Moving as cautiously as I ever have in my career and with thoughts that this could be the last day of my life, I buried my ice axe as deep as I could muster. On the Knife Edge in the San Juan Mountains of Colorado, winter was still keeping its grip in May, even after a record low snow year. I gently kick-chipped steps into rotten snow with insufficient crampons for the task. Stepping onto the next snowfield, I suddenly broke through, and dropped down nearly two feet, my axe suddlenly above my head. The next step would determine if I lived, or if I died.
I turned to the young hiker following behind me and said, “I’m climbing down.” He replied with a very earnest, “Yeah.” Slowly, we climbed a steep, rocky cliff to easier ground. We avoided an emergency situation, or worse.
In 2018 I thru-hiked the Continental Divide Trail, and nearly every day I wondered if I, or the hikers around me would make it safely from Mexico to Canada. Covering nearly 3000 miles in four and a half months, I encountered hikers with extreme foot trauma: blistering from heat and massive skin flappers from continuous submersion in water. Hikers with foot infections, in-grown toenails, and a broken big toe. I came upon a woman and her friend who had fractured her forearm, and another who couldn’t continue due to a damaged patella tendon. I approached or talked to several hikers who had cases of bee stings, tick bites, and allergic reactions. Another hiker fell down a 60-foot snow field and hurt his back. A member of the group I hiked with for the last month of the trail, sprained his ankle badly and had to manage that injury just to finish. I helped everyone I could as best as I could on the fly.
With all the preparations needed for a five month thru-hike, knowledge and preparation for first aid wasn’t on my list. Certainly it did not occur to me to get any kind of first aid training in advance of the wilderness scenarios I would be submersed in for days and weeks at a time. After all, I’d done that 25 years ago in an Outdoor Pursuits club as an undergrad in college. I figured it all would come back to me if I needed it. And, the long hikes I had done up to the CDT I’d somehow, luckily, encountered minor to no medical emergencies. Luck does run out. Too many thru hikers have too little to no emergency medical training. I put myself in this category. When I looked to the National Outdoor Leadership School (NOLS), for a first responder course, I wanted to walk away with the confidence that I could assess and manage the types of medical situations I encountered on the CDT.
Three months after completing the CDT I enrolled in the nine day, 80-hour Wilderness First Responder (WFR), certification with NOLS. The course registration was managed through Seattle’s REI, who partners with NOLS who in turn execute the course. I’d heard of NOLS and outdoor leadership schools like Colorado Outward Bound. I have friends that worked for them, but being a figure-it-out-myself guy I’ve always, you know… figured it out. In hind sight, many of the scenarios I mentioned above stressed me out or exceeded my level of knowledge.
What Is Wilderness First REsponse?
Think first aid. And think about the long distances between you or a person with a minor, significant, or medical emergency, and getting to a doctor or hospital for medical care. One mile? Ten miles? On the CDT, there are many scenarios where you are ten, 20, even 60 miles away from the nearest town – let alone a hospital. That’s wilderness my friends.
the wfr course
On day one after introductions and an overview of our course schedule for the next ten days, I asked the instructors rhetorically, “…why take a NOLS course?” The initial response I received was, “Well, you’re here, aren’t you?” Initially I took that simply as, “doesn’t NOLS simply speak for itself?” Neither instructor meant anything condescending from that reply, but I wanted more. I knew I wanted wilderness response skills, but I’m not sure what else I was looking for in terms of an answer. By day ten as my classmates and I celebrated our new knowledge, I’d discovered the answers in the enormous value of what I’d just accomplished in the course.
Generally speaking, the certification is also referred to as CFR/EMR (Certified First Reponder or Emergency Medicine Responder), but with the NOLS course the focus is on response in wilderness scenarios where time and distance are far greater than an urban response situation (where additional help might only be minutes and/or a few miles away). However, it’s not just the focus on backcountry response that differentiates a NOLS course from a similar certification one might get through a college, community college, or fire department…
Five things that I thought made the NOLS experience unique:
- Well structured curriculum
- Knowledgeable instructors that brought curriculum to life
- Focus on team work
- Repetition to reinforce what we learned
- Development of leadership required for first response
Curriculum (and some history)
It’s relevant to understand the history and philosophy of NOLS’s founder, Paul Petzoldt, who at 16 years of age was one of the first groups to summit the Grand Teton in Jackson Hole. When Grand Teton National Park was formed in 1929 he was awarded the park’s mountain guiding concession and created the American School of Mountaineering. The Outward Bound school began in Wales in 1941, and in 1962 the first US school was opened where Petzolt was one of the original instructors at Colorado Outward Bound. Broadly speaking, outdoors education evolved from many different movements: transcendentalist to modern writings of Emerson, Thoreaux, Muir, Abbey, Dillard, etc., dude ranches in the U.S. west (which catalyzed Petzolt’s services), to camping in schools, and the scouting movement. Formed in 1965, NOLS represented the first real attempt to promote outdoor leadership as a profession. While chief instructor at Outward Bound, Petzolt recalls being
Shocked into the realization that nobody had really trained outdoors men in America… We couldn’t hire anyone that met my standard. We could hire people who knew how to do one thing well: climb mountains, fish, cross wild rivers, cook plain rations, recognize flora and fauna, read topographical maps, and teach and motivate. But we could not find a person who had been trained in all those things! They didn’t exist. I thought the best thing I could do for American youth, if they were to use the wild outdoors, was to prepare better leaders for such experiences.
Ewert, A.W. & Sibthorp, J. (2014) Outdoor Education: foundations, models and theories.
Starting with a clear and detailed introduction to the course and how days will be structured, all students receive the NOLS Wilderness Medicine Handbook and a copy of NOLS Wilderness Medicine.
The pace of each day’s class moved fluidly: swift when it needed to be, and slower when the subject matter required attention to detail and repetition. The entire class is build on the Patient Assessment System: an organized action pyramid for first aid response that is thorough and embeds the actions needed through prioritization, thoroughness, and thoughtfulness.
The bulk of the first two days is spent building and rehearsing the PAS. But as it’s introduced, there are discussions, activities, and scenarios – chances to go outside and treat your classmates who act as patients given instructions and details of acting out injuries or illness for you to diagnose. Scenarios build and reinforce each portion of the patient assessment triangle, and they are purposefully designed to test your evaluation, prioritization, and analytical skills. Scenarios get progressively more complex and in the craziness that ensues, you find yourself referring back to the patient assessment triangle. It’s what grounds you when stress is high and things are unknown: all realities when dealing with injuries and patients in the real world. Just as an example, on day two a group of classmates were led outside to be patients. The rest of us gathered indoors and got our equipment and teams ready then headed out to see what scenario was cooked up. Much to our surprise, there were six classmates submerged hip-deep in the creek that ran through the back of the park which served as our classroom! This is December and the temperature was in the mid 30s! It goes without saying that this scenario raised the stakes and the stress level – but the learning that resulted from this particular exercise was enormous. Every team came away applying lots of positive analysis and treatments, but every team likewise made big mistakes that could have led to further patient complication or evacuation problems. I still get emotional typing these words as I recall the intensity of many scenario moments and the takeaways that I gathered.
The Patient Assessment Triangle. 
Injury topics covered include spinal, chest, lung shock, head, musculoskeletal, wounds and burns. Environmental topics include cold and heat related, altitude, toxicology, lightening and submersion. Medical topics include cardiac, CPR , respiratory, neurological, abdominal, allergy, diabetes, urinary, and mental health. Common injuries are covered such as communicable diseases, water disinfection, eye, ear, nose, throat, skin, feet, dental. Some time is spent on leadership and decision making but those are more practiced elements than topics covered in detail. With completion of a written and practical exam, attendees will be certified WFR for two years and hold a CPR certification.
Instructors
I can’t say enough about John Hovey and Matt Halliday, our course instructors. Each brought his own style and personality to the table. Each would alternate subject matter throughout the day, keeping the message and learning fresh. For example, John might start the day with writing a few review questions on a whiteboard for us to think about then go over together, while Matt prepared the scenario which we would go outside and engage with to review things from the previous day. When we got back inside, John would have the next presentation ready covering certain types of injuries and treatments. Then Matt would guide us through an indoors exercise while John prepared a scenario. I complimented them both for how well they ran the class and they both credited the NOLS curriculum and how they are taught by NOLS to teach it. But let me be clear, it was John and Matt who brought the course to life with humor and levity, mixed with thorough knowledge (they are both Wilderness EMT’s) and humility when they didn’t have the answers. And get this: They had never taught the course together! NOLS instructors for WFR work as subcontractors of NOLS and rarely ever get teamed up in the same location with the same instructors. That format provides the instructors the ability to learn from one another and for constant adaptation. That’s the real world out there.
Teamwork
One of the things that becomes apparent real quickly during the WFR is the reliance on others as a team. Whether it’s pairing up with one person in a scenario, or being sent outside to the unknown as a group of five or six, there are plenty of opportunities to work on team dynamics. We stumbled, bumbled, and had many successes over the nine days. Personal dynamics and communication styles played a big part in our learning and honestly, sometimes these differences cause some stress. But I can say with confidence that while sometimes challenging, working with these dynamics is extremely beneficial in your learning.
During the course, I made a point of trying to sit at different tables each day and therefore get to know – at least on some level – everyone in the course. That said, the final day consists of a 100-question multiple choice test, and then a practical where you are randomly teamed up with one other classmate, given a scenario with a classmate as a patient, and off you go to do a full patient assessment. I was teamed up with Kelsey, who was probably the only person I hadn’t worked with during the nine days! But with some practice scenarios in the morning we quickly established our roles and kicked ass on our practical!
Because there were five of us all driving in to the class location from the same place about 30 minutes away, we created a car pool, and a nice little rapport developed between us all. Mornings and evenings we would anticipate what was to come and review what had gone on during the day. I watched other class members form quick bonds and associations with one another as well. Being with each other day after day over a ten day period contributed to the team building.
Repetition
In my view, the reps we got as team members to practice the patient assessment system were invaluable to making the content sink in and stick. I learn by doing and making mistakes then reviewing and doing it over again. As I’ve mentioned already, the curriculum has the repetition built in to accomplish this, yet is cognizant that repetition can make things seem stale. Changing up instructor duties means you’re not hearing the same person for too long. Utilizing different activities and games to present the medical material, results in consuming the information via different senses and thought patterns. Morning reviews allowed us the time to look back at yesterday and see how it would fit into that day’s content as we build our knowledge.
There has clearly been a great deal of thought and iteration put into how to teach the WFR course with consideration for how people learn differently. The scenarios enabled us to “hang” our new knowledge back onto the “bones” of the patient assessment system, reinforcing that structure. It’s that structure that will effectively guide you through managing a real incident in the outdoors when you’re far away from the help of a hospital or the quick call of an ambulance.
Leadership
Just like the emphasis on teamwork evolved right from the start of the course, so did the need for someone to lead a scenario. Several of the scenarios in the first few days made this obvious. On day two we had a scenario where our team of five had to extract someone unable to walk from underneath a flight of stairs. We had a designated leader, but with daylight fading to dark quickly everyone in the group had different ideas of what to do in the heat of the moment. Our designated leader didn’t have the confidence yet to clarify the process she wanted to unfold and settle the situation down. Instead, we ran around inefficiently doing things we saw needed to get done. We had a designated note taker, but wound up having multiple people gathering vitals, the patient’s level of responsiveness, and sample history. As a result, we missed recording a lot of information and if we were handing off this patient to a rescue crew or ambulance in the real world, would not have been able to effectively communicate what we had done to that point. That would have wasted the rescuer’s time and minimize the work that we had done to that point. As we finished and reentered our classroom, we had a scattered conversation about how things unfolded.
In the scenario where our patients were submerged in water, one team had a rescuer who was a pretty big guy who simply walked into the water and scooped up the patient and carried this person to the shore. While this was quite heroic, it turns out the patient had back injuries and this hasty water removal very well could have exacerbated the patient’s injuries.
All scenarios, whether it was teams of two or six persons, required some degree of communication before approaching the patient and scenario, emphasizing the scene sizeup – the very first part of the patient assessment triangle. This set the expectations and clarified roles. Likewise, there were large, elaborate scenarios where teamwork and leadership were really challenged. Interestingly, there isn’t a lot of time in the course allotted to discussion of leadership, and there is some, but I felt not often enough time to really digest and discuss what happened in the scenarios. However, you will definitely come away with ideas on your own style and effectiveness of leadership, and the value of effective team work. It’s really a crux of the WFR class experience in my view, and it left me wanting to learn more in this area.
Network
Lastly, by spending the time with your classmates you have the opportunity to network with people from all walks of life, in all areas of the outdoor industry and out. Attendees’ careers ranged from ski resort workers, aspiring mountain guides, wilderness therapy workers, people making career changes, undergraduate students, a horseshoe fitter, medical products UX designer, a county sheriff, and more. This made our class wonderfully diverse in both experience and age and everyone swapped contact information.
Likewise, the instructors make themselves available to call or email any time. I was able to get a copy of my certification (valid for two years from the date of our testing), a little early with the help of John. He’s also answered questions for a friend of mine considering another NOLS course.
Once you’re a NOLS grad, you have access to their Job Network site where hundreds of job postings can be found in all areas of the industry. I have had great discussions with a member of the NOLS Risk Management services as I’ve considered adding additional skills to my foundation of knowledge.
summary
With a deep background in outdoor education the NOLS Wilderness First Responder course is a nine day deep dive into the Patient Assessment System, an incident management system structure designed to manage wilderness response. A thoughtful and extensive curriculum is offered to introduce the PAS and injury, environmental, medical and common medical problems so the rescuer can assess, prioritize and treat what’s treatable in the scenario. Evacuation and patient hand off is covered thoroughly. Instructors are excellent in knowledge and teaching ability and act as guides through the curriculum and scenarios. Attendees apply teamwork and leadership skills to scenarios as they build their treatment knowledge and practice the PAS. A WFR will walk away certified and confident in his or her ability to manage wilderness response and have the professionalism and resources of the NOLS supporting their professional growth.