other immediate response).
  • Serious/Critical: other hospitalization, non-sexual abuse, disease or food-born illness outbreak, bomb threat, local publicity — report within 24 hours
  • Marginal: first aid, ER visit and released, emergency response initiated, serious near miss — report within five days
  • Negligible: near miss, injury or illness not requiring first aid — report by end of charter year

The Incident Information Report (fillable PDF) is linked from the appendix.

There is also a Near Miss Incident Information Report (fillable PDF), but that is not linked from the appendix. It is linked from the health and safety forms page. It should be linked from the Guide to Safe Scouting.

Instead of this colorful PDF for the incident types and definition, I’d like to see them printed in simple text on the back of each Incident Information Form and Near Miss form. The BSA seems to love over-decorative PDFs for basic information.

A set of specific examples would help, too. There is one in the GSS’s Incident Reporting Policy, but more would be useful. If there is lightning nearby and your hiking group takes lightning precautions, is that a near miss? A serious near miss? Not an incident at all? We helped extinguish a single tree fire on a 50 Miler. Is that a near miss or a good turn? Let’s hope the BSA gets enough reports this year that they can give better guidance in 2015.

Lowering the Risk of Acute Mountain Sickness (AMS)

The journal Wilderness & Environmental Medicine published an article in June with new evidence-based guidelines on acute mountain sickness (AMS), also known as altitude sickness, as well as HAPE and HACE. The article, Wilderness Medical Society Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness (also: the erratum, with a corrected risk table), is worth reading in full, but I’m going to pull out two highlights.

First, how to keep our risk low. The paper lists three risk categories: low, medium, and high. The description of the “low” category is a good rule for planning mountain trips. Note that the altitudes listed are sleeping altitudes. You can hike higher, but you need to sleep low.

  • Individuals with no prior history of altitude illness and ascending to ≤ 2800 m (9200 ft);
  • Individuals taking ≥ 2 days to arrive at 2500-3000 m with subsequent increases in sleeping elevation < 500 m/day and an extra day for acclimatization every 1000 m (arrive at ~8000-9000 feet, increases in elevation less than 1600 feet/day)

Some people are affected by AMS at 7000 feet, so don’t think you are risk-free by following these guidelines. There are other benefits to staying well under these limits. Slower climbing at the beginning of a trip can improve your performance later. At Philmont I was climbing Mt. Phillips (11,700 ft) stronger than I had climbed Emigrant Pass (9800 ft) the previous year. The difference? At Philmont, we took six days to get to Mt. Phillips instead of the three days we took to get to Emigrant Pass. The trailheads were at nearly the same altitude and we spent a night at the trailhead both times.

Monitor hydration carefully, because the symptoms of dehydration and AMS are very similar.

Second, how do we treat AMS? There is only one treatment that does not require extra equipment or medications, and that is “descend”. Luckily, it is also the only treatment given a grade of “1A” (strong recommendation, high-quality evidence).

The article also has a clear summary for diagnosing AMS, something you should print out and keep with that copy of the Lake Louise AMS Criteria that you already carry.

If you do have someone on your crew with a history of AMS, print out this article, with the erratum, and take it to your physician. There are established medications for AMS prevention.

BSA neckerchiefs are finally big enough

Our troop is considering a new source and maybe a new design for neckerchiefs, so I checked out the price for official BSA neckerchiefs and got a big surprise. The BSA has made them a lot bigger. They say:

Design reverts back to the standard larger size offering a variety of uses, as a sling, signal, bandage, belt, patrol ID, and more. Standard size is now 49.5 inch X 35 inch X 35 inch.

The previous size wasn’t documented anywhere I could find, but I measured mine as 41 X 29 X 29 for my post with a table of sizes for different Scout neckerchiefs. I’ve updated that table with the 2011 BSA neckerchief.

I’m not sure what they mean by “reverts back to the standard larger size”, since the new size is bigger than the original 1910 BSA necker.

The diagonal is only an inch and a half shorter than a common triangular bandage, which will be really nice for first aid practice. The ANSI Z308.1-2003 triangular bandage is six and a half inches bigger.

It could be a little larger, but I expect the new size is just fine. The old ones are really too small to use as a sling, even on an 11 year old Scout.

This is a great sign of progress from the BSA on the uniform. They have been painfully conservative about it, but this follows other small but significant improvements like the zip-off pants, the non-cotton shirt, and the new belt. Now to get rid of the epaulets so we can wear the uniform shirt with a backpack. The epaulets and tabs are only good for distinguishing council from national adults. The other sections (Cubs, Scouts, Venturing) are easy to distinguish without the tabs.

How big is a Scout neckerchief?

Note: Updated Jan 2011 with the new larger BSA neckerchief size.

The BSA’s Insignia Guide says this about the size and shape of the neckerchief, “Official neckerchiefs are triangular in shape.” There is a more info about how to wear it, who chooses the neckerchief (the troop), who approves special neckerchiefs (the council), and so on. It does say that special neckerchiefs are “the same size as official ones”. Oddly, they don’t say what size that is.

Scout with neckerchief

So I researched it. One reason to have a bigger neckerchief is so it can be used as a triangular bandage, so I also checked the common sizes for those, including the ANSI-standard size.

Source Shape Side Diag.
BSA 1926-1931 [1] Square 32 45
BSA 1938 [2] Square 30 42
BSA through 2010 [3] Triangle 29 41
BSA 2011 Triangle 35 49.5
Scouts UK, modern (Wood Badge) [3] Triangle 30.5 43
Chief Neckerchief (reg.) Triangle 31 44
Chief Neckerchief (large) Triangle 34 48
Moritz Triangle 29 40
Scoutneckers, UK (child) Triangle 27.5 39
Scoutneckers, UK (adult) Triangle 36 49
Zone West, Canada (small) Triangle 25.5 36
Zone West, Canada (med.) Triangle 32 45
Zone West, Canada (large) Triangle 39 54
Stadri Triangle 30 42
Traditional Scouting Square 32 45
Troop 151, Georgetown, TX Triangle 31 44
Triangular bandage Triangle 36 51
Large triangular bandage (ANSI Z308.1-2003) Triangle 40 56
  1. U.S. Scouting Collectibles, George Cuhaj, 2001, p 79. Neckerchiefs are describes as “Full Square, 28 x 32”. I am assuming that the cloth has shrunk along one axis of the weave. Other neckerchiefs are described as “Full Square 32 x 32”.
  2. Handbook for Scoutmasters, 1938, p 292. “of cotton, 30 inches square (or triangular in shape, cut diagonally from such a square), in plain or combination colors, as selected by the Troop, District, or Council.”
  3. Personal neckerchiefs, I made the measurements.