ReedOutdoorProgramsandEducation

(ROPE)

RiskManagementPlan***

Emergency/CrisisPlan

Riskmanagementplanningistheprocessofreviewingallthedifferentaspectsofaprogramoreventorcourseandtodeterminewhatstepsneedtobetakentoensuresafetyandwell‐beingofallthepartiesinvolved.RiskManagementreferstothosewhoplanit,thosewhosponsorit,andthosewhoenjoytheactivityasaparticipant.Afteridentifyingrisks,itisnecessarytodeterminehowthatriskwillbemanaged.WhileworkingatReedCollegetherearethreewaystomanagerisk.

Reduceit. Transferit. Avoidit.

TheROPERiskManagementPlanisaroadmapofthestepstoensurethatriskshavebeenidentifiedandaprocesshasbeenestablishedtomanagetherisks.

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RiskManagementandSafety

Thissectionofthemanualprovidesgoals,outlines,andproceduresforReedOutdoorProgramsEducationtofollowduringeachofitscourses.Thekindsofrisksacceptableforanindividualandindividualtravelareverydifferentfromthekindsofrisksacceptableforagroup

andgrouptravel.ReedCollegeoffersourstudentstheopportunitytopursueoutdoorpursuits,servicelearningprojects,andtravelbyexploringcommunitiesaroundthePacificNorthwest.Ourcoursesaresituatedinchallengingnaturalenvironments.ReedOutdoorProgramsandEducation

orROPEiscommittedtomanagingtherisksweassumeinordertomeetthegoalsofourprograms.Thefocusofoursafetystrategyisthreefold:

• Tocreateacultureofsafetywithourstaffandstudentsthrougheducation,training,and

informationdissemination.• Tocontinuallyimproveoursafetysupportsystemsofinformationgathering,

communication,contingencyplans,protocols,training,andinternalreviews.

• Tofosterexcellentrelationshipsinthecommunitieswherewetravel.GeneralOverview

ROPEplacesahighpriorityontherealisticmanagementofrisks.Becauseofthevariedterrainincludingmountains,rockwalls,whitewater,andoutdoorlivingcomponentsofourprogram,participationwithROPEcontainssomeelementsofrisk.Duetotherisksinherenttothis

program,ROPEcannotlegitimatelyofferaguaranteeofsafety.However,ouracuteawarenessofandfocusonproperriskmanagementdecreasesoverallriskandenablesustooperatewithinanacceptablelevelofrisk.

ThegoalofkeepingthegroupsafeandhealthyprecedesanydecisiontogorecreatingundertheguidanceofReedOutdoorProgramsandEducation.Itisimportantthateachindividualinthe

groupalsohasthisgoalinmindthroughouteachcourse,takingresponsibilityforhisorherownpersonalhealthandsafety.Asinotheraspectsoftheprogram,anexpeditionmentalityapplies.Poorchoicesonthepartofgroupmemberscanunnecessarilyputtherestofthegroupatrisk;

wisechoicesandtheinternalizationofourCoreValuedecision‐makingmakesthecoursesmootherforeveryone.

RiskManagementStatementROPEhasbeenentrustedwiththecareandeducationofitsstudentswhiletraveling.Assuch,thephysicalandemotionalhealthandwelfareofstudents,aswellasemployees,isofhighest

prioritytoROPE.Tothatendourriskmanagementplanincludesseveralkeycomponents:qualitystaff,informedstudents,contingencyplanning,andsupportservices(i.e.transportationandemergencycommunicationsystems).

QualityStaff

StaffatReedOutdoorProgramsandEducationwillbeexperiencedandqualifiededucators,

travelers,andoutdoorpeople.Instructorshavespecific,relevantexperienceandtrainingrelated

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tothosesubjectsofwhichtheyareincharge.Weprepareourleadinstructorsforvariousoutdooractivitiesbyrequiringwildernessfirstresponder(WFR),swiftwaterrescue16‐hour

course,avalanche116‐hourcourse,andotherAmericanMountainGuideAssociation(AMGA)certificationswhenapplicableforspecifictechnicalactivitiesforquickandefficientresponsetoemergencysituations.Staffsareawareofstudentmedicalhistories,potentialenvironmental

hazards,andROPEsafetyandriskmanagementprotocols.InformedStudents

Engaginginoutdooractivitiesinvolvesinherentandotherrisks‐‐manyofwhichcannotbecontrolled.WhileReedOutdoorProgramsandEducationcannotguaranteesafety,itcananddoesstrivetomanagetheassociatedrisksandinformitsstudentsofthoserisks.ROPE

deliberatelyteachesstudentshowtoadaptbehavior,recognizeandmanagerisks,anddevelopexpertisetominimizepotentiallydangeroussituations.Studentsknowtheyareexpectedtoconductthemselvesresponsiblybypromotingtheirownsafetyandwell‐beingaswellasthatof

otherparticipantsandleaderswithintheprogram.Thus,studentsplayanimportantroleinourriskmanagementpractices.

ContingencyPlanning

Asapartofroutinelogisticalplanning,ROPEstaffmustcreatecontingencyplansonboththesmallandlargescales.Majorcontingencyplanningoccursatthebeginningofeachcourseduring

thepre‐destinationprocesswhentheEmergencyKitispreparedanddestination/river/trail/mountainsafetydiscussed.TheEmergencyKitiswiththegroupatalltimesandincludescallsheets,compass,andasatellitephone(whenapplicable).Throughoutthe

courseminorcontingencyplanningisanongoingprocesswhichoccursduringthepre‐coursecheckandbeforeeachriveroradventureouting.Duringthepre‐coursecheck,individualmapsmaybeconsulted,localnumbersforthesatellitephone,cellphone,andSPOTLocatorBeacon,

batterieschecked,andgroupsafety/risksdiscussed.Whilewecarryasatellitephoneonapplicablecoursesandacellphone,theriskmanagementplanneedstoincludecontingenciesincasetechnologyfails.

SupportServices

ROPEcarriesmedicalkitswiththematalltimes,aswellasOutdoorCallSheetswithemergency

contactnumbersforlocalemergencyservices.AGPS/SPOTEmergencyBeaconforemergencyandnon‐emergencysituationdescriptionsandlocationsisalsocarriedonexcursionsthatwarrantpossibleemergencysituations.Thiswillfacilitatecommunicationwiththedepartment

headduringregularcheck‐in/reportsandforemergencysituationswhenitmaybenecessarytonotifyparents,initiateevacuations,and/orbegininsuranceproceedings.

RiskManagementTeam

AssistantDirectorofPhysicalEducation/DirectorofROPE‐WillSymms

TheDirectorofROPEprovidesoversighttotheoverallmanagementandoperationofReedOutdoorProgramsandEducation.TheDirectorisresponsibleforproducingtherisk

managementmanualandmakingrevisionsasneeded.

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MedicalAdvisor‐Dr.LizHatfield‐Keller

TheMedicalAdvisoristheresponsiblemedicaladvisorforReedOutdoorProgramsand

Education.

DirectorofPhysicalEducation‐MichaelLombardoTheDirectorofPhysicalEducationactsasdepartmentheadforPhysicalEducationdepartment,

whereReedOutdoorProgramsandEducationresides.S/heisactingdirectoroftheoutdoorprogramsiftheAssistantDirectorisunabletobereachedorperformhis/herduties.OutdoorSpecialist

TheOSistheleadspecialistinthefield‐facilitatinggroup.Thisindividualwillhaveavastarrayoftechnicalandmedicalskillsandactsinthefieldasthecollegerepresentative.

StudentSpecialist

Thestudentspecialisthasamoderatelevelofskillsandpossessesthemandatory80‐hrWildernessFirstRespondercertificationtoassisttheOutdoorSpecialistinmedicalassessmentsandevacuationswhennecessary.VehicleSafetyDrivingthevansisoneofthegreatestresponsibilitieswehaveatReedOutdoorProgramsand

Education.Statistically,thereismoredangerofanaccidentontheroadthananywhereelsewearewiththestudents,includingrivers.Itisimportanttorespectthisresponsibilityandtakeitonwiththeutmostcare.Driversmustpassthe15‐passengervehicle‐trainingprogramoperatedby

thevehiclecoordinatorforReedCollege,inordertooperatecollegevehicles.Additionalcertificationsarerequiredfortrailerdrivinganddrivingininclementconditions.ADMVbackgroundcheckisrequiredtoverifyacleandrivingrecordforeachpotentialoperator.

Anequallyimportantelementofsafetyisvehiclemaintenance.ThevehiclesandtrailersfallinlinewiththeReedOutdoorProgramsandEducationemphasisonprovidingaqualityexperience,

anditistheresponsibilityofallstaffmemberstomakesuretheyarewellmaintained.Tiresandfluidsshouldbecheckedfrequentlyandthevehiclesmustreceiveregularservice.ProblemsandserviceshouldbedocumentedandreportedtotheAssistantDirectorand/orVehicleCoordinator

forthecollege.Thestaffisalsoresponsibleforteachingthestudentstorespectandcarefortheequipment.ProgramEnvironmentsReedOutdoorProgramsandEducationviewssafetyasanintegralcomponenttothesuccessofitsprogramsandisvigilantinitscommitmenttosafetywithallROPEdestinations.Ifa

destinationisnotacceptableintermsofsecurityandgroupsafety,ROPEreservestherighttoalterorcancelaprogram.Examplesincludeflooding,volcaniceruptions,orforestfires.

TechnicalActivities

RockClimbing• AnOutdoorSpecialistshoulddirectlymonitorclimbingactivitiesatalltimes.

• Allgearshouldbeinspectedforexcessivewearordamage.

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• Helmetsshouldbewornatalltimeswhileclimbingorbelayingunlessonanindoorwall.Itisadvisabletodesignatespecificareaswithinaclimbingsitewherehelmetsareworn.

• Helmetsshouldbewornforallfourthandfifthclasstravel.• Aback‐upbelayer/ropehandlershouldbeemployedunlesstheOutdoorSpecialistcan

ensurepeoplehaverequisiteskills,attention,anddedicationforbelayingone‐on‐one.

• Nopersonshouldlead‐climbunlessspecificallyapprovedbytheOutdoorProgramManager(AssistantDirectorofPhysicalEducation.)Inthiscaseleadingshouldalwaysbedoneonclimbswellbelowaperson’sactualleadingability.Generally,theOutdoorSpecialistshould

betheonlyleadclimberandbebelayedbysomeoneproficientatbelayingleadclimbers.• Allclimbsshouldbesetupwithmultiple,solid,independentanchors.Thestandardset‐up

includesatleastthreesolidanchorsindependentlylinkedtotwoopposinglockingcarabiners

usingseparatepiecesof1”tubularwebbing.• Ifusingboltsfortop‐ropeanchors,theseshouldbeinspectedthoroughlypriortouse.Ifyou

doubttheirintegrity,pickanotheranchororclimb.Alowerboltmayalsobeclippedfor

redundancy.• Afigureeightfollowthroughtieddirectlytotheharnessshouldbeusedforallclimbers.• Allstudentrappelersmustuseaseparatebelay.Onemaybelayarappelerusingeithera

figureeightorabowlineonacoilthatisalsoattachedtotherappelersharness.Whenrappellingsinglepitchesforthesakeoftheexperienceorduringparticipant’sfirstrappels,amuenteronamulequickreleasesystemishighlyencouraged.

• Noperson’sfeetshouldgohigherthansixfeetwhilebouldering.Spottingshouldbetaughtandusedwhilebouldering.

• OnrareoccasionsandwithpriorapprovaloftheAssistantDirector,studentsmayfollowan

OutdoorSpecialistonashortmulti‐pitchroute.Naturally,theOutdoorSpecialistwillleadwellwithintheircapability,andtheparticipantfollowerwilldemonstratethattheyareadeptatbelayingaleaderandcatchingleadfalls.Thisteamshouldbemonitoredinthe

eventtheyneedfurtherassistance.Theteamneedstohaveclimbedenoughtogethertowitnesseachother’sskillsinsteadofsimplytalkingabouttheirrespectiveclimbingability.

• Usegoodjudgment!Ifyouhaveagutfeelingorintuitionthatyoushouldorshouldnotbe

doingsomething,payattentiontothatfeeling.Pleasedonotlettheenthusiasmfortheexperienceovershadowyourindependentgoodjudgment.

Mountaineering Forourpurposes,mountaineeringincludestravelonorundersteepsnowslopeswhere

avalanchesmaybeafactor,glaciertravel,anytimewhenaniceaxeisnecessaryorprudent,

whenrope‐workisnecessary,orspendingextendedperiodsoftimeonsnowabovetimberline.

• AllOutdoorSpecialistsmustconsultwiththeAssistantDirectortodiscusstheeducational

outcomesandriskmanagementparticulartotheirtrip.• Avalanchedangergenerallyshouldbeassessedaslowtoverylowintheterrainbeing

traveled.Exceptionsinvolvetransceiversandsnowanalysisasanintegralpartsofthe

experienceandshouldtakeplaceinnomorethanmoderateterrain.• Participantsmusthaveparticipatedina“snowschool”sessiontolearntravelandself‐arrest

skillsbeforetheneedarisestoemploythoseskills.

• Allparticipantsshouldhaveadequateequipment.Warmclothes,raingear,water,food,awhistle,andacompassareaminimum.

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• Afirstaidkit,extrafood,stove,pan,shelter,groundtarp,ensolitepad,shovel,andsleepingbagshouldaccompanygroupsonsnowsummitattempts.

• ParticipanttoOutdoorSpecialistratiosshouldnotexceed5:1.Thismayneedtobeaslowas3:1forcertainactivities.

• Aswithpurerockwork,allsnowandicerope‐workneedsmultiple,solid,independent

anchors.Thestandardset‐upincludesatleastthreesolidanchorsindependentlylinkedtotwoopposinglockingkarabinersusingseparatepiecesof1”tubularwebbing.

Rafting AllriversandrunsmustbeapprovedinadvancebytheAssistantDirectororDirectorof

PhysicalEducation.• OutdoorSpecialistsmustbefamiliarwiththerunonwhichtheyareteachingorguiding.

• AllOutdoorSpecialistsmustconsultwiththeAssistantDirectorofPhysicalEducationtodiscusstheeducationaloutcomesandriskmanagementparticulartotheirtrip.

• IfanOutdoorSpecialistdeemsittooriskytoundertakearunorcontinuedownariverfor

anyreason,theteamshouldplayitconservatively.• AllOutdoorSpecialistsmustwearafunctionalPFD,riverknife,andwhistle.• AllparticipantsshouldwearafullyfastenedPFDwhileonthewater.

• Whenpractical,aswimassessmentinapoolsettingshouldbedonepriortoatriporclassthatspendsagoodamountoftimeonorinwater.This150‐yardswimisgenerallynotusedasanadmissionrequirementbutgivestheOutdoorSpecialist(s)agoodideaofa

participant’scomfortinwater.• Boatsshouldsupporteachotheronthewaterinawaythattheycancommunicatewithand

lendsupporttooneanotherintimesofdifficulty.

• RescueandrepairkitsshouldaccompanyallReedCollegeraftingtrips.Thisshouldincludeover100’ofropecapableofbeingusedforadvantagesystems,prussiks,carabiners,1”tubularwebbingforanchors,apatchkit,andanairpump.Additionalsuppliesmaybe

requiredfromtheagencieswithwhomwework.• OutdoorSpecialistsmustgiveallparticipantsathoroughsafetytalkbeforeembarkingon

thewater.Thisshouldataminimumincludegeneralhazards,personoverboard,swimmer’s

position,footentrapment,strainersandholes,highside,andanunderstandingofhowtocatchathrowbag.

• Plannedswimsorperson‐overboarddrillsshouldonlytakeplaceinareasdeemed

appropriatebytheOutdoorSpecialists.

SeaKayaking,Canoeing,Sailing,andOtherWater‐BasedActivities• AllOutdoorSpecialistsmustconsultwiththeAssistantDirectorofPhysicalEducationto

discusstheeducationaloutcomesandriskmanagementparticulartotheirtrip.• AllparticipantsshouldwearfullyfastenedPFDswhileonthewater.• AllOutdoorSpecialistsmustwearafunctionalPFD,knife,andwhistle.

• Whenpractical,aswimassessmentinapoolsettingshouldbedonepriortoatriporclassthatspendsagoodamountoftimeonorinwater.This150‐yardswimgenerallyisnotusedasanadmissionrequirement,butgivestheSpecialist/sagoodideaofaparticipant’scomfort

inwater.• Ifconditionssuchaswaterflow,wind,orsurfheightaresubstantiallydifferentthan

anticipatedforagivenactivity,athoroughassessmentshouldbedonewithregardstothe

viabilityofachievingtheeducationaloutcomeswhilemanagingtheriskoftheactivity.The

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OutdoorSpecialistsmaydecidetoincludetheAssistantDirectorofPhysicalEducationinthisdecision‐making.

Oneactivityonthemarginsofbeingclassifiedaswater‐basedisfishing.Fly‐fishinginslowmovingcurrentmaybeundertakenwithoutaPFDprovidedthewaterlevelisnotovertheparticipant’skneesandthereisgoodrun‐outfromtheareainwhichtheyarestanding.

TransportationReedOutdoorProgramandEducationrecognizesthattravelingbetweensitesduringthecourse

containsanelementofrisk.Dependinguponthevariousmethodsoftransportationavailable,staffshouldselectthesafestmodeoftransportationatthattime.

PublicTransportation

Tochooseappropriatetransportation,staffmembersmustselectthesafestvehicle,driver,androuteavailable.ReedOutdoorProgramandEducationstrivestoprovidesafeanddependable

transportation.RentedVehicles

ROPEmayrentvehiclestotransportstudents.RentalvehiclesareoperatedbyapprovedROPEstaff.Eachstaffmembermusthaveanapproveddrivingrecordandmustreviewandadheretotheapplicablelawsandconditionsforthestatesinwhichtravelwilltakeplace.

ROPEOwnedandOperatedVehicles

• Vanoccupancywillnotexceed14students.• Allpassengersmustwearseatbelts.• Eachvehiclemusthaveafireextinguisher,firstaidkid,andemergencykit.• Allstatelawsandspeedlimitsmustbefollowed.• Allvehicledocumentsmustbefilledoutpre‐andposttrip.• Thevehiclemustbesafetycheckedpriortoeachuse.

RiskAwarenessInadventureeducationprogramming,studentsdieeachyearfromtraumaandillness,andmany

studentsareinjured.Thegreatestnumberofdeathsinadventureprogrammingresultfromtransportationanddrowning.

Negligence

ThenumberoneliabilityyouhaveasOutdoorSpecialistsisnegligence.Thefollowingfourconditionsmustbepresenttoprovenegligence:(1)adutytoact,(2)aninjurymusthave

occurred,(3)abreachofduty,and(4)causation.

DueDiligence

DueDiligenceisyournumberoneprotectionasanOutdoorSpecialistwithReedOutdoor

ProgramsandEducation.Duediligencemeansgoingthedistance,doingyourhomework,anddoingwhatanyonewouldexpectofyouduringspecificsituationsandconditions.Ifyouhaveaquestionaboutthis,calltheROPEofficetoaskforadvice.Youcanalsopictureyourselfincourt

answeringquestionsaboutyourdecision‐makingprocessandhowyoudeterminedasituation

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wasacceptable.Yourbiggeststrengthinreducingriskistounderstandyourhazardexposure,createplanstopreventhazardexposure,andmitigateconsequenceaseffectivelyaspossible.

Performthefollowingtothebestofyourabilitywhenmakingdecisions:

• Askyourselfwhatareyouaredoing(who,what,where,when,andhow).

• Doyourhomework/research(duediligence).Defineyourhazards.• Createrisk‐managementstrategiesincludingobjectivehazardavoidance.• Createsupportstrategies(transportation,medicalcare,andcommunication).

• Establisheffectivecontingencyplans.Whoareyourstudents?

Collegestudentsbetweentheagesof17‐24arethetypicalpopulationweserve.Knowtheirmedical,psychological,anddisciplinehistory.

PracticeDueDiligence

Gathergeneralinformation,understandregionalhazards,riverhazards/risks,snowconditions/risk,andupdatedtrailconditions.Researchandunderstandhowtheseissuesand

relatedriskswillaffectandinfluencethestudentgroup.• ROPEinvestigatestheseriskspriortodeparture.OutdoorSpecialistsareexpectedto

continuallyevaluatetheserisksduringthecourse.

ProgramAnalysis

AsOutdoorSpecialists,youhavetheinsightandtheknowledgetohelpROPEmakeeachcourse

safer.HelpROPElearnaboutopportunitiestomakethingssaferintermsofprogramphilosophy,leadershipstructure,policies/procedure,staffhiring,stafftraining,operations,medicalscreening,gearmalfunction/misuse,organizationalculture,and/ormiscommunications.

DiscriminationandHarassmentPolicyReedCollegeiscommittedtocreatingandmaintainingacommunityinwhichstudents,faculty,

andstaffcanwork,live,andlearntogetherinanenvironmentfreeofdiscriminationorharassmentbasedonrace,gender,nationalorigin,age,religion,sexualorientation,disability,oranyotherstatusorcharacteristicthatisprotectedbylaw.Thiscommunityextendsbeyondthe

campus’sphysicalboundariesandintothewildernesscontext.Membershipinthiscommunity,asgovernedbythehonorprinciple,imposesonstudents,faculty,andstaffanobligationtorespectthedignityandautonomyofothersandtotreatoneanothercivillyandwithoutregardto

factorsirrelevanttoparticipationinthelifeofthecollege.

Romanticorsexualrelationshipsthatmightbeappropriateinothercontextsmay,withinthecollegecommunity,createtheappearanceorfactofanabuseofpowerorofundueadvantage.Sensitivitytopossibleconflictsofinterestortomisuseofpowerisnecessaryincasesofother

romanticorsexualrelationshipswhereonepartnermaybeinapositionofpowerorauthorityoveranother(whichcanoccurbetweenfacultyandstaff,staffandstudents,orwithinthestaff,studentbody,orfaculty).

ProceduresfortheResolutionofComplaints:Thecollegehasbothprincipledreasonsandalegalobligationtoinvestigatepossibleviolationsof

itsantidiscriminationandharassmentpolicy.

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ThehonorprincipleandthetraditionsofReedCollegeencouragetheinformalresolutionofcomplaints.Informalresolutionmayoccurthroughdirectdiscussion,throughmediationunder

theauspicesofthehonorcouncil,orwithadviceobtainedfromadesignatedofficerofthecollege(alistofsuchofficersispublishedandmaybeobtainedfromtheofficeofthepresident).

Complainantswishingadviceabouthowtoproceedwithacomplaintshouldconsultamemberofthehonorcounciloradesignatedofficerofthecollege.

Forfurtherinformation,consultthefullpolicystatementonantidiscriminationandharassment

intheGuidebookforReed.CopiesoftherelevantsectionsoftheStudentJudicialCode,staffhandbook,andrulesandproceduresofthefacultyareavailableinthestudentservicesoffice.

ROPEEMERGENCYSYSTEMS

Ourprogramhashadanexcellenttrackrecordofmanagingriskeffectively,andwewanttokeepthefocusonmanagingandavoidingriskinsteadofrespondingtoaccidents.Westrivetoengage

inadventurousactivitieswhereriskislimited.AnOutdoorSpecialistorStudentLeadershouldbeabletoarticulatewhyagivenactivitywasundertakenandwhatmerittheactivityhasinlightof

anyinherentrisksthatexist.Ifone’sexperiencedictatesthatthegroupshouldbemoreconservative,theStudentLeadershouldgivecredencetohisorherexperience.IfOutdoor

SpecialistsandStudentLeaderscontinuetomanageriskwell,theprogramshouldcontinuetothriveandexpand.

Decision‐Making,TakingChargeoftheSituation

Ifanemergencyoccurs,thedesignatedleadershipshouldtakedirectcontrolofthesituation.Itis

proventhat,incrisissituations,adirecthierarchyhelpsclarifywhatactionsshouldbetakeneveniftheOutdoorSpecialistchoosestosharetheirdecision‐makingresponsibility.Pleasediscussthis

hierarchyandyourcomfortwithhandlingemergencieswithyourco‐leadersand,ifappropriate,theAssistantDirectorbeforethetripstarts.

UsingtheCallGuide–RequestingAid

Whenavailable,mobilephonesshouldbecarriedonalloutdoortrips.Thatsaid,therearemanylocationswhereitisdifficulttocall;youcannotassumeatelephonewillworkaspartofyourrisk

managementplan.Asaleaderyoushouldfamiliarizeyourselfwithboththemobilephoneandthecallguidebeforebeginningthetrip.Confirmtheareatowhichyouaretravelinghas

resourceslistedinthecallguide.Ifnot,itisyourresponsibilitytofindthenearesthospitalandsherifflocationsandnumbersbeforeleavinghome.Ifyoucallintoaskforhelpfromtheoutdoor

programmanager,youshouldhaveclearinformationaboutthesituationcompletewithaSOAPnote,ifapplicable,aswellasyourproposedplanofaction.

UnscheduledLossofContact–SearchandRescue

Ifsomeoneisthoughtorknowntobelost,aquicksearchshouldbedoneimmediately.Ifthe

trip’sleadersareexperiencedwithgridsearchesandiftheydecidetheycandoaninitialsetquicklyandsafely,thisoptionmaybeentertained.Afterthreehoursofconductinganysearchor

ifotherwiseconsideredappropriatebytheleaders,theAssistantDirectorofPhysicalEducationatReedshouldbecontactedtodetermineifoutsideassistanceisnecessary.Onceoutside

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agenciesarecontactedtoassistwithasearchtheleadersshouldacceptthattheynolongerhave

totalcontroloverthedirectionandnatureofthesearch.

Createemergencyplansforeachcourse!Eachcourseshouldhavethefollowingplans,asneeded.Togetherstaffneedstocreateanemergencyprocedureplantothinkaboutwhattodo

iftheworsthappens.

EmergencyProcedures• STOPandTHINK!

• Plan:Makeaplan• Review:Reviewandevaluatetheplan• Act:Implementtheappropriateplan(seebelow).

GenericDisasterPlans

EvacuationPlans

• Triggers• Stagesofpreparation• Taskteams/leadership

• Multipleroutes(riverevacuation,politicalunrest)• Designatedvehicles• Water,food,andfuel

• Communication• Emergencymedicine

“HunkerDown”Plans• Triggers• Stagesofpreparation

• Taskteams/leadership• Securetheareaofdebrisorhangingdangers• Water,food,fuel,shelter

• Communication• Medicalemergency

InitialResponseResponsestoincidentsvarywithseverity.Seriousincidentsarethosethatresultindeath,

threatenlimbs,orthelong‐termwell‐beingofanyindividual.Minorincidentsarethosethatdonotthreatenlife,limb,orthreatenthelong‐termwell‐beingofanyindividual.Thoughlesssevere,minorincidentsmaystillrequireapromptresponsesuchasavisittoaphysician.

MinorIncident:InformtheAssistantDirectortodetermineanappropriatecourseofaction.Filloutanincident/accidentreport(within3days)andemailtotheROPEoffice.

SeriousIncident:Stabilizethepatientasperyourtraining,notifytheAssistantDirectorimmediately,andifpossible,activateanemergencyresponsesystemortransportpatienttothe

besthospitalavailable.Allseriousincidentsmustberecordedinanincident/accidentreport.

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Protocolformajorincidents,seriousinjury,ordeath:Contact911,thenAssistantDirectorofROPE,thencommunitysafety.

Allincidents,majorandminor,mustbereportedtothecampusasquicklyaspossible.Parentsalsoneedtimelyinformation.Forminorincidents,adirectemailtoAssistantDirectorsoffice

outliningtheincidentwillsuffice;theAssistantDirectorwillpassthisinformationalongtotheparents.Formajorincidents,theOutdoorSpecialistmustcontacttheAssistantDirectorviatelephoneasquicklyaspossible.TheAssistantDirectorandOutdoorSpecialistwilldecidewhen/

howtoproceed.CrisisManagementPlan

Acrisisisdefinedasaneventthatneedsanimmediateresponseandaction.Thiseventmaypresentlong‐termchallengestoROPE,itmaybealifeorlimbsituation,itmaybeastaffcrisis,and/oritmaybeanenvironmentalevent.

IncidentCommandSystem

IncidentCommander–PersoninCharge

TBA SafetyOfficial–On‐sitePersoninCharge

TBA

PublicInformation/PlanningOfficialTBA

ROPEAdministrationOfficial

TBA

DivisionofLaborEveryemergency,nomatterhowlargeorsmall,requiresthatcertaintasksorfunctionsbeperformed.Theorganizationcanexpandorcontractdependingonthesizeoftheemergencyand

thenumberofstaffavailable.• IncidentCommander–Responsiblefordevelopmentofschool’splanandoverall

managementofemergencysituations

o Developsworkingknowledgeoflocal/regionalagenciesastheon‐scenecontactforoutsideagenciesassignedtoanincident,documentingactivitiesasnecessary.

• SafetyOfficial–Monitorssafetyconditionsofanemergencysituationanddevelops

measuresforensuringthesafetyofstudents,staff,volunteers,andresponders,documentingactivitiesasnecessary.

o Ensureseveryoneknowstheplan,monitorsmedical,environmental,psychologicalfirst‐aid,foodandwaterneeds,andensuresallneedsaremet.

• PublicInformation/Planning/IntelligenceOfficial–Developsworkingknowledgeoflocalmedia,preparesmediareleases,andcoordinatesinformationwiththeIncidentCommander.

o AssiststheIncidentCommanderinthecollectionandevaluationofinformation

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aboutanincidentasitdevelops,assistswithongoingplanningefforts,maintainsincidenttime‐log,anddocumentsactivities.

o Establishes/overseescommunicationcenteractivitiesduringanemergencybydevelopingaphonetreeforafter‐hourscommunication,documentingactivitiesasnecessary.

• AdministrationOfficial–Keepsallrecords

andensuresthereisapapertrailand

writtenlogofallactivity.

MediaAllstaffmustrefertotheAssistantDirector.ROPEassumesresponsibilityforissuingstatementsinan

emergency.• TheAssistantDirector,incooperationwith

thePublicInformationofficer,mayprepare

astatementtobeissuedtothemedia.• Updatethemediaregularly.Donotsay,“Nocomment.”• Donotarguewiththemedia.

• Maintainalogofalltelephoneinquiries,andrespondusingscriptforinquiries.MediaStatement

• Allmediastatementsmustcomefromtheofficeofpublicaffairs.

MediaResponse

"Wearefollowing

organizationalprotocol.

Duetotheemergency,wedo

nothavetimetodiscussit

withyou.Pleasecontactthe

officeofpublicaffairsfor

moreinformation.”

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RiskMitigation–CreateContingencyPlans(Including“triggers”forsendingastudenthome.)

• LostStudent:Immediatelygathertheentiregrouptogether,gatherallinformation,createasearchplan,andcontactROPEdepartment.Then,notifylocalauthorities.Last,createaCommunicationPlan.

o Trigger:Studentsenthomeiftheydeliberatelysetouttoleavetheprogram;thiscreatesadangertotheirpersonalsafety.

• AlcoholandOtherDruguse:Immediatelygatherstaffandallinformation,contacttheROPEdepartment,andfollowguidelinesforreportingtoCommunitySafetyandStudentServiceOffice.

o Trigger:Studentissenthomeforusingdrugs/alcohol.

• EmergencyEvacuationGuidelines:ItisthepolicyofROPEtoevacuatestudentswithany

injurythatcouldcausepermanentdamageifnottreatedwiththepropermedicalcare(i.e.faciallacerations,jointlacerations,orinjuriestogenitalia).Studentsshouldbeevacuatedtothenearestlargecitywhereahigherlevelofcarecanbeadministered.

• CarAccident:CheckforsafetyandinjuriesofallO.S.andstudents,andcontactmedical

personnelifnecessary.Contactlocalauthorities,theROPEOffice,andtheinsurance

provider/carrentalcompany.o Trigger:Studentsenthomeforanyinjurylistedin“emergencyevacuation.”

• Misbehavior:InformstudentsofHonorPrinciplepriortotripssothatallinformationisknownbeforehand.Documentincidentsofmisbehavior,notifytheROPEoffice,notifythestudentandfollowtheguidelinesforHonorCaseinvestigations.

o Trigger:StudentsenthomebaseduponbreakingtheHonorPrinciple.

• PsychologicalEmergency:Contactqualifiedpersonnelimmediately.Iflocalhelpisnot

availableorqualified,contacttheROPEofficetofindaqualifiedprofessional.TheROPEofficewillimmediatelynotifythehealthcenter.Ensurethestudentisnotadangertohimself/herselforothers.Beginevacuation,ifnecessary.

o Trigger:StudentsenthomeifthelevelofpsychologicaldifficultyisbeyondthequalificationsorcomfortoftheOutdoorSpecialist.

• NaturalDisaster:Createcontingencyplansbeforeadisaster,examiningphysicalsafety,accommodation,food,transportation,andcommunication.IfthedisastercompromisesthesafetyofthestudentsorOutdoorSpecialist,beginevacuationplansimmediately.

ShareacopyofthecontingencyplanwiththeROPEoffice,whichwillcommunicatewithparents.

o Trigger:Sendstudentshomeifthenaturaldisastercreatesanenvironmentor

situationthatisunsafeforthegroup.Analternativelocationfortheprogramisanotheroption.

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• SexualAssault:Ifassaultoccurs,immediatelycontactlocalauthoritiesanddirectorofROPE.Contactthedirector,astheROPEofficewillcontacttheappropriatecollege

officesandadvisorysexualassaultcounselor.o Trigger:Sendstudenthomebasedonstudentrequest.

• Death:Ensurephysicalandemotionalsafetyforthegroup.ContactlocalauthoritiesandtheROPEoffice,andtheROPEofficewillcontactparents.Createacommunicationplan.

o Trigger:Sendotherstudentshomeifmentaltraumaexists,and/orbystudentorparentrequest.

Fortheseexamples,itisimportantthestaffworkdirectlywiththeROPEofficetoensurerapidresponseinordertoworktogethertocreateanemergencyactionplanandacrisismanagementplanspecifictoeachincident.ROPEmitigatesriskwithplans,training,andexpertise.This

includesstafftraining,crisissimulationsduringstafforientation,incident/accidentreporting,evacuation,andstaffmedicaltraining.ROPEalsoutilizestheexpertisefromanadvisoryphysician,anadvisorycounselor,alegalcounsel,andaninsurancecounsel.

CommunicationCommunicationintheeventofaccidents,injuries,andillnessiscritical.Intheeventastudentis

ill(i.e.unabletoparticipateinclassesformorethan2days)orhasaninjury,whichrequiresavisittoaphysician,thehealthcentermustbecontacted.Inordertodoso,theassistantdirectorwillinitiateallcommunicationtothehealthcenterregardingparticipanthealthbasedofffield

instructor’sreport.DocumentLog/Records

ROPEstaffmustalwaysdocumentincidentsandnearmisses.MinorincidentsandseriousincidentsmustberecordedonanIncident/accidentreportform.Thepurposeofthesupplementalformsistodocumenttheobjectivefactsassociatedwithanygiven

incident/accident.Assuch,onlyknown,impartial,andobjectivefactsshouldberecorded.SOAPnotesshouldbecompletedforsignificantaccidentsandtheaccompanyingtreatment,andturnedintotheAssistantDirector.

PhoneLog

Recordphonecalls(numbers,person(s),andtime).

WitnessStatements

Getdescriptionof"what,where,who,andwhen”bywitnessesassoonaspossible.

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SectionII

TreatmentandEvacuation

Guidelines

REV:8/8/201211:30AM

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TreatmentandEvacuationGuidelines

TheseTreatmentandEvacuationGuidelinesaretheexclusivepropertyofReedOutdoorProgramsandEducationandmaybeusedonlybyROPEinstructorswhileleadingROPEcoursesinawildernesscontext.ThecontentsofthisdocumentarenottobecopiedorreproducedinanyformwithoutwrittenpermissionfromROPE.Theseprotocolshavebeendevelopedinconsultationwith________________________________,ROPEMedicalAdvisor.

MedicalAdvisorDutiesandResponsibilities

ThisservestodescribethedutiesandresponsibilitiesofDr.___________whoareservingastheMedicalAdvisorforReedOutdoorProgramsandEducation.

ROPEMedicalAdvisorDutiesandResponsibilitiesTheROPEMedicalAdvisorprovidesguidanceandadvisesROPEregardingstudentandstaffmedicalissuesrelatedtoparticipationonROPEcoursesoremploymentwithROPE.ReedOutdoorProgramsandEducationmakesfinaldecisionsregardingstudentparticipation,medicaltreatmentandevacuation.TheROPEMedicalAdvisor:

1. SupportsdevelopmentofROPEfieldmedicaltreatmentandevacuationprotocolsusedbyROPEinstructorsduringROPEprograms.

2. Reviewsprotocolsonaregularbasisandevaluatestheireffectiveness.

3. ProvidesadviceasneededastothedispositionofillorinjuredstudentsorfieldstaffduringROPEcourses.

4. ServesasaresourceregardingmedicalscreeningofstudentsorstaffforROPEprograms.

5. Providespost‐incidentreview.RoutinelyreviewsfieldmedicalpracticestoensureconsistencywithROPEprotocols.

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UsingtheROPEWildernessMedicineProtocolPackage

INTRODUCTION

ROPEinstructorsandstaffareexpectedtooperateeffectivelyinchallengingenvironmentalconditionswithlimitedequipmentandsupplies.FrequentlyprovidershavelittleornoaccesstocommunicationwithamedicalprofessionalorEmergencyMedicalServicessupportsystems.Inadditiontorecognition,treatmentandpreventionofmedicalemergenciesinremotesettings,aanymemberoftheROPEstaffmustunderstandhowandwhentomakeanevacuationdecision.

Thisdocumentisintendedtoprovidedetailedrecommendationsontreatmentandevacuationguidelines.Theseprotocolsshouldbeadministeredbyinstructionalstaffwithappropriatetraininginwildernessmedicine.Theyshouldbeutilizedinawildernesscontextorwhenmedicalsupportisnotavailable.Theyshouldbeutilizedduringsanctionedprogramactivities.Theyshouldnotsubstitutefordefinitivemedicalcarewhenitisnecessaryandavailable.Theyarenotasubstitutefortraining.

Theseprotocolscontaininformationontheadministrationofbothover‐the‐counter(non‐prescription)andprescriptionmedications.Typicallytheadministrationofover‐the‐counter,medicationfallswithintherealmofsimplefirstaid.Theadministrationofover‐thecountermedicationtominorsrequiresparentalapproval,whichareobtainedthroughpre‐tripauthorizationformsorbycommunicatingwiththeparentsonacasebycasebasis.

AdministeringprescriptionmedicationsisusuallyrestrictedtolicensedmedicalprofessionalsorindividualsactingwithinestablishedEmergencyMedicalServicessystems.Someremotecoursesmaycarryprescriptionmedicationsasacomponentoftheirmedicalsupplies.Frequentlyindividualswillbringtheirownprescriptionmedicationsonatrip,especiallyonaninternationaltrip.Whilestaffmaynotbeadministeringthesemedications,havinginformationabouttheirusecanbeveryhelpful.

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Onepotentialexceptiontotheguidelineofalicensedmedicalprofessionaladministeringaprescriptionmedicationistheuseofinjectableepinephrine.Thereareincreasingnumbersofstatelawsthatallowfortheadministrationofepinephrinetoanindividualexperiencingalifethreateningallergicreactionbya“layperson”.Oftentheepinephrineadministeredisthepatient’s.Thisislikelytobeanareaofcontinueddiscussionandevolvinglawsandregulationsintheensuingyears.

TheseprotocolsshouldbemodifiedinconsultationwiththeROPEMedicalAdvisor.Theprotocoldecisioncomponentofeachprotocolcoachesyouthroughpotentialmodifications.

DisclaimerThesedocumentsarenotasubstituteforprofessionalmedicalcareoradvice.

Introduction•WildernessMedicineOverview•TheRoleofaMedicalAdvisor•MedicalAdvisorJobDescription•ProtocolUseStatementProtocols•Abdominal•AllergicReactionsandAnaphylaxis•AltitudeIllnesses•Burns•CardiacEmergencies•CardiopulmonaryResuscitation•ChestTrauma•DentalProblems•Diabetes•Dislocations•EyesEarsNose•FemaleGenderMedicalIllnesses•FlulikeIllness.doc•HeadInjuries•HeatIllnesses

•Hypothermia•Lightning•LocalCold•MaleGenderMedicalIllnesses•MusculoskeletalInjuries•NeurologicalEmergencies•Poisoning•RespiratoryEmergencies•Shock•Skin•SnakesandLizards•SpidersandScorpions•SpinalInjuries•SubmersionIncidents•WildernessWoundManagement•ZoonosesExtras•DrugInformation•FirstAidKitContents•SOAPReportTemplate•VerbalSOAPTemplate

EvacuationWildernessMedicalTrainingCenter(WMTC)grantedthefollowinginformation.Attimestheevacuationofapatientmaybenecessaryfortheirtreatment.Allevacuationsinawildernessenvironmentcarrysomeinherentrisktomembersoftherescuepartyandthedecisionto

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evacuateapatientshouldNOTbetakenlightly.Theneedforevacuationdependsontheseverityofthepatient’sinjuryorillnessandyourresources.Thetypeofevacuationdependsonthemobilityofthepatient,thesizeofyourpartyanditsresources,thedifficultyofterrain,theweatherandthedistanceinvolved.

TheTYPEofevacuationdependson:

• theseverityofthepatient’sinjuryorillnessandtheirmobility

• thesizeofyourpartyanditsresources

• thedifficultyofterrain

• theweather

LevelsofEvacuationThefollowingdefinitionsforlevelsofevacuationarecorrelatedtotheseverityofthepatient’sinjuryorillnessandhencetheurgencyandspeedoftheirevacuation.Everyeffortshouldbe

madetoaccuratelydiagnosethepatient’scurrentandanticipatedproblemssinceanincorrectdiagnosismayleadtoafalsesenseofurgencyandawillingnessonthepartoftherescuerstoacceptmoreriskthanthesituationwarrants.Ingeneral,rescuersshouldONLYbewillingto

acceptalevelofrisktheybelievetheycansafelymanagebasedontheirskillandtheforeseeableproblems.Unfortunately,notallproblemsareforeseeableandtheamountofriskanygivenrescueriswillingtoaccepttendstorisewiththeseverityofthepatient’sinjuryor

illness.Sinceitisimpossibletolegislatejudgement,whenindoubtrescuersmustbasetheirdecisionsonthe“worstcase”situationbothindiagnosingthepatientandevaluatingtheriskassociatedwiththeevacuation.Thatsaid,theriskofaminorinjuryorillnesstoarescueris

generallypresentduringmostevacuationsandunavoidableunderthecircumstances.

Level1

Thepatient’sinjuryorillnessisimmediatelylifethreateningandthepatientmaydiewithoutrapidhospitalintervention(e.g.:increasedICP,volumeshock,severerespiratorydistress,respiratorydistressinaneardrowningpatient,advanceddisease,moderatetosevere

hypothermia,HAPE/HACEetc.)

Level2

Thepatient’sinjuryorillnessispotentiallylifethreateningorwillresultinapermanent

disability;thepatientmaydevelopalifethreateningproblemthatrequireshospitalintervention(e.g.:concussionthatisgettingworse,systemicinfection,spine&cordinjuries,neardrowning(norespiratorydistress),etc.)

Level3

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Thepatient’sinjuryorillnessisNOTlifethreatening,haslittleornopotentialtobecomelifethreatening,andmaybesuccessfullytreatedinthefieldwithnopermanentdisability;however,

thepatientisunabletoresumenormalactivitywithinareasonablelengthoftimeand/orrequiresadvancedassessment.(E.g.:concussionthatisgettingbetter,inunstableinjurieswithgoodCSM,reducedshoulder(dislocation)withgoodCSM,etc.)

Level4(noevacuation)

Thepatient’sinjuryorillnessisNOTlifethreatening,maybesuccessfullytreatedinthefield

withnopermanentdisability,andthepatientisabletoresumenormalactivitywithinareasonablelengthoftime.(E.g.:minorwounds,minorstableinjuries,minorenvironmentalinjuries,etc.)

WILDERNESSFIRSTRESPONDERANDALLERGICRESPONSETRAININGAllReedoutdoortripsthattraveltoareastwohoursormoreawayfrom“definitivecare”are

requiredtohavealeaderonthetripwithWFRaswellasOregon‐authorizedallergicresponsetraining.

SuchTrainedLeadersareExpectedto:

• Staywithinthescopeoftheirtraining,andifindoubt,followthewildernessguidelinesprovidedintheirtraining.

• KeepallWFR,CPRandOregon‐authorizedcertificationscurrentandonfilewiththe

DepartmentofPhysicalEducation.

• Takeuniversalprecautionsagainstbloodbornepathogens,makingsuretouseglovesandaCPRmask(whenappropriate)whenexposedtobodilyfluids.Biohazardsmustbedisposedofinanappropriatemanner,taggingtheseitemsandgivingthemtoAssistantDirector.

EmergencyCare

AllReedoutdoortripsthatatanytimearetwohoursormorefrom“definitivecare”shouldhaveatleastoneStudentLeaderorOutdoorSpecialistwithcurrentfirstaid,WFR,Oregon‐authorizedallergicresponse,andCardioPulmonaryResuscitationcertificates.WildernessFirstRespondertrainingandcertificationisgenerallyconsideredindustrystandardforthoseheadingintothewildernesscontext;thisisusuallydefinedbybeingovertwohoursfromclinicorhospitalcare.AllStudentLeadersandOutdoorSpecialistsareencouragedtoplayaproactiveroleinassessingemergencysituationsandprovidingcareforillnessesandinjuries,withthehopeofavoidingasmanymajormedicalsituationsaspossible.However,everyemergencysituationisuniqueandgoodjudgmentiscritical.Whetherandhowtoactinanemergencysituationcannotbedictated.

StudentleadersorOutdoorSpecialistsrespondingasvolunteerlaypersonstoemergencysituationsshouldusepracticesonlywithinthescopeoftheirtraining.Oneshouldalwaysactthoughtfullywiththebestinterestofthepersonhavingtheemergencyinmind.AStudentLeaderorOutdoorSpecialistrenderingvolunteeremergencycareshouldobtainverbal

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permissionfromthepersonhavingtheemergencyforactionsthattheyintendtotakeincludingthespecificswheneverpossible.MedicalKits

MedicalkitsshouldbewellmaintainedbytheStudentLeadersandOutdoorSpecialists.Thecontentsshouldbecheckedbothbeforeandafteratriptomakesurethattheyarecomplete.Anoteshouldbeleftwiththekitstatingthatitiscomplete;iftherearemissingitemstheyshould

belistedcarefully.ThisnotethenshouldbesignedbyoneoftheStudentLeadersorOutdoorSpecialistsforthetrip.Alistoftheitemsthatwecarryinmedicalkitscanbefoundinthefrontpocketofthekitsthemselves.Medicalkitswithover‐the‐countermedicationssuchas

ibuprofen,acetaminophen,andantihistamines,maybeusedbyleaderswithaWildernessFirstRespondercertificatewhoareheadingintothewildernesscontext,asdefinedbybeingtwohoursormorefromclinicorhospitalcare.Epinephrineforuseintheeventofanaphylaxis

shouldbeavailabletothosewhohaveobtainedtherequiredOregon‐authorizedcertificateforlaypersons.

EMERGENCYSYSTEMS

Ourprogramhashadanexcellenttrackrecordofmanagingriskeffectively,andwewanttokeepthefocusonmanagingandavoidingriskinsteadofrespondingtoaccidents.Westrivetoengageinadventurousactivitieswhereriskislimited.AOutdoorSpecialistorStudentLeadershouldbeabletoarticulatewhyagivenactivitywasundertaken,andwhatmerittheactivityhasinlightofanyinherentrisksthatexist.Ifone’sexperiencedictatesthatthegroupshouldbemoreconservative,thentheStudentLeadershouldgivecredencetohisorherexperience.IfOutdoorSpecialistsandStudentLeaderscontinuetomanageriskwell,theprogramshouldcontinuetothriveandexpand.

Decision‐Making,TakingChargeoftheSituation

Ifanemergencyoccurs,thedesignatedleadershipshouldtakedirectcontrolofthesituation.It

isproventhatincrisissituations,adirecthierarchyhelpsclarifywhatactionsshouldbetaken,eveniftheleadSpecialistchoosestosharetheirdecision‐makingresponsibility.Pleasediscussthishierarchyandyourcomfortwithhandlingemergencieswithyourco‐leadersand,if

appropriate,theAssistantDirectorbeforethetripstarts.

UsingtheCallGuide–RequestingAid

Whenavailable,mobilephonesshouldbecarriedonalloutdoortrips.Thatsaid,therearemany

locationsfromwhichitisdifficulttocall;youcannotassumethatatelephonewillworkaspartofyourriskmanagementplan.Asaleader,youshouldfamiliarizeyourselfwithboththemobile

phoneandthecallguidebeforebeginningthetrip.Confirmthattheareatowhichyouaretravelinghasresourceslistedinthecallguide.Ifnot,itisyourresponsibilitytofindthenearesthospitalandsherifflocationsandnumbersbeforeleavinghome.Ifyoucallintoaskforhelp

fromtheoutdoorprogrammanager,youshouldhaveclearinformationaboutthesituation,completewithaSOAPnoteifapplicable,aswellasyourproposedplanofaction.

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UnscheduledLossofContact–SearchandRescue

Ifsomeoneisthoughtorknowntobelost,aquicksearchshouldbedoneimmediately.Ifthetrip’sleadersareexperiencedwithgridsearches,andiftheydecidethattheycandoaninitial

setquicklyandsafely,thisoptionmaybeentertained.Afterthreehoursofconductinganysearch,orifotherwiseconsideredappropriatebytheleaders,theAssistantDirectorofPhysicalEducationatReedshouldbecontactedtodetermineifoutsideassistanceisnecessary.Once

outsideagenciesarecontactedtoassistwithasearch,theleadersshouldacceptthattheynolongerhavetotalcontroloverthedirectionandnatureofthesearch.

AccidentandIncidentReports

Allillnesses,injuries,ornearmissesmustbedocumentedonanIncidentReportingFormandsubmittedtotheAssistantDirector.SOAPnotesshouldbecompletedforsignificantaccidentsandtheaccompanyingtreatment.

MedicalProtocolsandStandingOrders

StandingOrder:AbdominalIllnessandInjury

GeneralCommentsGeneralizedabdominalcomplaintsarecommonandleadtochallengingdifferentialdiagnoses.Courseinstructorsmustbediligentintheinterviewandexaminationofthispatientfocusingnotondiagnosis,butonidentifyingcriticalevacuationtriggers.TreatmentforAbdominalIllnessandInjuryIfthepatientdoesnottriggertheevacuationcriteria:1. Allowthepatienttorestinapositionofcomfort.2. Maintainhydrationlevelswithclearfluids.Rehydratewithanelectrolytesolutionifthepatientisdehydrated.3. Blanddiet.TheBRATdietworkswell:Bananas,rice,applesauceandtoast.4. Consideranti‐diarrheals(e.g.ImodiumAD®orLomotil®)and/oranti‐emetics(e.g.Compazine®orPhenergan

®)asnecessarytomaintainhydrationlevels.5. Considerprophylacticanti‐motionsicknessmedication(e.g.meclizine,Dramamine®)toavoidnauseaand

vomiting.6. Ifthepatientisconstipated,aggressivelyhydrate,avoidhighfatfoodsandincreasegrains,vegetablesand

fruit,attempttostimulatebowelmovementswithcaffeineoralternatinghotandcoldliquidsandconsideralaxative(e.g.ExLax®).Iftreatmentisunsuccessfulconsidermanualremovalofthehardenedstools.

7. Monitorthepatientforworseningsignsandsymptoms.Ifthepatientdoesnotshowimprovementin12‐24hoursconsiderevacuation.

8. Ifevacuationispossiblewithinafewhours,givenothingbymouth.EvacuationGuidelinesforAbdominalInjuryorIllnessEvacuateRapidly:

Anypatientwith…

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Abdominalpainthat:• Persistsgreaterthan12hours,especiallyifconstant.• Islocalized,especiallywithguarding,tenderness,distensionorrigidity.• Occurswithmovement,jarring,orfootstrike.

Orisassociatedwith:

• Signsandsymptomsofshock.• Bloodinthevomit,fecesorurine.• Persistentanorexia,vomitingordiarrheagreaterthan24hours.• Feverabove102°F(39°C).• Signsandsymptomsofpregnancy(historyofsexualactivity,amenorrhea,excessivefatigue,breast

tenderness,polyuriaandnausea).Evacuate:

•Anypatientwithabdominalpainthatdoesnotimprovewithtreatmentin12‐24hours.•Anypatientwithabdominalpainwhoisunabletostayhydrated.ProtocolDecision:ImodiumAD®isanover‐the‐counteranti‐diarrhealmedication.ExLax®isanover‐the‐counterlaxative.MeclizineandDramamine®areover‐thecountermotionsicknessmedications.Theadministrationofover‐thecountermedicationtominorsrequiresparentalapprovalwhichcanbeobtainedthroughpre‐tripauthorizationformsoronacasebycasebasis.YourMedicalAdvisorshouldadviseyouontheuseanddoseofover‐the‐counteranti‐diarrheal,laxativemedicationandmotionsicknessmedicationsforminors.Ifyourprogramdoesnotcarryanti‐diarrheals,laxativesormotionsicknessmedicationsinthebackcountry,deletethesereferencesfromthetreatmentprotocol.Lomotil®isaprescriptionanti‐diarrhealmedicationandCompazine®andPhenergan®areprescriptionanti‐emeticmedications.Theadministrationofaprescriptionanti‐diarrhealmedicationorprescriptionanti‐emeticmedicationrequiresaphysician.Thesemedicationsmayalsobeself‐administeredbypatientswithaprescriptionforthem.Manualremovalofhardenedstoolsinapatientisaninvasiveprocedure.YourMedicalAdvisorshouldadviseyouinchoosingthisprocedureorincoachingapatienttoattemptremovaloftheirownstools.References:

EmergencyMedicalTechnician‐Basic:NationalStandardCurriculumModule4Medical/BehavioralEmergenciesandObstetrics/Gynecology.22June1995.NationalHighwayTrafficSafetyAdministrationUnitedStatesDepartmentofTransportation.2Dec2004.<www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd>“Gastrointestinal.”UnitedStatesSpecialOperationsCommand.SpecialOperationsForcesMedicalHandbook.Jackson,Wyoming:TetonNewMedia,2001.4‐70.Schimelpfenig,Tod.“AbdominalPain.”WildernessMedicine.Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter18.SpecificProtocolsforWildernessEMSAbdominalPain.Version1.2May19,1994.TheWildernessEmergencyMedicalServicesInstitute.2Dec.2004.<http://www.wemsi.org/specific.html>TheMerckManual16thEdition.Rathaway,NewJersey:Merck&Co.,Inc.,1992.Tilton,Buck.“AbdominalInjuries.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter11.Tilton,Buck.“AbdominalIllnesses.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter29.

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Wilkerson,JamesA.“AcuteAbdominalPain.”MedicineforMountaineering5thed.Seattle,Washington:TheMountaineersBooks,2001.Chapter13.

StandingOrder:AllergicReactionsandAnaphylaxis

GeneralCommentsTheincidenceoftrueanaphylaxisisrare.Mostallergicreactionscanbemanagedwithover‐the‐counteranti‐histamines.TreatmentforAllergicReactionsandAnaphylaxis1. Removetheallergenorthepatientfromtheoffendingenvironment.2. Administeroralantihistamines(e.g.diphenhydramine50mgPOevery4‐6hours).3. Ifpatientshowssignsandsymptomsofanaphylaxis(Swollenface,lipsandtongue;systemichives;respiratory

distress;inabilitytospeakinmorethanoneortwowordclusters;signsandsymptomsofshock)administerepinephrine.3ml/1:1000SQorIM.

4. Ifreactionreoccursortheepinephrineisineffective,continuetoadministerepinephrine.EvacuationGuidelinesforAllergicReactionsandAnaphylaxisEvacuateRapidly:

• Anypatientwhocontinuestoshowrespiratorycompromiseorsignsandsymptomsofshockaftertreatmentwithepinephrineandantihistamines.

Evacuate:

• Anypatientwhohasreceivedepinephrine.Continuetoprovideanti‐histaminesduringevacuation.ProtocolDecision:

Diphenhydramineisanover‐the‐counterantihistaminemedication.Theadministrationofover‐thecountermedicationtominorsrequiresparentalapprovalwhichcanbeobtainedthroughpre‐tripauthorizationformsoronacasebycasebasis.YourMedicalAdvisorshouldadviseyouontheuseanddoseofover‐the‐counterantihistaminemedicationforminors.Ifyourprogramdoesnotcarryantihistaminesinthebackcountry,deletethissectionfromthetreatmentprotocol.Epinephrineisaprescriptionmedicationusedtotreatsevereallergicresponses.Thismedicationiscommonlypackagedinanauto‐injectorintendedtobeself‐administeredbypatientswithaprescriptionforit.Itisadvisablethatpatientswithaknownhistoryofanaphylaxisbringatleastthreetofourdosesofepinephrinewhentravelinginremoteenvironments.Participantsmayalsobringepinephrineinavialorglassampoulewithanaccompanyingsyringe.Theuseofepinephrinetomanageanaphylaxisiswellestablished,however,thethresholdforadministrationvarieswidely.Somephysiciansadvocateadministeringepinephrineifthepatient'sonlysymptomishives,othersadvocatewaitinguntildefinitivesignsandsymptomsofrespiratoryorcardiovascularcompromiseareevident.Thepossessionandadministrationofepinephrinebylaypeopleandoutdoorprogramsisacomplexissue.Thelawstatesyoucanonlypossessepinephrinethatisprescribedtoyou,and,ingeneral,youcanonlyuseitonyourself.Thereare,however,exceptionstothisstatement.

References:

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EmergencyMedicalTechnician‐Basic:NationalStandardCurriculumModule4Medical/BehavioralEmergenciesandObstetrics/Gynecology.22June1995.NationalHighwayTrafficSafetyAdministrationUnitedStatesDepartmentofTransportation.2Dec2004.<www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd>“PositionStatement26:TheUseofEpinephrineintheTreatmentofAnaphylaxis.”AmericanAcademyofAllergyAsthma&Immunology.28Dec.2004.<http://www.aaaai.org/media/resources/position_statements/ps26.stm>Schimelpfenig,Tod.“Poisons,Stings,andBites.”WildernessMedicine.Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter12.SpecificProtocolsforWildernessEMSAllergicReactions.Version1.2May19,1994.TheWildernessEmergencyMedicalServicesInstitute.2Dec.2004.<http://www.wemsi.org/specific.html>TheMerckManual16thEdition.Rathaway,NewJersey:Merck&Co.,Inc.,1992.Tilton,Buck.“AllergicReactionsandAnaphylaxis.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter28.WildernessFieldProtocolsProtocol1Anaphylaxis.2001.WildernessMedicalAssociates.2Dec.2004<http://www.wildmed.com/field_protocols/anaphylaxis_protocol05.01.html#top>Wilkerson,JamesA.“Allergies.”MedicineforMountaineering5thed.Seattle,Washington:TheMountaineersBooks,2001.Chapter20.

StandingOrder:BurnsGeneralCommentsLargeburnsareuncommoninthebackcountry,butevensmallburnscanbedebilitating,painfulanddifficulttokeepclean.Smallburnsarerelativelycommonbackcountryinjuries,typicallysecondarytohotwaterspills.TreatmentforBurns1. Ensurethesceneissafe.2. Immediatelyapplycoolcompressesorirrigateburnswithcoolwater.Smallareasofburn(<10%)maybe

soakedincoolwater.Avoidhypothermia.Removeclothingandconstrictingobjects(e.g.jewelry,watches,belts).

3. AssessandmanageAirway,BreathingandCirculationproblems.4. Gaugethedepth,extentandlocationoftheburns.5. Properlydresstheburnswithantibioticointment,burngelorsheets,Silvadene®creamor2ndSkin®covered

looselywithcleandressings.Inextendedcaresituationsdebridedeadskinaroundblistersthathaveself‐drainedandcleanseveraltimesdaily.Donotdrainintactblisters.

6. Painmedicationasneeded(NSAIDsoftenrecommended).7.Aggressivehydration.8.Ifsnowblindnessissuspected,providecoolwaterflushesoftheeyeandcoolcompresses.Restandavoidsun

exposureuntilsymptomsresolve.EvacuationGuidelinesforBurnsEvacuateRapidly:

• Anypatientwithsignsandsymptomsofanairwayburn.• Anypatientwithpartialorfullthicknessburnscoveringmorethan10%TBSA.• Anypatientwithpartialorfullthicknesscircumferentialburns.

Evacuate:

• Anypatientwithafullthicknessburn.• Anypatientwithburnstoaspecialfunctionarea:face,neck,hands,feet,armpits,orgroin.

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• Anypatientwithaburnthatcannotbemanagedeffectivelyinthebackcountry.ProtocolDecision:Silvadene®creamisaprescriptiontopicalantibioticthatiseffectiveforburns.Theadministrationofanantibioticrequiresaphysician.Thismedicationmayalsobeself‐administeredbypatientswithaprescriptionforit.Apatientwithburnsmaybenefitfromover‐the‐counterpainmedication.Theadministrationofover‐thecounterpainmedicationtominorsrequiresparentalapproval,whichcanbeobtainedthroughpre‐tripauthorizationformsoronacasebycasebasis.Oxygenisrecommendedforallpatientswithburnstothefaceandairway.Theadministrationofoxygenrequiresaphysician.

References:“Burns.”UnitedStatesSpecialOperationsCommand.SpecialOperationsForcesMedicalHandbook.Jackson,Wyoming:TetonNewMedia,2001.3‐17.EmergencyMedicalTechnician‐Basic:NationalStandardCurriculumModule5Trauma.22June1995.NationalHighwayTrafficSafetyAdministrationUnitedStatesDepartmentofTransportation.2Dec2004.<www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd>Forgey,William.“BurnManagement.”WildernessMedicalSocietyPracticeGuidelinesforWildernessEmergencyCare5thed.Guilford,Connecticut:TheGlobePequotPress,2006.Chapter7.Schimelpfenig,Tod.“Burns.”WildernessMedicine.Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter8.SpecificProtocolsforWildernessEMSWounds.Version1.2May19,1994.TheWildernessEmergencyMedicalServicesInstitute.2Dec.2004.<http://www.wemsi.org/specific.html>Stewart,CharlesE.“Burns.”EnvironmentalEmergencies.Baltimore,Maryland:Williams&Wilkins,1990.Chapter2.TheMerckManual16thEdition.Rathaway,NewJersey:Merck&Co.,Inc.,1992.Tilton,Buck.“WildernessWoundMangament.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter15.Wilkerson,JamesA.“Burns.”MedicineforMountaineering5thed.Seattle,Washington:TheMountaineersBooks,2001.Chapter8.

StandingOrder:CardiacEmergenciesGeneralComments:

Differentialdiagnosisofnon‐traumaticchestpainischallenging.Thereforeanypatientexhibitingsignsandsymptomsofchestpainthatcannotbeattributedtoanon‐cardiacorigin,shouldbemanagedasiftheoriginiscardiac.TreatmentforCardiacEmergencies:1. Reduceanxietyandactivity.Placepatientinapositionofcomfort.Avoidwalkingifpossible.2. Administeroxygen,ifavailable.3. Assistpatientwithadministrationofhisorhernitroglycerin,0.4mgSLsprayortablet,mayberepeatedevery

5minutesforatotalofthreedosesifthesystolicBPremainsabove100mmHgorthepatienthasastrongradialpulse,andthepatienthasnottakenViagra®,Levitra®orCialis®for48hours.

4. Administerone‐adultaspirin(325mg)or3‐4babyaspirin(8lmgeach)every24hours.EvacuationGuidelinesforCardiacEmergencies:

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EvacuateRapidly:

• Anypatientwithchestpainthatdoesnotrelieveasexpectedwithrestandmedication.Evacuate:

• Anypatientwithnon‐traumaticchestpainthatsubsidedwithrestormedication.• Anypatientwithchestpainthatisnotclearlymusculoskeletal,pulmonaryorgastrointestinal.

ProtocolDecision:Oxygenisrecommendedforallpatientswithcardiacchestpain.Theadministrationofoxygenrequiresaphysician.Thismedicationmayalsobeself‐administeredbypatientswithaprescriptionforit.Nitroglycerinisaprescriptionmedicationcommonlycarriedbypatientswithknowncardiachistory.Manypatientsareabletoself‐administerthismedication.Thecontraindicationsvary,specificallytheminimumsystolicbloodpressure.Aspirinisrecommendedforallcardiacchestpaininarangeofdoses.

References:ACLSProviderManual.Dallas,Texas:AmericanHeartAssociation,2002.BLSforHealthcareProviders.Dallas,Texas:AmericanHeartAssociation,2002.“Cardiac/Circulatory.”UnitedStatesSpecialOperationsCommand.SpecialOperationsForcesMedicalHandbook.Jackson,Wyoming:TetonNewMedia,2001.4‐1.EmergencyMedicalTechnician‐Basic:NationalStandardCurriculumModule4Medical/BehavioralEmergenciesandObstetrics/Gynecology.22June1995.NationalHighwayTrafficSafetyAdministrationUnitedStatesDepartmentofTransportation.2Dec2004.<www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd>Schimelpfenig,Tod.“RespiratoryandCardiacEmergencies.”WildernessMedicine.Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter17.TheMerckManual16thEdition.Rathaway,NewJersey:Merck&Co.,Inc.,1992.Tilton,Buck.“CardiacEmergencies.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter23.

StandingOrder:ChestInjuriesGeneralCommentsIsolatedribinjuriesareoftenevacuatedduetopatientdiscomfort.Lunginjuryisaprimaryconcernsecondarytoablowtothechestwall.Specificdiagnosisisdifficult,butsignsandsymptomsofdifficultybreathing,especiallyatrest,shouldtriggerevacuation.Spontaneouspneumothorax,withoutablowtothechest,canoccurandoutdoorleadersshouldbeattentivetosuddencomplaintsofdifficultybreathing.TreatmentforChestInjuries1. Placethepatientinapositionofcomfortorontheinjuredside.2. Stabilizeanyinjuries.Forafracturedribslingandswatheortapetheaffectedside.Foraflailsegmentsplint

withabulkydressing.3. Foranopenchestinjurysealthewoundwithanocclusivedressingsecuredonallfoursides.4. Administeroxygenifavailable.Supportrespirationsifnecessary.5. Painmanagement.6. Periodicallyencouragethepatienttobreathedeeply.

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7. MonitorforincreasingShortnessofBreath(SOB)atrestanddiminishingbreathsounds.EvacuationGuidelinesforChestInjuriesEvacuateRapidly:•Anypatientwithsignsandsymptomsofseriouschesttraumaorrespiratorydistress.•Anypatientexhibitingincreasingshortnessofbreath,especiallyatrest.•Anypatientwithdiminishedorabnormallungsounds.Evacuate:•Anypatientwithasuspectedriborclaviclefracture.ProtocolDecision:Apatientwithchesttraumamaybenefitfromprescriptionlevelpainmedication.Theadministrationofprescriptionpainmedicationrequiresaphysician.Thismedicationmayalsobeself‐administeredbypatientswithaprescriptionforitApatientwithchesttraumamaybenefitfromover‐the‐counterpainmedication.Theadministrationofover‐thecounterpainmedicationtominorsrequiresparentalapproval,whichcanbeobtainedthroughpre‐tripauthorizationformsoronacasebycasebasis.

References:EmergencyMedicalTechnician‐Basic:NationalStandardCurriculumModule5Trauma.22June1995.NationalHighwayTrafficSafetyAdministrationUnitedStatesDepartmentofTransportation.2Dec2004.<www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd>“ThoracicTrauma.”PHTLSBasicandAdvancedPrehospitalTraumaLifeSupport.St.Louis,Missouri:Mosby,2003.Chapter5.Schimelpfenig,Tod.“ChestInjuries.”WildernessMedicine.Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter3.SpecificProtocolsforWildernessEMSChestInjury.Version1.2May19,1994.TheWildernessEmergencyMedicalServicesInstitute.2Dec.2004.<http://www.wemsi.org/specific.html>Tilton,Buck.“ChestInjuries.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter10.Wilkerson,JamesA.“ChestInjuries.”MedicineforMountaineering5thed.Seattle,Washington:TheMountaineersBooks,2001.Chapter11.

StandingOrder:CardiopulmonaryResuscitation(CPR)GeneralComments:CPRcanbeaneffectivelifesustaininginterventionintheshort‐term;howeverthereisnoevidencethatprolongedCPRisvaluable.ThestandardsforperformingCPRarewellestablishedbytheAmericanHeartAssociation.ContraindicationstoCPRintheWildernessThereisnoreasontoinitiateCPRifthereis:

• Anysignoflifeinthepatient.• Dangertorescuers.• Dependentlividity.• Rigormortis.• Obviouslethalinjury(e.g.decapitation,frozen).• Awell‐definedDoNotResuscitate(DNR)status.

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DiscontinuationofCPRintheWilderness

OnceinitiatedCPRshouldbecontinueduntil:

• Resuscitationissuccessful.• Therescuersareexhausted.• Therescuersareplacedindanger.• Thepatientisturnedovertomoredefinitivecare.• Thepatientispronounceddeadbyaqualifiedperson.• Thepatientdoesnotrespondtoprolongedresuscitativeefforts,greaterthan30minutes.

ProtocolDecision:ThestandardsforcontraindicationstoCPRarewelldefinedbytheAmericanHeartAssociation.Inawildernesscontext,severelyhypothermicor“frozen”patientspresentanadditionalcontraindication,unlessdeathcanbeestablishedwithacardiacmonitor.ThestandardsfordiscontinuingCPRarewelldefinedbytheAmericanHeartAssociation.Inawildernesscontext,itisrecommendedbytheWildernessMedicalSocietytoceaseresuscitativeeffortsafter30minutes.YourMedicalAdvisorshouldadviseyouinthisadditionalparameter.Whileavalanches,lightningandsubmersioncreateadditionalmechanismsfortraumaticcardiacarrestinawildernesssetting,theydonotrequireadditionalguidelinesforCPR.Theymaycreatecircumstancesrequiringprolongedrescuebreathingefforts.

References:ACLSProviderManual.Dallas,Texas:AmericanHeartAssociation,2002.Forgey,William.“MyocardialInfarction,AcuteCoronarySyndromes,andCPR.”WildernessMedicalSocietyPracticeGuidelinesforWildernessEmergencyCare5thed.Guilford,Connecticut:TheGlobePequotPress,2006.Chapter2.Goth,PeterandGeorgeGarnett.“NationalAssociationofEMSPhysiciansClinicalGuidelinesforDelayed/ProlongedTransportCardiorespiratoryArrest.”PrehospitalandDisasterMedicineVol.6No.3July‐Sept.1991:335‐339.SpecificProtocolsforWildernessEMSCardioPulmonaryResuscitation.Version1.2May19,1994.TheWildernessEmergencyMedicalServicesInstitute.2Dec.2004.<http://www.wemsi.org/specific.html>Tilton,Buck.“CardiopulmonaryResuscitation.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter5.WildernessFieldProtocolsProtocol3CardiopulmonaryResuscitation(CPR).2001.WildernessMedicalAssociates.2Dec.2004<http://www.wildmed.com/field_protocols/cpr_protocol05.01.html#top>

StandingOrder:DentalEmergenciesGeneralCommentsDentalemergenciescanberemarkablypainfulanddebilitatingandunfortunatelycommononwildernesstrips.Therearesomesimpletoolsandtreatmentguidelinesthatmayallowaparticipanttofinishabackcountryexpeditioninrelativecomfort.TreatmentforDentalEmergencies

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1. Cleanandrinsethemouth.Brushandflosstheteethifthepatientcantolerateit.2. Ifacrownorfillingislostorthetoothbreaks,coverthe“hole”withCavit®.Cavit®mayalsobeusedto“glue”

thecrownorfillinginplace.IfyoudonothaveCavit®trysugarlessgumorwax.3. Ifthetoothbreaksandthepulpisexposed,applyasmallpieceofcrushedaspirinto“cauterize”thepulp.4. Ifthetoothisknockedoutofthesocket,irrigatethetoothwithdisinfectedwaterandattempttoreplaceitin

thesocket.Iftoothcannotbereplaced,wrapinsterilegauzeandhavepatientcarrythetoothbetweentheircheekandgum.FacilitybasedprogramsmightconsiderSave‐a‐tooth®,aspecialfluidandcontainerthatmayextendthelifeofabrokentooth.

4. Applytopicaloilofcloveforpain.5. Painmedicationasneeded.6. Ifaperiodontalabscessissuspected,cleanandflossteeth,garglewithwarmsaltywater3‐4timesdaily,and

administerantibioticsandpainmedication.EvacuationGuidelinesforDentalEmergencies

Evacuate:•Anypatientwithatoothknockedoutofthesocket.•Anypatientwithabrokentoothwithexposedpulp.•Anypatientwithaperiodontalabscess.ProtocolDecision:Apatientwithdentalproblemsmaybenefitfromprescriptionlevelpainmedication.Theadministrationofprescriptionpainmedicationrequiresaphysician.Thismedicationmayalsobeself‐administeredbypatientswithaprescriptionforit.Apatientwithdentalproblemsmaybenefitfromover‐the‐counterpainmedication,includingoilofclove.Theadministrationofover‐thecounterpainmedicationtominorsrequiresparentalapprovalwhichcanbeobtainedthroughpre‐tripauthorizationformsoronacasebycasebasis.Theuseofaspirintocauterizetoothpulpisaggressive,butmaysignificantlyreducethepatient’spainandwillingnesstostayfedandhydratedAntibioticsarerecommendedforaperiodontalabscess.Theadministrationofanantibioticrequiresaphysician.Thismedicationmayalsobeself‐administeredbypatientswithaprescriptionforit.

References:Auerbach,PaulS.“WildernessDentistryandManagementofFacialEmergencies.”WildernessMedicine5thed.St.Louis,Missouri:Mosby,2007.Chapter26.“Dentistry.”UnitedStatesSpecialOperationsCommand.SpecialOperationsForcesMedicalHandbook.Jackson,Wyoming:TetonNewMedia,2001.5‐9.Schimelpfenig,Tod.“DentalEmergencies.”WildernessMedicine.Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter23.SpecificProtocolsforWildernessEMSDentalInjury.Version1.2May19,1994.TheWildernessEmergencyMedicalServicesInstitute.2Dec.2004.<http://www.wemsi.org/specific.html>TheMerckManual16thEdition.Rathaway,NewJersey:Merck&Co.,Inc.,1992.Tilton,Buck.“CommonSimpleMedicalProblems.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter31.

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StandingOrder:DiabeticEmergencies

GeneralComments

Well‐controlleddiabeticsperformwellinbackcountrysettings.Outdoorprogramsshoulddevelopascreeningprogramforeligibility;thiswillvaryonprogramtypeandlocation.Programsshouldalsohaveaplanformedicationstorageandadministrationandthediabeticparticipantshouldbringadequatesupplies(glucometer,sparebatteries,duplicatemedicationssuchasinsulin,glucagonhydrochloride,andglucosepasteortabs,syringesandketonestrips)andanestablishedsickdayplan.TreatmentforDiabeticEmergencies1. Checkbloodsugarusingthepatient’sglucometer.2. Ifhypoglycemiaissuspected,givetheawakepatientsugar(glutosepasteortabs,sweetliquids,table

sugarinwater)untiltheyregainanadequatelevelofresponsiveness.Ifthepatientisnotawake,placethepatientontheirsideandrubsugarintotheirgumsrepeatedlyuntiltheyregainanadequatelevelofresponsiveness.

3. Iftheunresponsive,hypoglycemicpatientdoesnotregainresponsiveness,administerglucagonhydrochlorideIM.

4. Ifhyperglycemiaissuspected,checkketonelevelswithketoneurinestrips.Assistthepatienttohydrateandadjustinsulindoseinaccordancewithhisorhersickdayplan.Ifthehyperglycemicpatientisunresponsive,donotadministerinsulin.

5. Checkbloodsugarfrequently.Havethepatientcontinuetoeatand/ormedicateuntilanadequatelevel(80‐120mg/dl)isobtained.

6. Ifunknownwhetherapatientissufferingfromhypoglycemiaorhyperglycemia,givesugartothepatient.EvacuationGuidelinesforDiabeticEmergenciesEvacuateRapidly:

•Anypatientwhoisunresponsiveduetoadiabeticemergency.Evacuate:

•Anydiabeticpatientwhoisunabletokeephisorhersugarlevelsundercontrolinabackcountrysetting.

•Anydiabeticpatientwhoexperiences:severaldaysofillness,hasvomitingordiarrheaformorethan6hours,hasmoderatetolargeamountsofketonesintheirurine,cannotmoderatetheirbloodsugarreadingswithadditionalinsulinorfeelsalossofcontrolofbloodsugarlevels.ProtocolDecision:Supportingadiabeticduringanemergencymayrequirestafftoadministerglucagoninjectionsandassessbloodsugarandketonelevels.YourdiabeticparticipantandyourMedicalAdvisorshouldadviseyouintheseprocedures.

References:

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EmergencyMedicalTechnician‐Basic:NationalStandardCurriculumModule4Medical/BehavioralEmergenciesandObstetrics/Gynecology.22June1995.NationalHighwayTrafficSafetyAdministrationUnitedStatesDepartmentofTransportation.2Dec2004.<www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd>“Endocrine.”UnitedStatesSpecialOperationsCommand.SpecialOperationsForcesMedicalHandbook.Jackson,Wyoming:TetonNewMedia,2001.4‐27.Schimelpfenig,Tod.“Diabetes,SeizuresandUnresponsiveStates.”WildernessMedicine.Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter9.SpecificProtocolsforWildernessEMSDiabetes.Version1.2May19,1994.TheWildernessEmergencyMedicalServicesInstitute.2Dec.2004.<http://www.wemsi.org/specific.html>TheMerckManual16thEdition.Rathaway,NewJersey:Merck&Co.,Inc.,1992.Tilton,Buck.“DiabeticEmergencies.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter26.

StandingOrder:Dislocations

GeneralCommentsDislocationsoftheshoulder,digitandpatellaaremostcommon.Patientsmayhaveahistoryofchronicdislocations.Themechanismofinjurymaybedirectorindirect,andthedislocationmaybeassociatedwithotherinjuriessuchasfractures.Ingeneral,thedifficultyofreductionandtheamountoflong‐termcomplicationsbothincreasewithdelayinreductionattempts.TreatmentforDislocations1. Assesscirculation,sensationandmotion(CSM).2. ConsiderattemptingtoreducedislocationsoftheshoulderifevacuationtimeexceedsonehourorCSMhas

beencompromisedbythedislocation.Treatallotherdislocationsasunusablemusculoskeletalinjuries.3. Reductionisusuallyachievedbyapplyingslow,steadyandgentletraction‐in‐line(TIL).Relaxationiskey.Slow

downordiscontinueyourattemptifpainincreasessignificantlyoryoumeetresistance.4.Inunabletoreduceaftermultipleattempts,splintinthepositionfound.5. Afterreduction,Rest,Ice,CompressionandElevation(RICE)therapy,painmedicationandimmobilizationas

needed.6. Monitorcirculation,sensationandmotion(CSM)beforeandafterreductionand/orimmobilization.7. Passiverangeofmotion(ROM)2‐3timesperday,ortopatienttolerance.EvacuationGuidelinesforDislocationsEvacuateRapidly:•Anypatientwithanunreduceddislocation.•AnypatientwithalteredCSMafterreduction.Evacuate:•Anypatientwithafirsttimedislocation.•AnypatientwithalteredCSMpriortoreduction.•Anypatientunabletousethereducedjoint.•Anypatientwithpersistentpain.ProtocolDecision:Apatientwithadislocationmaybenefitfromprescriptionlevelpainmedication.Theadministrationofprescriptionpainmedicationrequiresaphysician.Thismedicationmayalsobeself‐administeredbypatientswithaprescriptionforit

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Apatientwithadislocationmaybenefitfromover‐the‐counterpainmedication.Theadministrationofover‐thecounterpainmedicationtominorsrequiresparentalapprovalwhichcanbeobtainedthroughpre‐tripauthorizationformsoronacasebycasebasis.References:Auerbach,PaulS.“WildernessOrthopaedics.”WildernessMedicine5thed.St.Louis,Missouri:Mosby,2007.Chapter24.Forgey,William.“OrthopedicInjuries.”WildernessMedicalSocietyPracticeGuidelinesforWildernessEmergencyCare5thed.Guilford,Connecticut:TheGlobePequotPress,2006.Chapter8.Goth,PeterandGeorgeGarnett.“NationalAssociationofEMSPhysiciansClinicalGuidelinesforDelayed/ProlongedTransportDislocations.”PrehospitalandDisasterMedicineVol.8No.1Jan.‐Mar.1993:77‐80.Schimelpfenig,Tod.“FracturesandDislocations.”WildernessMedicine.Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter5.SpecificProtocolsforWildernessEMSDislocations.Version1.2May19,1994.TheWildernessEmergencyMedicalServicesInstitute.2Dec.2004.<http://www.wemsi.org/specific.html>Tilton,Buck.“Dislocations.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter13.“JointDislocations.”UnitedStatesSpecialOperationsCommand.SpecialOperationsForcesMedicalHandbook.Jackson,Wyoming:TetonNewMedia,2001.3‐64.

StandingOrder:Eyes,EarsandNoseTreatmentforEyes,EarsandNose:

1. Blackeyescanbetreatedwithcoolcompressesandpainmedication.2. Objectsintheeyeshouldbeflushedoutwithdisinfectedwaterordabbedoutwithacleancloth.Ifthe

objectisembeddedintheeyeitshouldbestabilizedandbotheyesbandaged.3. Objectsintheearmaybedrownedwithoil,wateroralcohol,ifneeded,andthenflushedoutwithan

irrigationsyringeorgraspedwithtweezersifvisible.4. Outerearinfectioncanbetreatedbykeepingtheeardryandflushingtheearwithdilutesolutionof

alcoholorvinegardaily.5. Bloodynosescanbemanagedbypinchingthenosejustbelowcartilageandleaningforward.Ifunableto

controlbleeding,considerpackingthenosewithgauze.EvacuationGuidelinesforEyes,EarsandNose:EvacuateRapidly:

• Anypatientwithanuncontrollablenosebleed.

Evacuate:• Anypatientwithpersistentvisionchanges,extraordinaryandpersistentsensitivitytolight,ordischargeof

fluidotherthantears,oranimbeddedobjectintheeye.• Anypatientwithanearinfectionnotrespondingtotreatment.

References:Auerbach,PaulS.“TheEyeintheWilderness.”WildernessMedicine5thed.St.Louis,Missouri:Mosby,2007.Chapter25.

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Auerbach,PaulS.“WildernessDentistryandManagementofFacialInjuries.”WildernessMedicine5thed.St.Louis,Missouri:Mosby,2007.Chapter26.Forgey,William.“EyePathology.”WildernessMedicalSocietyPracticeGuidelinesforWildernessEmergencyCare5thed.Guilford,Connecticut:TheGlobePequotPress,2006.Chapter9.“GeneralSymptoms.”UnitedStatesSpecialOperationsCommand.SpecialOperationsForcesMedicalHandbook.Jackson,Wyoming:TetonNewMedia,2001.3‐1.Schimelpfenig,Tod.“CommonNon‐UrgentMedicalProblems.”WildernessMedicine.Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter24.TheMerckManual16thEdition.Rathaway,NewJersey:Merck&Co.,Inc.,1992.Tilton,Buck.“CommonSimpleMedicalProblems.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter31.Wilkerson,JamesA.“Eye,EarNose,andThroatDisorders.”MedicineforMountaineering5thed.Seattle,Washington:TheMountaineersBooks,2001.Chapter17.

StandingOrder:FemaleGenderMedicalConcerns

GeneralCommentsMostfemalegendermedicalconcernsaremanageableinabackcountrysetting.Itisimportanttocreateanenvironmentthatencouragesparticipantstodiscusstheseconcernswithtripleaders.Thedecisiontoallowpregnantgroupmembersonthetripshouldbeestablishedaheadoftime.TreatmentforFemaleGenderMedicalConcerns1. Bothdysmenorrheaandmittleschmerzcanbemanagedwithanalgesics,mildexerciseandheatpacks.2. Ifvaginitisissuspected,washthevaginalareathoroughlyandairdry.Considereitheranover‐the‐counter

anti‐fungal(e.g.Monistat®)oraprescriptionanti‐fungal(e.g.Diflucan®).3. Ifaurinarytractinfectionissuspected,restthepatient,provideaggressivehydration,aurinarytractanalgesic

(e.g.Pyridium®)andanantibiotic.4. Ifanectopicpregnancyissuspected,treatforshock.EvacuationGuidelinesforFemaleGenderMedicalConcernsEvacuateRapidly:•Anypatientwithsignsandsymptomsofurinarytractinfectionwhodevelopstendernessoverthekidneys.•Anypatientwithasuspectedectopicpregnancy(lowabdominal/pelvicpain,abnormalvaginalbleeding,signsandsymptomsofshock.)Evacuate:•Anypatientsuspectedofbeingpregnantorwithpregnancycomplications.•Anypatientwithvaginitisoraurinarytractinfectionthatdoesnotrespondtotreatment.ProtocolDecisionAnti‐fungalmedication(e.g.Monistat®)isrecommendedfortreatingvaginitisandaurinarytractanalgesic(e.g.Pyridium®)isrecommendedformanagingaurinarytractinfection.Theadministrationofover‐thecounteranti‐fungalandpainmedicationtominorsrequiresparentalapprovalwhichcanbeobtainedthroughpre‐tripauthorizationformsoronacasebycasebasis.

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Prescriptionanti‐fungalmedicationandantibioticsarerecommendedfortreatingvaginitisandurinarytractinfections.Theadministrationofprescriptionanti‐fungalmedication(e.g.Diflucan®)andantibioticsrequiresaphysician.Thesemedicationsmayalsobeself‐administeredbypatientswithaprescriptionforthem.

References:EmergencyMedicalTechnician‐Basic:NationalStandardCurriculumModule4Medical/BehavioralEmergenciesandObstetrics/Gynecology.22June1995.NationalHighwayTrafficSafetyAdministrationUnitedStatesDepartmentofTransportation.2Dec2004.<www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd>“Genitourinary.”UnitedStatesSpecialOperationsCommand.SpecialOperationsForcesMedicalHandbook.Jackson,Wyoming:TetonNewMedia,2001.4‐87.“GynecologicalProblems.”UnitedStatesSpecialOperationsCommand.SpecialOperationsForcesMedicalHandbook.Jackson,Wyoming:TetonNewMedia,2001.3‐37.Schimelpfenig,Tod.“Gender‐SpecificMedicalConcerns.”WildernessMedicine.Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter20.SpecificProtocolsforWildernessEMSUrinaryTractInfection.Version1.2May19,1994.TheWildernessEmergencyMedicalServicesInstitute.2Dec.2004.<http://www.wemsi.org/specific.html>TheMerckManual16thEdition.Rathaway,NewJersey:Merck&Co.,Inc.,1992.Tilton,Buck.“Gender‐SpecificEmergencies.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter32.Wilkerson,JamesA.“GenitourinaryDisorders.”MedicineforMountaineering5thed.Seattle,Washington:TheMountaineersBooks,2001.Chapter18.

StandingOrder:Flu‐likeIllness

GeneralComments:Viral“flu‐like”illnessarecommononwildernessexpeditions.Theymayincludegastrointestinalsymptoms(nausea,vomitinganddiarrhea)orrespiratorysymptoms(cough,congestion,runnynose,sorethroat).Viralillnessesalsocauseaviralheadache,malaise,fatigue,low‐gradefever,muscleaches,bodyaches,etc.Fluisamedicallydistinctillnessfromthe“commoncold”.Itusuallyhasamoreabruptonsetthanacoldwithastrongeroverallimpactonthepatient.Theillnesscanpersistforseveralweeks.Managementisfocusedonsymptomaticreliefforthepatient.TreatmentforFlu‐likeIllness:

1.Generalmanagementforflu‐likeillnessissymptomatictreatment.2.Restandhydration.3.Handwashingandhygiene.4.Acetaminophen,aspirinorNSAIDsforfever,sorethroatheadacheandmuscleaches.5.Decongestants(e.g.pseudophedrine)forcongestion.6.Anti‐coughmedicationsasneeded(e.g.Robitussin®orhydrocodone).7.Blanddietforgastrointestinaldistress.

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EvacuationGuidelinesforFlu‐likeIllness:EvacuateRapidly:Anypatientwithsignsandsymptomsofflu‐likeillnesswhodevelops:

• Stiffneck,severeheadache,difficultbreathingorwheezing.• Gastroenteritiswithpersistentorworseningabdominalpainover24hours,spikingfever,bloodydiarrhea

ordehydration.• Aninabilitytotolerateanyoralfluidsmorethan48hours,especiallyifaccompaniedbydiarrheavolume

losses,feverorvomiting.• Aheadachethatdoesnotrespondtotreatment,suddensevereheadaches,oraheadacheassociatedwith

alteredmentalstatus.

Evacuate:Anypatientwithsignsandsymptomsofflu‐likeillnesswhodevelops:

• Feverpersistingmorethan48hoursorishigh(>102°F/39°C).• Signsorsymptomsofpneumonia.Thisisusuallyassociatedwithincreasingshortnessofbreath,

decreasingexercisetolerance,worseningmalaiseandweaknesswithapredominanceofcough.• Anisolatedsorethroatwithfeverandaredthroatwithwhitepatches.• Asorethroatinconjunctionwithinabilitytoswallowwaterandmaintainadequatehydration.

ProtocolDecision:Arangeofover‐the‐countermedicationsincludingdecongestants,coughsuppressants,painmedicationsandfever‐reducingmedicationsmayhelppatientswithflu‐likeillness.Theadministrationofover‐thecounterdecongestants,coughsuppressants,painmedicationsandfever‐reducingmedicationstominorsrequiresparentalapprovalwhichcanbeobtainedthroughpre‐tripauthorizationformsoronacasebycasebasis.

References:“GeneralSymptoms.”UnitedStatesSpecialOperationsCommand.SpecialOperationsForcesMedicalHandbook.Jackson,Wyoming:TetonNewMedia,2001.3‐1.“Respiratory.”UnitedStatesSpecialOperationsCommand.SpecialOperationsForcesMedicalHandbook.Jackson,Wyoming:TetonNewMedia,2001.4‐10.Schimelpfenig,Tod.“CommonNon‐UrgentMedicalProblems.”WildernessMedicine,Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter24.TheMerckManual16thEdition.Rathaway,NewJersey:Merck&Co.,Inc.,1992.Tilton,Buck.“CommonSimpleMedicalProblems.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter31.Wilkerson,JamesA.“Eye,EarNose,andThroatDisorders.”MedicineforMountaineering5thed.Seattle,Washington:TheMountaineersBooks,2001.Chapter17.

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StandingOrder:HeadInjuriesGeneralCommentsDecidingwhethertoevacuateapatientwhosustainsablowtotheheadandexhibitsonlyminorsymptomscanbechallengingforoutdoorleaders.Providingdetailedguidancecanbehelpful.TreatmentforMildHeadInjuriesConservativetreatmentwithcloseobservationfor24hoursinthefieldcanbedoneifthepatientwasawakeandalert(A+Ox3or4)orwasonlymomentarilydazedorstunned,butrecoveredappropriatelyandthepatientremainsawakewithoutnegativechangeinmentalstatusandhasonlytransientnauseaorvomiting.1.Monitorthepatientfordevelopingsignsofseriousheadinjury.2.Letthepatientrest,butwakethemupeveryfewhourstomonitorLOR.TreatmentforSeriousHeadInjuries1. Iftheinjuryisopen,usediffusepressurewithabulkydressingtocontrolbleeding.2. ManageAirway,BreathingandCirculation.Considerpositioningthepatientontheirside.3. Administeroxygenifavailable.4. Immobilizethespineandelevatetheheadatapproximately6‐8”(15‐20cm).EvacuationGuidelinesforHeadInjuriesEvacuateRapidly:•AnypatientwhoisnotA+Ox3or4.•Anypatientwithdistinctchangesinmentalstatus(disoriented,irritable,combative).•Anypatientwithpersistentvomiting,lethargy,excessivesleepiness,ataxia(extremeuncoordination),seizures,worseningheadacheorvisiondisturbances.

•Anypatientwithsignsofaskullfracture.Evacuate:•Anypatientwithalossofresponsiveness,whorecoverstoA+Ox3or4.•Anypatientwhosesignsandsymptoms(headache,nausea/vomiting,irritabilityorothersignsandsymptomsofmildheadinjury)donotshowimprovementafter24hours.

Observefor24Hours:•AnypatientwhowasassessedasA+Ox3or4.•Anypatientwithsignsandsymptomsofmildheadinjury.ProtocolDecisionHavingalossofresponsivenessprotocolisessentialforanorganization.Oxygenisrecommendedforallseriousheadinjuries.Theadministrationofoxygenrequiresaphysician.Thismedicationmayalsobeself‐administeredbypatientswithaprescriptionforit.

References:EmergencyMedicalTechnician‐Basic:NationalStandardCurriculumModule5Trauma.22June1995.NationalHighwayTrafficSafetyAdministrationUnitedStatesDepartmentofTransportation.2Dec2004.<www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd>Forgey,William.“TraumaticBrainInjury.”WildernessMedicalSocietyPracticeGuidelinesforWildernessEmergencyCare5thed.Guilford,Connecticut:TheGlobePequotPress,2006.Chapter4.

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McCrory,PaulR.andKarenM.Johnston.“AcuteClinicalSymptomsofConcussionAssessingPrognosticSignificance.”ThePhysicianandSportsmedicineVol.30No.8August2002.“HeadTrauma.”PHTLSBasicandAdvancedPrehospitalTraumaLifeSupport.St.Louis,Missouri:Mosby,2003.Chapter8.Schimelpfenig,Tod.“BrainandSpinalCordInjuries.”WildernessMedicine.Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter4.Tilton,Buck.“HeadInjuries.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter9.Wilkerson,JamesA.“HeadandNeckInjuries.”MedicineforMountaineering5thed.Seattle,Washington:TheMountaineersBooks,2001.Chapter16.

StandingOrder:Hypothermia

GeneralCommentsMostmild‐moderatelyhypothermicpatientsaremanagedeffectivelyinthefieldanddonotrequireevacuation.TreatmentforHypothermia1. Changetheenvironmentandfindshelter.Replacewetclothingwithdryclothingandaddwindand

waterprooflayers.Treatgently.2. Addinsulationunderandaroundthepatient.Considerahypothermiawrapformoderatelyandseverely

hypothermicpatients.Addexternalheatsourcesandwell‐insulatedheatpacksathands,feet,armpits,groin,andneck.

3. Encourageexerciseifthepatientisableandallowshiveringinadry,insulatedenvironment.4. Givewarm,sweet,non‐caffeinated,non‐alcoholicliquidsandencouragethepatienttoeatameal,iftheyare

able.5. Foraseverelyhypothermicpatient,administerwarm,humidifiedoxygen,ifavailable.Assistventilationsfor5‐

15minutespriortomovement.6. Avoidchestcompressionsifthereareanysignsoflifeorthepatientisrigidfromthecold.Performrescue

breathingduringevacuation.EvacuationGuidelinesforHypothermiaEvacuateRapidly:•Anypatientwithseverehypothermia.ProtocolDecision:

Thedecisiontowithholdchestcompressionsisawildernessprotocol.YourMedicalAdvisorshouldadviseyouonthedecisiontowithholdchestcompressions.

References:Auerbach,PaulS.“AccidentalHypothermia.”WildernessMedicine5thed.St.Louis,Missouri:Mosby,2007.Chapter5.Forgey,William.“Hypothermia.”WildernessMedicalSocietyPracticeGuidelinesforWildernessEmergencyCare5thed.Guilford,Connecticut:TheGlobePequotPress,2006.Chapter11.Giesbrecht,GordonG.“PrehospitalTreatmentofHypothermia.”WildernessandEnvironmentalMedicine122001:24‐31.Schimelpfenig,Tod.“ColdInjuries.”WildernessMedicine.Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter9.StateofAlaskaColdInjuriesandColdWaterNearDrowningGuidelines.Revision01/96.HypothermiaPrevention,RecognitionandTreatment.

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Articles,ProtocolsandResearchonLife‐savingskills.27Dec.2004.<http://www.hypothermia.org/protocol.htm>Stewart,CharlesE.“GeneralizedHypothermia.”EnvironmentalEmergencies.Baltimore,Maryland:Williams&Wilkins,1990.Chapter4.Tilton,Buck.“Cold‐InducedEmergencies.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter16.Wilkerson,JamesA.“ColdInjuries.”MedicineforMountaineering5thed.Seattle,Washington:TheMountaineersBooks,2001.Chapter23.

StandingOrder:LightningGeneralCommentsLightningstrikescancauseavarietyofinjuriesincludingdeath.Thebestdefenseisastrongpreventionplanspecificforyourgeographicareaandgroupprofile.TreatmentforLightningInjuries1. Scenesafety:Lightningwillstriketwiceinthesamespot.2.AggressiveBasicLifeSupport:Rescuersshouldbepreparedtoprovideprolongedrescuebreathing.3. Thoroughpatientexamandtreatmentofanyinjuriesfound.4. Monitorcloselyforcardiovascular,respiratoryandneurologicalcollapse.EvacuationGuidelinesforLightningInjuriesEvacuateRapidly:•Anypatientshowingsignsofcardiovascular,respiratoryorneurologicalcompromise.Evacuate:•Anypatientstruckbylightningeveniftheyappearuninjured.

References:Auerbach,PaulS.“LightningInjuries.”WildernessMedicine5thed.St.Louis,Missouri:Mosby,2007.Chapter3.Forgey,William.“LightningInjuries.”WildernessMedicalSocietyPracticeGuidelinesforWildernessEmergencyCare5thed.Guilford,Connecticut:TheGlobePequotPress,2006.Chapter14.Gookin,John.“NOLSBackcountryLightningSafetyGuidelines.”Lander,Wyoming:TheNationalOutdoorLeadershipSchool,2000.Schimelpfenig,Tod.“LightningInjuries.”WildernessMedicine.Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter13.Stewart,CharlesE.“ElectricalInjuries.”EnvironmentalEmergencies.Baltimore,Maryland:Williams&Wilkins,1990.Chapter9.Tilton,Buck.“Lightning.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter20.

StandingOrder:LocalColdInjuriesGeneralCommentsItispossibletoseebothfreezingandnon‐freezinglocalcoldinjuriesinthewildernesssetting.Bothcancauseinjuriesrangingfromminorirritationtosignificanttissuelossandpermanentdisability.TreatmentforLocalColdInjuries1.Ifnotfrozen:Warmtheinjurywithskin‐to‐skincontact,donotmassageoruseradiantheat.2.Iffrozen:Ifpossible,warmtheinjuryinacirculatingwarmwaterbathat99‐102°F(37‐39°C),otherwiseuseskin‐

to‐skincontact.Donotmassageoruseradiantheat.3.Protectblistersanddamagedtissue,avoidconstriction.Protectfromre‐freezing.Elevate.

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4.Painmedicationasneeded.EvacuationGuidelinesforLocalColdInjuriesEvacuateRapidly:•Anypatientwithfullthicknessfrostbite.Evacuate:•Anypatientwithmorethanafew,small,isolatedclearfluidfilledblistersformedafterwarmingalocalcoldinjury.•Anypatientunabletousetheinjuredarea.•Anypatientunabletoprotecttheareafromcontinuedexposuretoacoldwetenvironmentorfromre‐freezing.•Anypatientwhosepaincannotbemanagedinthefield.ProtocolDecision:

Apatientwithlocalcoldinjurymaybenefitfromprescriptionlevelpainmedication.Theadministrationofprescriptionpainmedicationrequiresaphysician.Thismedicationmayalsobeself‐administeredbypatientswithaprescriptionforit.Apatientwithlocalcoldinjurymaybenefitfromover‐the‐counterpainmedication.Theadministrationofover‐thecounterpainmedicationtominorsrequiresparentalapproval,whichcanbeobtainedthroughpre‐tripauthorizationformsoronacasebycasebasis.

References:Auerbach,PaulS.“NonfreezingColdInjuries.”WildernessMedicine5thed.St.Louis,Missouri:Mosby,2007.Chapter7.Auerbach,PaulS.“Frostbite.”WildernessMedicine5thed.St.Louis,Missouri:Mosby,2007.Chapter8.Forgey,William.“Frostbite/ImmersionFoot.”WildernessMedicalSocietyPracticeGuidelinesforWildernessEmergencyCare5thed.Guilford,Connecticut:TheGlobePequotPress,2006.Chapter12.Schimelpfenig,Tod.“ColdInjuries.”WildernessMedicine.Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter9.StateofAlaskaColdInjuriesandColdWaterNearDrowningGuidelines.Revision01/96.HypothermiaPrevention,RecognitionandTreatment.Articles,ProtocolsandResearchonLife‐savingskills.27Dec.2004.<http://www.hypothermia.org/protocol.htm>Stewart,CharlesE.“FrostbiteandColdInjuries.”EnvironmentalEmergencies.Baltimore,Maryland:Williams&Wilkins,1990.Chapter3.Tilton,Buck.“Cold‐InducedEmergencies.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter16.Wilkerson,JamesA.“ColdInjuries.”MedicineforMountaineering5thed.Seattle,Washington:TheMountaineersBooks,2001.Chapter23.Wilkerson,JamesA.,CameronC.BangsandJohnS.Hayward.“Frostbite.”HypothermiaFrostbiteandOtherColdInjuries.Seattle,Washington:TheMountaineers,1986.Chapter7.Wilkerson,JamesA.,CameronC.BangsandJohnS.Hayward.“OtherLocalizedColdInjuries.”HypothermiaFrostbiteandOtherColdInjuries.Seattle,Washington:TheMountaineers,1986.Chapter8.

StandingOrder:MaleGenderIllnessandInjury

GeneralCommentsItcanbechallengingtodifferentiatebetweentraumaticandinfectiousproblemswiththemalegenitalia.Sincedelayincarecanresultinthelossofatesticle,treatmentshoulderrorontheconservativeside.

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MaleGenderIllnessandInjury

1. Painmanagementasneeded,NSAIDsoftenrecommended.2. Coolcompresses.3. Elevation/supportofthetesticles.4. Iftesticulartorsionissuspectedconsiderselforassistedreductionoftheaffectedtesticle.5. Ifepididymitisissuspectedconsiderantibiotics.6. Ifinguinalherniaissuspected,attemptreduction.

EvacuationGuidelinesforMaleGenderIllnessandInjuryEvacuateRapidly:•Anypatientwithsuspectedtesticulartorsionthatdoesnotreduce.•Anypatientwithtesticularpainofunknownorigin.Evacuate:•Anypatientwithasuspectedepididymitis.•Anypatientwithaninguinalherniathatdoesnotreduceorreappearsafterreduction.ProtocolDecision:

Apatientwithinjuryorillnesstothemalegenitaliamaybenefitfromover‐the‐counterpainmedication.Theadministrationofover‐thecounterpainmedicationtominorsrequiresparentalapproval,whichcanbeobtained

throughpre‐tripauthorizationformsoronacasebycasebasis.

Antibioticsarerecommendedforepididymitis.Theadministrationofanantibioticrequiresaphysician.Thismedicationmayalsobeself‐administeredbypatientswithaprescriptionforit.Ifyourprogramdoesnotcarryantibioticsinthebackcountry,deletethissectionfromthetreatmentprotocol.References:EmergencyMedicalTechnician‐Basic:NationalStandardCurriculumModule4Medical/BehavioralEmergenciesandObstetrics/Gynecology.22June1995.NationalHighwayTrafficSafetyAdministrationUnitedStatesDepartmentofTransportation.2Dec2004.<www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd>“Genitourinary.”UnitedStatesSpecialOperationsCommand.SpecialOperationsForcesMedicalHandbook.Jackson,Wyoming:TetonNewMedia,2001.4‐87.“MaleGenitalProblems.”UnitedStatesSpecialOperationsCommand.SpecialOperationsForcesMedicalHandbook.Jackson,Wyoming:TetonNewMedia,2001.3‐77.Schimelpfenig,Tod.“Gender‐SpecificMedicalConcerns.”WildernessMedicine.Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter20.SpecificProtocolsforWildernessEMSTesticularPain.Version1.2May19,1994.TheWildernessEmergencyMedicalServicesInstitute.2Dec.2004.<http://www.wemsi.org/specific.html>TheMerckManual16thEdition.Rathaway,NewJersey:Merck&Co.,Inc.,1992.

StandingOrder:MusculoskeletalInjuriesGeneralCommentsTreatmentandevacuationdecisionsofmusculoskeletalinjuriesarebasedonthepatient’sabilitytousetheinjuredarea.Useableinjuriesaresupportedandcanbekeptinthefieldorevacuatednon‐urgently.Un‐usableinjuriesareimmobilizedandevacuated.TreatmentforStrains,Sprains,TendonitisandMinorFractures

1. Assessinjuryforstabilityandusability.2. Assesscirculation,sensationandmotion(CSM).

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RICETherapy• Rest:Getthepressureoffoftheinjurysite.• Ice:Cooltheareafor20minutes.• Compression:ElasticWrap,distaltoproximal.• Elevation:Abovethepatient’sheart.

1. Painmedicationasneeded.2. Allowtheinjurysitetopassivelywarm.3. Assessagainforusability.4. Supportusableinjurieswithtapeorotheradjuncts.5. ContinueRICETherapyasneeded.

***1. TreatmentforObviousFractures,OpenFracturesandUnusableInjuries2. Assessinjury.Checkcirculation,sensationandmotion(CSM).3. Iffractureisopen,thoroughlyirrigateandcleanwoundpriortomanipulatinginjury.4. Ifnecessary,usegentletraction‐in‐line(TIL)toestablishnormalanatomicalposition.Slowdownor

discontinueyourattemptifpainincreasessignificantlyoryoumeetresistance.Iftheboneendsdonotreduce,protectfromfreezingordrying.

5. Dresswounds.6. Splintinapositionoffunctionwithawell‐paddedandrigidsplint.7. Tractionsplintmid‐shaftfemoralfractures.8. RICEtherapy.Painmedicationasneeded.9. MonitorCSMbeforeandafterTILandsplinting.10. Monitorwoundsiteforinfectionandconsiderantibiotictherapyforopenfractures.

EvacuationGuidelinesforAthleticInjuriesandFracturesEvacuateRapidly:

• Anypatientwithanopenfracture.• AnypatientwithalteredCSM.

Evacuate:

• Anypatientwithanunusablemusculoskeletalinjury.

ProtocolDecision:

Thereductionofangulatedfracturesiswithinthescopeofurbanpre‐hospitalcareproviders,especiallyifthepatienthasalteredCSM.Thoughthisisnotawildernessprotocol,itispotentiallyviewedasaggressive.Apatientwithamusculoskeletalinjurymaybenefitfromprescriptionlevelpainmedication.Theadministrationofprescriptionpainmedicationrequiresaphysician.Thismedicationmayalsobeself‐administeredbypatientswithaprescriptionforit.

Apatientwithmusculoskeletalinjurymaybenefitfromover‐the‐counterpainmedication.Theadministrationof

over‐thecounterpainmedicationtominorsrequiresparentalapproval,whichcanbeobtainedthroughpre‐tripauthorizationformsoronacasebycasebasis.

Antibioticsarerecommendedforopenfractures.Theadministrationofanantibioticrequiresaphysician.Thismedicationmayalsobeself‐administeredbypatientswithaprescriptionforit.References:

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Auerbach,PaulS.“WildernessOrthopaedics.”WildernessMedicine5thed.St.Louis,Missouri:Mosby,2007.Chapter24.EmergencyMedicalTechnician‐Basic:NationalStandardCurriculumModule5Trauma.22June1995.NationalHighwayTrafficSafetyAdministrationUnitedStatesDepartmentofTransportation.2Dec2004.<www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd>Forgey,William.“OrthopedicInjuries.”WildernessMedicalSocietyPracticeGuidelinesforWildernessEmergencyCare5thed.Guilford,Connecticut:TheGlobePequotPress,2006.Chapter8.“MusculoskeletalTrauma.”PHTLSBasicandAdvancedPrehospitalTraumaLifeSupport.St.Louis,Missouri:Mosby,2003.Chapter10.Schimelpfenig,Tod.“AthleticInjuries.”WildernessMedicine.Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter6.Schimelpfenig,Tod.“FracturesandDislocations.”WildernessMedicine.Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter5.Tilton,Buck.“AthleticInjuries.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter14.Tilton,Buck.“Fractures.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter12.

StandingOrder:NeurologicalEmergencies

GeneralCommentsStrokesarerareeventsinabackcountrysetting,butwhentheydooccurrequireimmediateevacuation.Seizuresareamorecommonoccurrence,fortunatelytheyarerarelylifethreatening.TreatmentforNeurologicalEmergencies

1. Forasuspectedstrokeortransientischemicattack(TIA),provideemotionalreassurance.Placethepatientinapositionofcomfortunlessunresponsive,thenplaceinstablesidepositionwiththeaffectedairwaysidedowntoprotecttheairway.Administeroxygen,ifavailable.Documentpreciselythetimeofonsetofsignsandsymptoms

2. Forapatientwithaseizure,protectfromharm,butdonotrestrain.Donotplacebitestickoranyotherobjectinmouth.Placethepatientonsidetomaintainopenairwayduringpost‐seizurerecoveryphase.Performacompletepatientassessmenttocheckforinjuries.Protectthepatient’sdignity.Administeroxygen,ifavailable.

3. Foranunresponsivepatientofunknownorigin,stabilizethespine,managetheairway,considerpositioningthepatientontheirsideandsearchforcluestothepatient’sunresponsivestate.Consideradministeringoralsugar.

EvacuationGuidelinesforNeurologicalEmergenciesEvacuateRapidly:

• AnypatientwithsignsandsymptomsofastrokeorTIA.• Anypatientwithmultipleseizuresinashorttimeperiod.• Anypatientwithpersistentunresponsivenessoralteredmentalstatus.

Evacuate:

• Anypatientwithafirsttimeseizure.• Anypatientwithaseizurethatoccurredinspiteofmedication(breakthroughseizure).• Anypatientwithanisolatedseizureofunknownorigin.

References:ACLSProviderManual.Dallas,Texas:AmericanHeartAssociation,2002.

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BLSforHealthcareProviders.Dallas,Texas:AmericanHeartAssociation,2002.EmergencyMedicalTechnician‐Basic:NationalStandardCurriculumModule4Medical/BehavioralEmergenciesandObstetrics/Gynecology.22June1995.NationalHighwayTrafficSafetyAdministrationUnitedStatesDepartmentofTransportation.2Dec2004.<www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd>Schimelpfenig,Tod.“Diabetes,SeizuresandUnresponsiveStates.”WildernessMedicine,Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter19.TheMerckManual16thEdition.Rathaway,NewJersey:Merck&Co.,Inc.,1992.Tilton,Buck.“NeurologicalEmergencies.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter25.

StandingOrder:PoisonsGeneralCommentsWhendealingwithpossiblepoisoninggatherdetailedinformationaboutwhatwasingested,howmuch,when,bodysizeandage,whatisinhisorherstomachandwasitintentional.CarbonmonoxidepoisoningfromstovesandlanternsinenclosedspacesandmotorvehicleexhaustiscommoninoutdoorrecreationaccordingtotheCentersforDiseaseControlandPrevention.Poisoningisdifficulttomanageinthefieldandisbestdealtwiththroughprevention.TreatmentforPoisons

1. Callthepoisoncontrolcenter(1‐800‐222‐1222),ifpossible.2. Ifpoisonisingestedandisnon‐corrosive,non‐petroleumbasedandthepatientisfullyresponsive:Induce

vomitingmanually.3. Ifpoisonisinhaled,removepatientfromexposure.Administeroxygen,ifavailable.Assistventilationsif

necessary.4. Ifpoisonisabsorbed,takeuniversalprecautionsandremovecontaminatedclothing.Brushdrypoison

off,flushareawithwaterandwashwithsoap.EvacuationGuidelinesforPoisoningEvacuateRapidly:

• Anypoisonedpatientwhohasanalteredlevelofresponsivenessorshowssignsofrespiratorydistress.Evacuate:

• Anypatientwhohasingestedquantitiesofapotentiallyharmfulsubstance.ContacttheAmericanAssociationofPoisonControlCentersat1‐800‐222‐1222foradvice.

ProtocolDecision:Oxygenisrecommendedforallinhaledpoisonpatients.Theadministrationofoxygenrequiresaphysician.Thismedicationmayalsobeself‐administeredbypatientswithaprescriptionforit.Ifyourprogramdoesnotcarryoxygeninthebackcountry,deletethissectionfromthetreatmentprotocol.References:Auerbach,PaulS.“ToxicPlantIngestions.”WildernessMedicine5thed.St.Louis,Missouri:Mosby,2007.Chapter58.

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EmergencyMedicalTechnician‐Basic:NationalStandardCurriculumModule4Medical/BehavioralEmergenciesandObstetrics/Gynecology.22June1995.NationalHighwayTrafficSafetyAdministrationUnitedStatesDepartmentofTransportation.2Dec2004.<www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd>Forgey,William.“BotanicalEncounters.”WildernessMedicalSocietyPracticeGuidelinesforWildernessEmergencyCare5thed.Guilford,Connecticut:TheGlobePequotPress,2006.Chapter17.Keyes,LindaE.,RobertS.Hamilton,andJohnS.Rose.“CarbonMonoxideExposurefromCookinginSnowCavesatHighAltitude.”WildernessandEnvironmentalMedicine,12,2001:208‐212.Schimelpfenig,Tod.“Poisons,Stings,andBites.”WildernessMedicine.Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter12.Stewart,CharlesE.“PlantsThatPoison.”EnvironmentalEmergencies.Baltimore,Maryland:Williams&Wilkins,1990.Chapter8.TheMerckManual16thEdition.Rathaway,NewJersey:Merck&Co.,Inc.,1992.Tilton,Buck.“PoisoningEmergencies.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter27.

StandingOrder:RespiratoryEmergenciesGeneralComments:Themostcommonlyreportedrespiratoryproblemsareupperrespiratoryinfectionsassociatedwithcoldsorflu‐likeillness.Otherrespiratoryemergenciesrangefromminorepisodesofhyperventilationandasthmatomoreseriousinfections,embolismsandsevereasthma.Agoodpatienthistorywillhelpyoudeterminethelikelycauseandcreatethemostappropriatemanagementplan.Cold,altitude,dehydrationandfatiguecanallbecomplicatingfactors.TreatmentforRespiratoryEmergencies:

1. Forsuspectedhyperventilation,calmthepatient,bedirectbutreassuring.Assistthepatienttoslowhisorherbreathing.Oxygenisnotindicated.

2. Forsuspectedpulmonaryembolism,administeroxygen,ifavailable.Placethepatientinapositionofcomfortandevacuaterapidly.

3. ForasuspectedUpperRespiratoryInfection(URI)allowthepatienttorestandhydrate.Considerover‐the‐counterdecongestantsandanalgesics.

4. Forsuspectedpneumonia,encouragepatienttocoughandbreathedeeply.Ensurethepatientstayshydrated.Givefever‐reducingmedications.Administeroxygen,ifavailable.Ifevacuationislengthy,administeroralantibiotics.

5. Forasuspectedasthmaattackhelpcalmthepatientandchangetheenvironment.Assistthepatient,ifnecessary,withhisorherbronchodilatorsorAlbuterolinhaler(2puffsevery5minutesupto12puffs)untilattackabates.Continuedmaintenancetreatmentisusually2puffsevery4hoursandasneeded.Encouragepursedlipbreathing.Administeroxygen,ifavailable.Providehydrationandrest.Apatientwithsevereasthmaunresponsivetotheirnormalmedicationsmayneedtreatmentwithsteroidsandepinephrine.

EvacuationGuidelinesforRespiratoryEmergencies:EvacuateRapidly:

•Anypatientwithsuspectedpulmonaryembolus.•Anypatientwithsignsorsymptomsofasevereasthmaattack.

Evacuate:

•Anypatientwithsuspectedpneumonia.

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•Anypatientsufferingfromasthmawhoisunresponsivetomedicationorwithincreasingfrequencyand/ordurationofattacks.

ProtocolDecision:

Oxygenisrecommendedforallseriousrespiratoryemergencies.Theadministrationofoxygenrequiresaphysician.Thismedicationmayalsobeself‐administeredbypatientswithaprescriptionforit.Ifyourprogramdoesnotcarryoxygeninthebackcountry,deletethissectionfromthetreatmentprotocol.Arangeofover‐the‐countermedicationsincludingdecongestants,painmedicationsandfever‐reducingmedicationsmayhelppatientswithrespiratoryemergencies.Theadministrationofover‐thecounterdecongestants,painmedicationsandfever‐reducingmedicationstominorsrequiresparentalapprovalwhichcanbeobtainedthroughpre‐tripauthorizationformsoronacasebycasebasis.Antibioticsarerecommendedforanypatientwithpneumonia.Theadministrationofanantibioticrequiresaphysician.Thismedicationmayalsobeself‐administeredbypatientswithaprescriptionforit.Albuterolisaprescriptionmedicationcommonlycarriedbypatientswithaknownasthmahistory.Manypatientsareabletoself‐administerthismedication.Peoplewithmildtomoderatecontrolledasthmaparticipateinoutdoorprograms.Theuseofepinephrinetomanagesevereasthmaiscontroversialandisnotlistedbythemanufacturerasan

indicationforuseoftheauto‐injectordevices.

References:Busse,WilliamW.andRobertF.Lemanske.Jr.“Asthma.”NewEnglandJournalofMedicineVol.344,No.5February1,2001:350‐362.EmergencyMedicalTechnician‐Basic:NationalStandardCurriculumModule4Medical/BehavioralEmergenciesandObstetrics/Gynecology.22June1995.NationalHighwayTrafficSafetyAdministrationUnitedStatesDepartmentofTransportation.2Dec2004.<www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd>“Respiratory.”UnitedStatesSpecialOperationsCommand.SpecialOperationsForcesMedicalHandbook.Jackson,Wyoming:TetonNewMedia,2001.4‐10.Schimelpfenig,Tod.“RespiratoryandCardiacEmergencies.”WildernessMedicine.Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter17.SpecificProtocolsforWildernessEMSAsthma.Version1.2May19,1994.TheWildernessEmergencyMedicalServicesInstitute.2Dec.2004.<http://www.wemsi.org/specific.html>TheMerckManual16thEdition.Rathaway,NewJersey:Merck&Co.,Inc.,1992.Tilton,Buck.“RespiratoryEmergencies.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter24.WildernessFieldProtocolsProtocol6SevereAsthma.2001.WildernessMedicalAssociates.2Dec.2004<http://www.wildmed.com/field_protocols/joint_dis_protocol05.01.html#top>Wilkerson,JamesA.“RespiratoryDisorders.”MedicineforMountaineering5thed.Seattle,

StandingOrders:Shock

GeneralComments:

Serioustraumaticinjuryandlargeareasofsignificantburnsareunusualintheoutdoors.Themorecommonriskforshockmaybefromlossoffluidvolumefromsweating,vomiting,diarrheaandinadequatehydration.Outdoorleadersshouldfocusonearlyrecognitionandinterventiontocontrolfluidlossandmaintainpatientsinthefield.TreatmentforShock:

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1. Treatbeforeserioussignsdevelop.2. Treatthecause.Keepthepatientcalm.3. Keepthepatientwarm.4. Keepthepatientflatwithlegselevatednomorethan12inches(30.5cm)(Headorlowerextremityinjury

mayprecludethis.)5. Consideradministeringoralfluidsinanextendedcaresituation(Ifpatientcantoleratethefluids,mental

statusisadequatetoswallowandthereisnoabdominalinjury.)6. Administeroxygen,ifavailable.7. Monitorthepatientcloselyfordeterioratingvitalsigns.

EvacuationGuidelinesSummaryEvacuateRapidly:

•Anypatientwithdecreasedlevelofresponsivenessorworseningvitalsigns.

Evacuate:

•Anypatientwhosevitalsignsdonotstabilizeorimproveovertime.ProtocolDecision:Oxygenisrecommendedforallpatientsexhibitingsignsandsymptomsofshock.Theadministrationofoxygenrequiresaphysician.

References:“ShockandFluidResuscitation.”PHTLSBasicandAdvancedPrehospitalTraumaLifeSupport.St.Louis,Missouri:Mosby,2003.Chapter6.Schimelpfenig,Tod.“Shock.”WildernessMedicine.Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter2.Tilton,Buck.“Shock.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter7.

StandingOrder:SkinIrritation

GeneralComments:Skinirritationscanoftenbepreventedthoughimprovedhygienepracticesandappropriateclothing.Theactiveingredientinpoisonivy,oakandsumacisurushiol.Thisoilcanbetransferredtotheskinregardlessofwhetherornottheplanthasitstraditionalshinythreeleavesinbloom.Inhaledsmokefromburningplantscanalsocauseasignificantreaction.Therearebarriercreamsforhypersensitiveindividuals.TreatmentforSkinIrritation:1.Fungalinfectionsoftheskincanbetreatedbywashingtheareathoroughlywithsoapandwater,airdryingand

applyingathinlayerof1%hydrocortisonecreamoratopicalanti‐fungal(e.g.Tinactin®).Considerprescriptionantifungals(e.g.Diflucan®)forsevereinfections.

2. Forasuspectedcontactwithpoisonivy,oakorsumac,washtheareaimmediatelyafterexposurewithsoapandcoolwater.ForhighlysensitivepersonsconsiderusingTecnu®orZanfel®asasoap.Washallclothesandequipmentthatmayhavebeenexposed.Oncetherashappears,applyathinlayerof1%hydrocortisonecreamorcalaminelotiontoreduceitching.Oralantihistaminesmayhelpreduceitching.

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EvacuationGuidelinesforSkinIrritation:EvacuateRapidly:•Anypatientwithrespiratorydistressafterinhalingsmokefromburningpoisonivy,oakorsumac.

Evacuate:•Anypatientwithaskinirritationthatmakesthemtoouncomfortabletocontinue.ProtocolDecision:Anti‐fungalmedication(e.g.Tinactin®)isrecommendedfortreatingfungalinfectionsoftheskin.Theadministrationofover‐thecounteranti‐fungalmedicationtominorsrequiresparentalapprovalwhichcanbeobtainedthroughpre‐tripauthorizationformsoronacasebycasebasis.Prescriptionanti‐fungalmedicationmaybeusefulintreatingfungalinfectionsoftheskin.Theadministrationofprescriptionanti‐fungalmedication(e.g.Diflucan®)requiresaphysician.Thismedicationmayalsobeself‐administeredbypatientswithaprescriptionforitOver‐the‐counterantihistamines,topicalhydrocortisonecreamandcalaminelotionmaybehelpfulinmanagingthesymptomsofpoisonivy,oakandsumac.Theadministrationofover‐thecountermedicationtominorsrequiresparentalapprovalwhichcanbeobtainedthroughpre‐tripauthorizationformsoronacasebycasebasis.

References:Auerbach,PaulS.“Plant‐InducedDermatitis.”WildernessMedicine5thed.St.Louis,Missouri:Mosby,2007.Chapter57.“Skin.”UnitedStatesSpecialOperationsCommand.SpecialOperationsForcesMedicalHandbook.Jackson,Wyoming:TetonNewMedia,2001.4‐38.

StandingOrder:NorthAmericanPitVipers,CoralSnakesandPoisonousLizardsGeneralCommentsFatalitiesduetoenvenomationbysnakesorlizardsareextremelyrareinNorthAmerica,thoughtissuelossisapossibility.Venomwillnotbeinjectedinallbites.Theinjuryshouldbemonitoredcloselyforsignsofenvenomation.Anti‐venomisavailableformostbites.TreatmentforBitesfromNorthAmericanPitVipers,CoralSnakesandPoisonousLizards1. Ensurethesceneissafe.Remaincalmandputthepatientatrest.Avoidwalkingifpossible.2. Removeconstrictingclothingandjewelryfromthebitesite.3. Washanddressthewound.4. Measureandmonitorswellingandsignsofenvenomation.Donotapplyice.5. Painmedicationsasneeded.6. Awideelasticbandagewrappeddistaltoproximalisrecommendedforcoralsnakebites.7. Splinttheextremityandkeepitatthesamelevelastheheart.8. Monitorforshockandcardiacandrespiratorydepression.EvacuationGuidelinesforBitesfromNorthAmericanPitVipers,CoralSnakesandPoisonousLizardsEvacuateRapidly:•Anypatientexhibitingshock,orcardiacorrespiratorydepression.•Anypatientwithsignsorsymptomsofenvenomation.

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Evacuate:•Anypatientbittenbyapoisonoussnake,ideallybycarryingorslowlywalking.ProtocolDecision:Apatientwithasnakeorlizardbitemaybenefitfromprescriptionlevelpainmedication.Theadministrationofprescriptionpainmedicationrequiresaphysician.Thismedicationmayalsobeself‐administeredbypatientswithaprescriptionforit.Apatientwithasnakeorlizardbitemaybenefitfromover‐the‐counterpainmedication.Theadministrationofover‐thecounterpainmedicationtominorsrequiresparentalapproval,whichcanbeobtainedthroughpre‐tripauthorizationformsoronacasebycasebasis.

References:

Auerbach,PaulS.“BitesbyVenomousReptilesintheAmericas.”WildernessMedicine5thed.St.Louis,Missouri:Mosby,2007.Chapter48.Forgey,William.“ReptileEnvenomations.”WildernessMedicalSocietyPracticeGuidelinesforWildernessEmergencyCare5thed.Guilford,Connecticut:TheGlobePequotPress,2006.Chapter20.Gold,BarryS.,RichardC.DartandRobertA.Barish.“BitesofVenomousSnakes.”NewEnglandJournalofMedicineVol.347,No.5,August1,2002:347‐356.Russell,FindlayE.SnakeVenomPoisoning.GreatNeck,NewYork:ScholiumInternationalInc.,1983.Schimelpfenig,Tod.“Poisons,Stings,andBites.”WildernessMedicine,Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter12.Stewart,CharlesE.“BitesandStings.”EnvironmentalEmergencies.Baltimore,Maryland:Williams&Wilkins,1990.Chapter7.Tilton,Buck.“NorthAmericanBitesandStings.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter21.Wilkerson,JamesA.“AnimalBitesandStings.”MedicineforMountaineering5thed.Seattle,Washington:TheMountaineersBooks,2001.Chapter25.

StandingOrder:NorthAmericanSpidersandScorpions

GeneralCommentsManyspiderbitesareinitiallypainlessmakingitdifficulttoidentitythespecificspider.Fatalitiesarerare.Scorpionstingsarepainful,buttypicallyself‐limiting.SystemicreactionsarepossiblefromscorpionsintheextremesouthwesternUS.TreatmentforBitesandStingsfromNorthAmericanSpidersandScorpions1. Cleanthebite/stingsite.Continuetocleanthesiteifwounddoesnotheal.2. Icethebitesiteforpainandconsiderpainkillersforabdominalcramps.3. Monitorthebitesitefornecrosis.4. Monitorthepatientforsystemicsignsandsymptoms.EvacuationGuidelinesforBitesandStingsfromNorthAmericanSpidersandScorpionsEvacuateRapidly:•Anypatientexhibitingslurredspeech,difficultyswallowing,blurredvision,seizures,orrespiratoryorcardiovascularinvolvement.

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Evacuate:•Anypatientwithasuspectedblackwidowspiderbite.•Anypatientwithawoundthatwillnotheal.ProtocolDecisionApatientwithaspiderbiteorscorpionstingmaybenefitfromprescriptionlevelpainmedication.Theadministrationofprescriptionpainmedicationrequiresaphysician.Thismedicationmayalsobeself‐administeredbypatientswithaprescriptionforit.Apatientwithaspiderbiteorscorpionstingsmaybenefitfromover‐the‐counterpainmedication.Theadministrationofover‐thecounterpainmedicationtominorsrequiresparentalapproval,whichcanbeobtained

throughpre‐tripauthorizationformsoronacasebycasebasis.References:Auerbach,PaulS.“SpiderBites.”WildernessMedicine5thed.St.Louis,Missouri:Mosby,2007.Chapter46.Auerbach,PaulS.“ScorpionEnvenomation.”WildernessMedicine5thed.St.Louis,Missouri:Mosby,2007.Chapter47.Forgey,William.“ArthropodEnvenomations.”WildernessMedicalSocietyPracticeGuidelinesforWildernessEmergencyCare5thed.Guilford,Connecticut:TheGlobePequotPress,2006.Chapter21.MMWRWeekly45(21)May31,1996:433‐436.“NecroticArachnidism‐‐PacificNorthwest,1988‐1996.”CentersforDiseaseControlandPrevention.27Dec.2004.<http://www.cdc.gov/mmwr/preview/mmwrhtml/00042059.htm>Schimelpfenig,Tod.“Poisons,Stings,andBites.”WildernessMedicine,Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter12.Stewart,CharlesE.“BitesandStings.”EnvironmentalEmergencies.Baltimore,Maryland:Williams&Wilkins,1990.Chapter7.Tilton,Buck.“NorthAmericanBitesandStings.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter21.Wilkerson,JamesA.“AnimalBitesandStings.”MedicineforMountaineering5thed.Seattle,Washington:TheMountaineersBooks,2001.Chapter25.

StandingOrder:SpinalInjuries

GeneralComments:Theutilizationofthefocusedspineassessmenttodeterminepresenceorabsenceofspinalinjuryhasbeenwellstudiedintheclinicalsetting.Outdoorleadersshouldbeattentivetosuspiciousmechanismsofinjury,takeearlyspinalprecautionswithpatientsandwhenappropriateusethefocusedspineassessmenttomakeacarefuldecisionaboutcontinuedimmobilization.FocusedSpineAssessment:Ifthepatienthasamechanismforspinalinjurybutdoesnotexhibitsignsandsymptomsofspinalinjuryduringthecompletepatientassessment;performafocusedspineassessmenttodeterminewhetherfurtherspinalimmobilizationiswarranted.FocusedSpineAssessment1. Patientmustbereliable:A+Ox3or4,sober,andhavenodistractions.2. PatientmusthavenormalCirculation(warm,pinkdigitsorgoodpedal/radialpulse),Sensation(nonumbness,

tinglingorunusualhotorcoldsensations)andMotion(unlessotherwiseexplainablebyanotherinjuryorillness)inallfourextremities.

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3. Patientmustdenyspinalpainandtenderness.Ifpatientmeetsallcriteriafurtherspinalimmobilizationisnotwarranted.TreatmentforSuspectedSpinalInjury:Ifthepatientexhibitssignsandsymptomsofspinalinjuryduringeitherthepatientassessmentorthefocusedspineassessment:1. Stabilizethespineandcontroltheheadmanually.2. Checkcirculation,sensationandmotion(CSM)intheextremities.3. Establishneutralalignmentofthespine.4. Applyacervicalcollar.5. BEAMorlog‐rollthepatientintoacommerciallitterorontoabackboard.6. Securetheentirebodytothelitterorbackboardwithpaddingandstraps.7. Securetheheadtothelitterorbackboard.8. RecheckCSMintheextremities.9. Evacuate.EvacuationGuidelinesforSpinalInjuries:EvacuateRapidly:•Anypatientwhodemonstratessignsandsymptomsofneurologicalinjury.Evacuate:•Anypatientbeingtreatedforaspinalinjury,ideallyonacommerciallitteroronabackboard.ProtocolDecision:ThoughsomeurbanEMSsystemshaveadopteduseofafocusedspinalassessmentallowingpre‐hospitalproviderstomakeadecisionabouttheneedforspinalimmobilization,thisisstillessentiallyawildernessprotocolanditsuseshouldbediscussedwithROPEMedicalAdvisor.

References:EmergencyMedicalTechnician‐Basic:NationalStandardCurriculumModule5Trauma.22June1995.NationalHighwayTrafficSafetyAdministrationUnitedStatesDepartmentofTransportation.2Dec2004.<www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd>DomeierR.M.“PositionPaper,NationalAssociationofEMSPhysicians:Indicationsforprehospitalspinalimmobilization.”PrehospitalEmergencyCare3(3)1999:251–253.Forgey,William.“SpinalInjury.”WildernessMedicalSocietyPracticeGuidelinesforWildernessEmergencyCare5thed.Guilford,Connecticut:TheGlobePequotPress,2006.Chapter5.HoffmanJ.R.andW.R.Mower.“Out‐of‐hospitalcervicalspineimmobilization:Makingpolicyintheabsenceofdefinitiveinformation.”AnnalsofEmergencyMedicine37June2001:632–634.“SpinalTrauma.”PHTLSBasicandAdvancedPrehospitalTraumaLifeSupport.St.Louis,Missouri:Mosby,2003.Chapter9.Schimelpfenig,Tod.“BrainandSpinalCordInjuries.”WildernessMedicine,Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter4.Tilton,Buck.“SpineInjuries.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter8.

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WildernessFieldProtocolsProtocol4SpineInjuries.2001.WildernessMedicalAssociates.2Dec.2004.<http://www.wildmed.com/field_protocols/spine_man_protocol05.01.html#top>Wilkerson,JamesA.“HeadandNeckInjuries.”MedicineforMountaineering5thed.Seattle,Washington:TheMountaineersBooks,2001.Chapter16.

StandingOrder:SubmersionIncidents

GeneralCommentsRescuersafetyisparamountwhendealingwithsubmersionevents.Itiscommontounderestimatetheeffectsofwatercurrentandtemperatureontheabilityofbothrescuersandpatientstoavoidsubmersion.TreatmentforSubmersionInjuries1. Scenesafety:Reach,Throw,Row,Tow,Go!Getthepersonontoasafe,firmsurface.Donotenterthewater

toattemptrescueifyouhavenotbeentrained.2. AggressiveBasicLifeSupportwithsupplementaloxygen,ifavailable.EvacuationGuidelinesforSubmersionInjuriesEvacuateRapidly:•Anypatientwhodevelops:Wetlungsounds,productivecough,rapid,shallow,respirations,cyanosis,substernalburning,inabilitytotakeadeepbreath,irregularand/ordepressedheartrate,oradecreasedlevelofresponsiveness.Evacuate:•Anypatientwhowasunresponsiveatanytimeduringthesubmersion.ProtocolDecision:Oxygenisrecommendedforsubmersionvictims.Theadministrationofoxygenrequiresaphysician.Thismedicationmayalsobeself‐administeredbypatientswithaprescriptionforit.References:ACLSProviderManual.Dallas,Texas:AmericanHeartAssociation,2002.Auerbach,PaulS.“SubmersionIncidents.”WildernessMedicine5thed.St.Louis,Missouri:Mosby,2007.Chapter68.Forgey,William.“SubmersionInjuries.”WildernessMedicalSocietyPracticeGuidelinesforWildernessEmergencyCare5thed.Guilford,Connecticut:TheGlobePequotPress,2006.Chapter3.Harries,Mark.“ABCofResuscitationNearDrowning.”BMJVol.3276Dec.2003:1336‐1338.Schimelpfenig,Tod.“DrowningandColdWaterImmersion.”WildernessMedicine,Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter14.StateofAlaskaColdInjuriesandColdWaterNearDrowningGuidelines.Revision01/96.HypothermiaPrevention,RecognitionandTreatment.Articles,ProtocolsandResearchonLife‐savingskills.27Dec.2004.<http://www.hypothermia.org/protocol.htm>Stewart,CharlesE.“Near‐Drowning.”EnvironmentalEmergencies.Baltimore,Maryland:Williams&Wilkins,1990.Chapter11.Tilton,Buck.“ImmersionandSubmersionIncidents.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter19.

StandingOrder:WoundsandInfection

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GeneralCommentsWoundsandinfectionarecommonlyreportedmedicalproblemsinawildernesssetting.Establishedinfectionischallengingtomanagesoeffortsshouldbedirectedataggressivewoundcleaningandeffectivedressingtopreventinfectionandpromotehealing.TreatmentforWoundsandInfection1. Controlbleedingusingdirectpressureandelevation,pressuredressings,andinextremecases,tourniquets.2. Properlycleanthewound:Washyourhandsandputonyourgloves;Cleanaroundthewoundwithsoapand

water,anabrasionmaybeaggressivelyscrubbed,andrinsewithdisinfectedwater;Removeanyforeignmatterwithdisinfectedtweezersorbygentlybrushingitoutofthewound;Pressureirrigatethewoundwithdisinfectedwater(minimum½literrecommended).

3. Coverwoundwiththecleanestdressingavailableandbandage.Keepwoundmoistwithadressingcoatedwithantibioticointmentoratransparentfilmdressing.Ifthecutgapesopenlessthan1/2inch(1.3cm),approximatewoundedgeswithwoundclosurestrips.Monitorcirculation,sensationandmotion(CSM).Keepthedressingscleananddry.Changedressingsatleastevery24hours.Ifusingtransparentfilmdressings,dressingsmaybeleftinplaceuntilwoundheals.

4. Ifthecutcausesgapingofmorethan1/2inch(1.3cm)orwoundisinfected,packthewoundopenwet‐dryandkeepthewoundmoistduringevacuation.

5. Incaseofanamputation,wrapthepartinamoiststeriledressingandsealinaplasticbag.Immersethebagincoolwaterandtransportrapidlytothehospitalwiththepatient.

6. Considerremovinganimpaledobjectifitisthroughthecheek.Inremoteenvironmentsconsiderremovaliftheobjectisinanextremityandinterfereswithtransport.

7. Ifthewoundshowssignsandsymptomsofinfection:Hotsoaksfor20‐30minutesseveraltimesdaily;cleanthewoundfollowingthehotsoak;keepthepatienthydrated;considerpackingthewoundopen(wettodry)toallowdrainage;considerantibioticandfeverreducingtherapy.

EvacuationGuidelinesforWoundsandInfectionEvacuateRapidly:•Anypatientwithanamputation.•Anypatientwithanobjectstillimpaled.•Anypatientwithawoundthat:Isheavilycontaminated,opensajointspace,involvesunderlyingtendonsorligaments,wascausedbyananimalbite,isontheface,orwascausedbyacrushingmechanism.•Anypatientwithawoundthatshowssignsandsymptomsofseriousinfection.Evacuate:•Anypatientwithawoundthatcannotbeclosedinthefield.•Anypatientwithaninfectionthatdoesnotimprovewithin12‐24hours.ProtocolDecision:Tourniquetsareusedtomanageseverebleedinguncontrolledbydirectpressure.Thedecisiontoreleaseatourniquetinawildernessenvironmentiscontroversial.ROPEMedicalAdvisorshouldadviseyouonthecircumstancesunderwhichheorsheiscomfortablewithatourniquetbeingreleasedinthebackcountry.Closingwoundsisgenerallyconsideredaclinicalprocedure.ROPEMedicalAdvisorshouldadviseyouonthecircumstancesunderwhichheorsheiscomfortablewithwoundclosureinthebackcountryusingwoundclosurestripsorbutterflybandages.

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Theremovalofimpaledobjectsiscontroversial.ROPEMedicalAdvisorshouldadviseyouonthecircumstancesunderwhichheorsheiscomfortablewiththeremovalofanimpaledobject.Antibioticsarerecommendedforallseriouslyinfectedwounds.Theadministrationofanantibioticrequiresaphysician.Thesemedicationsmayalsobeself‐administeredbypatientswithaprescriptionforthem.

References:

EmergencyMedicalTechnician‐Basic:NationalStandardCurriculumModule5Trauma.22June1995.NationalHighwayTrafficSafetyAdministrationUnitedStatesDepartmentofTransportation.2Dec2004.<www.nhtsa.dot.gov/people/injury/ems/pub/emtbnsc.pd>Goth,PeterandGeorgeGarnett.“NationalAssociationofEMSPhysiciansClinicalGuidelinesforDelayedorProlongedTransportWounds.”PrehospitalandDisasterMedicineVol.8No.3July‐Sep.1993:253‐255.Forgey,William.“WoundManagement.”WildernessMedicalSocietyPracticeGuidelinesforWildernessEmergencyCare5thed.Guilford,Connecticut:TheGlobePequotPress,2006.Chapter6.Schimelpfenig,Tod.“SoftTissueInjuries.”WildernessMedicine,Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter7.SpecificProtocolsforWildernessEMSWounds.Version1.2May19,1994.TheWildernessEmergencyMedicalServicesInstitute.2Dec.2004.<http://www.wemsi.org/specific.html>TheMerckManual16thEdition.Rathaway,NewJersey:Merck&Co.,Inc.,1992.Tilton,Buck.“WildernessWoundManagement.”WildernessFirstResponder2nded.Guilford,Connecticut:TheGlobePequotPress,2004.Chapter15.WildernessFieldProtocolsProtocol2WoundManagement.2001.WildernessMedicalAssociates.2Dec.2004.<http://www.wildmed.com/field_protocols/spine_man_protocol05.01.html#top>Wilkerson,JamesA.“Soft‐TissueInjuries.”MedicineforMountaineering5thed.Seattle,Washington:TheMountaineersBooks,2001.Chapter6.

StandingOrder:Zoonoses

GeneralCommentsThereisawide‐rangeofdiseasestransmittedfromanimalstohumans.TheonesweworryaboutthemostintheUnitedStatesare:TickFevers,WestNileVirus,Hantavirus,RabiesandPlague.Fielddiagnosiscanbeextremelydifficultandisunnecessary.Thepatientshouldbeassessedforahistoryofabiteandinregardstotheflu‐likeillnessevacuationcriteria.Educationaleffortsshouldfocusoneffectiveprevention.TreatmentforZoonoses1. Symptomaticmanagement,e.g.feverreducingmedication,painmedication,antihistaminesandantibiotic

therapy.2.Treatallmammalbitesasapotentialrabiesexposure.Cleanwoundthoroughlywithsoapanddisinfected

water.EvacuationGuidelinesforZoonosesEvacuateRapidly:•Anypatientwithamammalbiteforinitiationoftherabiesvaccine.Evacuate:•Anypatientwithahistoryofanembeddedtickwhodevelopsfever,rashandflu‐likesymptoms.•Anypatientwhotriggerstheflu‐likeillnessevacuationcriteria.

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ProtocolDecision:Arangeofover‐the‐countermedicationsincludingantihistamines,painmedicationsandfever‐reducingmedicationsmayhelppatientswithazoonosis.Theadministrationofover‐thecounterantihistamines,painmedicationsandfever‐reducingmedicationstominorsrequiresparentalapprovalwhichcanbeobtainedthroughpre‐tripauthorizationformsoronacasebycasebasis.Antibioticsmaybehelpfulforpatientswithazoonosis.Theadministrationofanantibioticrequiresaphysician.Thesemedicationsmayalsobeself‐administeredbypatientswithaprescriptionforthem.

References:Auerbach,PaulS.“Tick‐BorneDiseases.”WildernessMedicine5thed.St.Louis,Missouri:Mosby,2007.Chapter45.Auerbach,PaulS.“Wilderness‐AcquiredZoonoses.”WildernessMedicine5thed.St.Louis,Missouri:Mosby,2007.Chapter53.Forgey,William.“Tick‐TransmittedDiseases.”WildernessMedicalSocietyPracticeGuidelinesforWildernessEmergencyCare5thed.Guilford,Connecticut:TheGlobePequotPress,2006.Chapter22.“InfectiousDiseases.”UnitedStatesSpecialOperationsCommand.SpecialOperationsForcesMedicalHandbook.Jackson,Wyoming:TetonNewMedia,2001.Chapter13,5‐33.Schimelpfenig,Tod.“Poisons,Stings,andBites.”WildernessMedicine,Mechanicsburg,Pennsylvania:StackpoleBooks,2000.Chapter12.SpecificProtocolsforWildernessEMSRabies.Version1.2May19,1994.TheWildernessEmergencyMedicalServicesInstitute.2Dec.2004.<http://www.wemsi.org/specific.html>Stewart,CharlesE.“BitesandStings.”EnvironmentalEmergencies.Baltimore,Maryland:Williams&Wilkins,1990.Chapter7.

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ReedCollegeCourseDrugKitAdministeringprescriptionmedicationsisusuallyrestrictedtolicensedmedicalprofessionalsorindividualsactingwithinestablishedEmergencyMedicalServicessystems.Somecoursesmaycarryprescriptionmedicationsasacomponentoftheirmedicalsuppliesincludingepinephrine.NotetoROPEstaff:Thereareincreasingnumbersofstatelawsthatallowfortheadministrationofepinephrinetoanindividualexperiencingalifethreateningallergicreactionbya“layperson”.Mostcommonlytheepinephrineadministeredisthepatient’s,andthestaffmemberassiststhepatient.Thisislikelytobeanareaofcontinueddiscussionandevolvinglawsandregulationsintheensuingyears.Frequentlyindividualswillbringtheirownprescriptionmedicationsonatrip,especiallyonaninternationalcourseortrip.Whileyoumaynotbeadministeringthesemedications,havingsomebasicinformationabouttheiruses,doses,sideeffectsandcontraindicationswillbehelpful.Typicallytheadministrationofnon‐prescription,orover‐the‐counter,medicationfallswithintherealmofsimplefirstaid.Havingsomepainmedications,anti‐histamines,anti‐fungalsandantacidsmayhelpmanagesomeone’ssymptomsandallowthemtoremaininthebackcountry.Beforeadministeringanymedicationreadtheprotocols,confirmthedosage,readthelabelandconfirmthemedication,askthepatientaboutprevioushistorywiththismedicationandanyknownallergies,askthepatientiftheyarecurrentlyonanymedicationandifso,reviewtheprotocolsforcontraindications.Theadministrationofover‐thecountermedicationtominorsrequiresparentalapprovalwhichcanbeobtainedthroughpre‐tripauthorizationformsorbycommunicatingwiththeparentsonacasebycasebasis.PleasenotethatthefollowingmedicationinformationisformedicationavailableintheUnitedStates.OutsideoftheUnitesStatesmedicationmaycarrydifferenttradenames.SomemedicationavailableonlybyprescriptionintheUnitedStatesmaybeavailablewithoutaprescriptioninothercountriesandmaybepreparedindifferentdosing.IfyoupurchasemedicationoutsideoftheUnitedStatesyoushouldbeawareofqualitycontrolconcernsinmanufacturingthesemedications,andyoushouldconfirmclassification,dose,indication,contraindicationandpossiblesideeffectsbeforeadministeringit.Alldosingisindicatedforadults.PediatricdosingshouldbedictatedbyourMedicalAdvisor,Dr.Hatfield‐Keller.Abbreviations:

PO:OralSQ:SubcutaneousinjectionIM:Intramuscularinjection

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DrugInformationProvidedOnAnalgesic(Painkillers)‐Over‐The‐Counter Acetaminophen(e.g.Tylenol) Aspirin(e.g.Bayer,Ecotrin) Ibuprofen(e.g.Advil,Motrin) Ketoprofen(e.g.OrudisKT) Naproxen(e.g.Aleve) Phenazopyridinehydrochloride(e.g.Pyridium,Uristat)Analgesics(Painkillers)‐Prescription Hydrocodonebitartrate/acetominophen(e.g.Vicodin) Oxycodone/acetominophen(e.g.Percocet,Roxicet)Anti‐Allergy‐Over‐The‐Counter Phenylephrine(e.g.Neo‐Synephrine) Hydrocortisoneacetate(e.g.Cortaid) Diphenhydraminehydrochloride(e.g.Benadryl) Pseudoephedrinehydrochloride(e.g.Sudafed)Bronchodilator‐Prescription AlbuterolEpinephrine‐Prescription Epinephrine(e.g.AdrenalinorEpiPen)Antibiotic‐Over‐The‐Counter PolymyxinBsulfate/bacitracin(e.g.Polysporin)Antibiotic‐Prescription Erythromycin TrimethoprimSulfamethoxazole(e.g.SeptraorBactrim) Cephalexin(e.g.Keflex) Ciprofloxacinhydrochloride(e.g.Cipro)Anti‐Fungal‐Over‐The‐Counter Tolnaftate(e.g.Tinactin) Miconazolenitrate(e.g.Monistat3)Anti‐Fungal‐Prescription Fluconazole(e.g.Diflucan)Anti‐Emetics(Anti‐Vomiting)andAnti‐Acids‐Over‐The‐Counter Calciumcarbonate(e.g.Tums,Maalox) Bismuthsubsalicylate(e.g.Pepto‐Bismol)Anti‐Emetics(Anti‐Vomiting)andAnti‐Acids‐Prescription Prochlorperazine(e.g.Compazine) Promethazine(e.g.Phenergan)Anti‐Vertigo(Anti‐MotionSickness)‐Over‐The‐Counter Meclizine(e.g.Antivert,Bonine)Anti‐Vertigo(Anti‐MotionSickness)‐Prescription Scopolamine(e.g.Trans‐DermScop)Anti‐Diarrheal‐Over‐The‐Counter Loperamidehydrochloride(e.g.Imodium)Anti‐Diarrheal‐Prescription Diphenoxylatehydrochloridewithatropinesulfate(e.g.Lomotil)

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AltitudeMedications‐Prescription Acetazolamide(e.g.Diamox) Dexamethasone(e.g.Decadron) Nifedipine(e.g.Procardia)

Analgesics(Painkillers)‐Over‐The‐Counter

Acetaminophen(e.g.Tylenol)

Classification:Non‐narcoticanalgesic,antipyretic

Dose:650mg/4‐6hoursPO(Regularstrength),1000mg/6hoursPO(Extrastrength).Maximumdose4g/24hours

PO.

Indications:Forreliefofpainduetoheadache,coldandfludiscomfort,minormuscleandjointdiscomfortand

menstrualcramps.Forreductionoffever.Especiallyusefulforthoseallergictoaspirinoraspirin‐containing

products.Doesnotcontrolinflammation.

Contraindications:Hypersensitivity,activealcoholism,liverdisease,hepatitis.Acetaminophenisacommon

ingredientinover‐the‐counterpain,coldandflumedicine.Becarefulofaccidentaloverdoseincombinationwith

otherproducts.

SideEffects:Hypersensitivityisrare.

Aspirin(e.g.Bayer,Ecotrin)

Classification:Analgesic,Non‐SteroidalAnti‐InflammatoryDrug(NSAID),antipyretic,anticoagulant.

Dose:325‐650mg/4hoursPO(Regularstrength),500‐1000mg/4‐6hoursPO(Extrastrength),162‐325mg/24hours

POforcardiacchestpain.Maximumdose4g/24hoursPO.

Indications:Forreliefofpainduetoheadache,coldandfludiscomfort,minormuscleandjointdiscomfortand

menstrualcramps.Forreductionoffever.Controlsinflammation.Canbeusedto“cauterize”exposedtoothpulp.

Foruse

withcardiacchestpain.

Contraindications:Allergicsensitivity.Gastrointestinalbleeding,bleedingdisorders,impairedliverfunction.Do

notgivetochildrenunder12.

SideEffects:Gastrointestinaldistress,allergicreaction.

Ibuprofen(e.g.Advil,Motrin)

Classification:Analgesic,Non‐SteroidalAnti‐InflammatoryDrug(NSAID),antipyretic.

Dose:400‐800mg/4‐8hoursPO.Maximumdose2400mg/24hoursPO.

Indications:Forsymptomaticreliefofpainassociatedwithheadache,colds,flu,frostbite,toothache,arthritis,

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burnsandmenstrualcramps.Maybeusedtoreducefever.Forpainofinflammationandreductionof

inflammationassociatedwithmuscle,jointandover‐useinjuries.

Contraindications:Activepepticorgastrointestinalulcer,gastrointestinalbleedingdisorder,historyof

hypersensitivitytoaspirinorotherNSAIDs.

SideEffects:Nausea,epigastricpain,dizzinessandrash.

Ketoprofen(e.g.OrudisKT)

Classification:Analgesic,Non‐SteroidalAnti‐InflammatoryDrug(NSAID).

Dose:75mg/8hrsPO

Indications:Forsymptomaticreliefofpainassociatedwithheadache,colds,flu,frostbite,toothache,arthritis,

burnsandmenstrualcramps.Maybeusedtoreducefever.Forpainofinflammationandreductionof

inflammationassociatedwithmuscle,jointandover‐useinjuries.

Contraindications:Activepepticorgastrointestinalulcer,gastrointestinalbleedingdisorder,historyof

hypersensitivitytoaspirinorotherNSAIDs.

SideEffects:Nausea,diarrheaandepigastricpain.

Naproxen(e.g.Aleve)

Classification:Analgesic,Non‐SteroidalAnti‐InflammatoryDrug(NSAID).

Dose:550mg/12hrsPO

Indications:Forsymptomaticreliefofpainassociatedwithheadache,colds,flu,frostbite,toothache,arthritis,

burnsandmenstrualcramps.Maybeusedtoreducefever.Forpainofinflammationandreductionof

inflammationassociatedwithmuscle,jointandover‐useinjuries..

Contraindications:HypersensitivitytoaspirinorotherNSAIDs.

SideEffects:Nausea,constipation,abdominalpain,headache,dizzinessanddrowsiness.

Phenazopyridinehydrochloride(e.g.Pyridium,Uristat)

Classification:Urinarytractanalgesic

Dose:100‐200mg/6‐8hrsPO

Indications:Forsymptomaticreliefofburning,pain,urgencyandfrequencyassociatedwithurinarytract/bladder

infections.Shouldbeusedconcurrentlywithanantibiotic.

Contraindications:Hypersensitivity.Renal/liverinsufficiency.

SideEffects:Headache,gastrointestinaldisturbanceandrash.Dyestainsclothing.

Analgesics(Painkillers)‐Prescription

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Hydrocodonebitartrate/acetominophen(e.g.Vicodin)

Classification:Narcoticanalgesic,antitussive.

Dose:5‐10mg/4‐6hoursPO

Indications:Formoderatetoseverepain.Narcotic.Goodformusculoskeletal

anddentalpain.Goodforpeopleallergictocodeine.Suppressescoughreflex.

Contraindications:Hypersensitivity.

SideEffects:Sedation,decreaseinbloodpressure,sweatingandflushedface,drowsinessanddizziness.

Oxycodone/acetominophen(e.g.Percocet,Roxicet)

Classification:Narcoticanalgesic.

Dose:5‐10mg/4hoursPO

Indications:Forseverepain.

Contraindications:Hypersensitivity.CautionwithCNSdepression,respiratorydepression,seizuresandshock.

SideEffects:Drowsiness,dizziness,hypotension,anorexia,nausea,vomitingandconstipation.

Anti‐Allergy‐Over‐The‐CounterPhenylephrine(e.g.Neo‐Synephrine)

Classification:Nasaldecongestant

Dose:Blownosebeforemedicationisadministered,tiltheadback,apply2‐3dropsor1‐2spraysineachnostril.

Wait5minutesbetweennostrils.

Indications:Forreliefofnasalcongestionthataccompaniescoldsandallergies.Maybeusefultohelpstop

nosebleed.Maybeusefultorelievesinus“squeeze”associatedwithdiving.

Contraindications:Severehypertension,ventriculartachycardia,pancreatitis,hepatitis,thrombosis,heartdisease,

narrowangleglaucoma.

SideEffects:Reboundnasalcongestionduetooveruse(>3days),stinging,burning,dryingofnasalmucosa.

Hydrocortisoneacetate(e.g.Cortaid)

Classification:Glucocorticoid

Dose:Topical1%cream,2‐4times/day

Indications:Forreliefofpainanditchingofnematocyststings,poisonivy,oakandsumac,insectbitesandother

allergicskinreactions.Mayhelpdryupoozingrashofallergicskinreactions.

Contraindications:Seriousinfections,viral,fungalortubercularskinlesions.

SideEffects:Itching,rednessandirritation.

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Diphenhydraminehydrochloride(e.g.Benadryl)

Classification:Antihistamine

Dose:25‐50mgper4‐6hours

Indications:Fortemporaryreliefofrespiratoryallergysymptomsandcoldsymptoms.Helpsrelievetheitchingof

allergicskinreactions.Usefulintreatmentofmoderateallergicandanaphylacticreactions.Maybeusedasamild

sedativeandforinsomnia.Mayhelpalleviateseasickness.Canbeusedtotreatdistonicreations.

Contraindications:Hypersensitivity,acuteasthmaattack,glaucoma,pepticulcer,hypertensionandCOPD.

SideEffects:Drowsiness,dizziness,weakness,hypotension,drymouth,thickeningbronchialsecretionsandurinary

retention.

Pseudoephedrinehydrochloride(e.g.Sudafed)

Classification:Nasaldecongestant

Dose:60mgper4‐6hours

Indications:Decongestantusefulintreatingupperairwaysinusesandnasalpassages.Useofmorethat5daysmay

causereverseeffects.

Contraindications:Severehypertension,coronaryarterydisease,lactatingwomen,MAOinhibitortherapy.

SideEffects:Nervousnessrestlessness,insomnia,tremblingandheadache.

Bronchodilator‐PrescriptionAlbuterol

Classification:Bronchodilator

Dose:Twopuffsofmetereddoseinhaler(MDI)withuseofaspacerevery4hoursandasneeded.

Indications:Shortnessofbreathorrespiratorydifficultythoughttobesecondarytoreactiveairwaydysfunction

(asthma)orHAPE.

Contrainidications:Tachycardiasecondarytounderlyingheartcondition.

SideEffects:Palpitations,tachycardiaandtremor.

Epinephrine‐PrescriptionEpinephrine(e.g.AdrenalinorEpiPen)

Classification:Bronchodilator,antiallergenic,cardiacstimulant.

Dose:.3ml1:1000SQorIM.Repeatasnecessary.

Indications:Forsevereallergicreactionsincludinganaphylaxisandstatusasthmaticus.

Contraindications:Notruecontraindicationswithanaphylaxis.Hypertension,cardiacdisease,glaucomaand

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shock.

SideEffects:Increasedheartrate,nervousness,dizziness,lightheadedness,nauseaandheadache.

Antibiotic‐Over‐The‐CounterPolymyxinBsulfate/bacitracin(e.g.Polysporin)

Classification:Antibiotic

Dose:Topical

Indications:Containsingredientsforpreventionofinfectioninminorwounds.Worksasalubricant,offerssome

relieffromitching.

Contraindications:Hypersensitivity.

SideEffects:Hypersensitivityreactions‐burning,itching,inflammation,contactdermatitis.

Antibiotic‐PrescriptionErythromycin

Classification:Antibiotic

Dose:250mg/6hrsfor5days.Takewithfood.

Indications:Forsinus,pulmonary,ear,eye,respiratoryandsofttissueinfections.

Contraindications:Hypersensitivity,liverdisease,hepatitis.

SideEffects:Abdominaldiscomfortandcramping,nausea,vomiting,diarrheaandrash.

TrimethoprimSulfamethoxazole(e.g.SeptraorBactrim)

Classification:Antibiotic

Dose:Singlestrengthtabletcontains80mgtrimethoprimand400mgsulfamethoxazole.Doublestrengthtablet

contains160mgtrimethoprimand800mgsulfamethoxazole.Doseis2singlestrengthtabletsor1doublestrength

tablet/12hoursPO.Recommendedlength,5daysforUTIandinfectiousdiarrhea,10‐14daysforkidneyinfection.

Indications:Formarinewounds,kidney,ear,sinusandsomerespiratoryinfections.Bestforurinarytract

infections.Workswithinfectiousdiarrheaifciprofloxacinunavailable.

Contraindications:Hypersensitivity,anemia.

SideEffects:Nausea,vomiting,diarrhea,decreasedappetite,stomachcramps,headache.

Cephalexin(e.g.Keflex)

Classification:Antibiotic

Dose:250‐500mgper6hoursforatleast5days.

Indications:Forskin,bone,pnuemoniaandurinarytractinfections.

Contraindications:Hypersensitivity.Sensitivitytopenicillins.

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SideEffects:Oralandvaginalfungalinfections,diarrheaandabdominalcramping.

Ciprofloxacinhydrochloride(e.g.Cipro)

Classification:Antibiotic

Dose:250mg/12hoursPOforUTI.500mg/12hoursPOforkidneyinfection,infectiousdiarrhea,boneandjoint

infection.SeePhysicianforlengthofcourse.

Indications:Bestforinfectiousdiarrhea.Okayforboneandurinary

tractinfections.

Contraindications:Hypersensitivity.

SideEffects:Nausea,diarrhea,vomitingandconstipation.

Anti‐Fungal‐Over‐The‐Counter

Tolnaftate(e.g.Tinactin)

Classification:Antifungal

Dose:Topical,2applications/day

Indications:Fortreatmentofsuperficialskinfungisuchasringworm,jockitchandathlete’sfoot.

Contraindications:Hypersensitivity.

SideEffects:Mildirritation.

Miconazolenitrate(e.g.Monistat3)

Classification:Antifungal

Dose:200mgvaginalsuppositoriesnightlyforthreenightsortopicalcreamasneeded.

Indications:Vaginalcandidiasis.

Contraindications:Hypersensitivity,firsttrimesterofpregnancy.

SideEffects:Itching,burningandstinging.

Anti‐Fungal‐PrescriptionFluconazole(e.g.Diflucan)

Classification:Antifungal

Dose:150mgonce.

Indications:Vaginalcandidiasis.

Contraindications:Hypersensitivity.

SideEffects:Fever,chills,dizziness,drowsiness,headache,constipation,diarrhea,nausea,vomiting,abdominal

pain.

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Anti‐Emetics(Anti‐Vomiting)

andAnti‐Acids‐Over‐The‐CounterCalciumcarbonate(e.g.Tums,Maalox)

Classification:Antacid

Dose:500mgtabletasneeded

Indications:Forsymptomaticreliefofheartburn,acidindigestion,sourstomachandotherconditionsrelatedtoan

upsetstomach,includingintestinalgasproblems.

Contraindications:Hypersensitivity.

SideEffects:Swellingoflegsandfeet,fecalimpaction,metabolicalkalosis.

Bismuthsubsalicylate(e.g.Pepto‐Bismol)

Classification:Antidiarrheal,antinauseant.

Dose:

Indications:Foruseinthecontrolofdiarrhea,nauseaandupset

stomach.Mayhelpprevent“traveler’sdiarrhea.”

Contraindications:Bleedingulcers,hemophilia,kidneyimpairment.Shouldnotbetakenbytheaspirinallergic.

SideEffects:Mayturntongueandstoolblack.

Anti‐Emetics(Anti‐Vomiting)andAnti‐Acids‐PrescriptionProchlorperazine(e.g.Compazine)

Classification:Antiemetic

Dose:5‐10mg/6‐8hoursPOor10mg/12hoursPO(Extendedrelease)or25mg/12hoursrectalsuppository.

Indications:Nauseaandvomiting.

Contraindications:Hypersensitivity.Glaucoma,bonemarrowsuppression,liverorcardiacimpairment,blood

pressureproblems,CNSdepression.

SideEffects:Musclespasmsoftheneckareacommonsideeffect,butaretreatablewithdiphenhydramine.

Promethazine(e.g.Phenergan)

Classification:Antihistamine,antiemetic.

Dose:12.5‐25mg/4‐6hoursrectalsuppository

Indications:Nauseaandvomiting,motionsickness.

Contraindications:Glaucoma,CNSdepression,intestinalorurinarytractobstruction.

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SideEffects:Drowsiness,disorientation,hypotensionandsyncope.Musclespasmsoftheneckareacommonside

effect,butaretreatablewithdiphenhydramine.

Anti‐Vertigo(Anti‐MotionSickness)‐Over‐The‐CounterMeclizine(e.g.Antivert,Bonine)

Classification:Antiemetic,antivertigo

Dose:25‐50mgPOperday,Ihourbeforeexposuretomotion.

Indications:Preventionandtreatmentofmotionsickness,vertigo.

Contraindications:Hypersensitivity.

SideEffects:Drowsiness.

Anti‐Vertigo(Anti‐MotionSickness)‐Prescription

Scopolamine(e.g.Trans‐DermScop)

Classification:Antinausea,antiemetic

Dose:1.5mgtransdermalpatch.Keepoutofeyes.Putonepatchbehindear4‐5hoursbeforeneeded.Remove

after72hours.

Indications:Preventionofmotionsickness.

Contraindications:Glaucoma,urinaryorintestinalobstruction,tachycardia.

SideEffects:Drymouth,drowsiness,blurredvision,hallucinations,confusion.

Anti‐Diarrheal‐Over‐The‐CounterLoperamidehydrochloride(e.g.Imodium)

Classification:Antidiarrheal

Dose:4mgPOinitiallyfollowedby2mgPOaftereachloosestool

Indications:Foruseinthecontrolofdiarrhea.Thoughttolimitperistalsis.Helpfulinevacuatingsomeonewith

severediarrhea.

Contraindications:Hypersensitivity.Diarrheasecondarytocertainbacteria(e.g.,E.Coli)

SideEffects:Drymouth,dizziness,abdominaldiscomfort.

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Anti‐Diarrheal‐PrescriptionDiphenoxylatehydrochloridewithatropinesulfate(e.g.Lomotil)

Classification:Antidiarrheal

Dose:5mg/6hoursPO

Indications:Forseverediarrhea.Evacuateafter24hourswithnoimprovement.

Contraindications:Liverdisease,dehydration,glaucoma.

SideEffects:Drowsiness,lightheadedness,dizziness,nausea.

AltitudeMedications‐PrescriptionAcetazolamide(e.g.Diamox)

Classification:Diuretic.

Dose:250mg/6to12hoursPO(preventiondose=125mg/12hoursPO)

Indications:Forpreventionandtreatmentofmildtomoderateacutemountainsickness.

Contraindications:Sulfa‐allergies,pregnancy,dehydrationorrenaldisease.

SideEffects:Dehydration,tiredness,alteredtaste,nausea,numbnessinextremitiesandlips.

Dexamethasone(e.g.Decadron)

Classification:Corticosteroid.

Dose:8mgPOor10mgIMinitiallythen4mg/6hoursPOorIMduringevacuation.

Indications:FortreatmentofHighAltitudeCerebralEdemaandincreasingICPfromheadtrauma.

Contraindications:Noabsolutecontraindicationsforshort‐termemergencyuseexcepthypersensitivity.

SideEffects:Cough,drymouth,throatirritation,blurredvision,indigestion,personalityandbehavioralchanges,

muscleweakness.

Nifedipine(e.g.Procardia)

Classification:Antihypertensive

Dose:10mg/8hoursPOor30‐60mg/24hoursPO(Extendedrelease).

Indications:HighAltitudePulmonaryEdema(HAPE).

Contraindications:Hypersensitivity.Hypotension.

SideEffects:Peripheraledema,headacheflushedskin,dizziness.

References:Mosby’s2005DrugConsultforNurses.ElsevierMosby,St.Louis,MO.2005.ISBN0‐323‐02847‐0.OgdenMD,HerbandTodSchimelpfenig.EditedbyDrewLeemon.NOLSFieldMedicalProtocolsandDrugOrders2004.Unpublisheddocument.

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Considerationsfora

WildernessMedicalKit

GeneralCommentsThereisnomagicrecipeforcreatingtheultimatefirstaidkit.Thereisnoonesizefitsallwhenitcomestofirstaidkits.Yourkitshouldvarydependingongroupsize,activity,seasonandpopulation.Therearehoweversomebasiccontentsthathaveuniversalapplicability.Dopayattentiontoexpirationdatesanddamagetocontents,ensurethatkitsarecleanedandrepackedaftereachuseandmakenoteofsuppliesyouconstantlyrunoutof.Thoughthebeautyofwildernessmedicineistheabilitytoimprovise,agoodfirstaidkitgoesalongwaytoo!Considercarryingthefollowingsupplies:Equipment

Traumashears Tweezers Safetypins Scalpel Thermometer BPcuffandstethoscope Rescuemask(withaonewayvalve) Emergencyblanket Patientassessmentforms Epi‐Pen

InjuryManagement

Gloves(multiplesizes) 12ccirrigationsyringe(withneedle

nosetip) Providone‐iodinesolution Antiseptictowelettes Sterilescrubbrush Greensoapsponges Woundclosurestrips Tinctureofbenzoinswabs 2ndSkin®dressings Moleskindressings Antibioticointmentpackets 1x3fabricbandages Knuckleandfingertipfabric

bandages 4x4sterilegauzepads 3x4non‐stickgauzepads 3‐inchconformingrollgauze. 3‐inchx5‐yardsCoban®wrap Transparentfilmdressings 1‐inchclothtape WireorSAM®splint Triangularbandages Traumadressing

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VerbalSOAPReportScript

“Mynameis andmylocationis .”Subjective“Wehavea yearoldmale/femalepatientwhosechiefcomplaintis…(SymptomwithOPQRSTdescription(Onset,Provoke/Palliate,Quality,Radiate/Region/Refer,Severity,TimeofOnset)”.“Thepatientstates”,or“witnessesstate”…(MechanismofInjuryorHistoryofPresentIllness).Objective(Head‐to‐Toe)“Thepatientwasfound…(Describeposition/location)”.“Thepatientexamrevealed…”(Describewhatyoufound,includepertinentnegativese.g.“Thepatient(does/doesnot)reportlossofresponsiveness,spinepainortendernessand(has/doesnothave)normalCSM.)”.“Nootherinjuriesfound.”Objective(Vitalsigns)“At_______AM/PMthepatient’svitalsignswere:”LOR(AVPU)HR(rate,rhythm,quality)RR(rate,rhythm,quality)

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SCTM(color,temperature,moisture)BP(Systolic/Diastolic)Pupils(PERRL)TºObjective(PatientHistory)

“Thepatientreportedthefollowinghistory.”Symptoms:“Inadditiontothechiefcomplaintpatienthas….”Allergies:“Patientisallergicto….”Medications:“Patientistaking….”Pertinentmedicalhistory:“Patienthasahistoryof….”Lastintake/output:(Describerecenturine/boweloutput,waterandfoodintake.)Events:(Describepertinentrecenteventsoreventsthatmayhavecausedtheproblem.)Assessment“BasedonthisMechanismofInjurythereis/isnotapossiblespineinjury.”“Possibleproblemsinclude….”Plan“Basedonafocusedspineassessmentwehavedecidedtocontinue/discontinuespineimmobilization.”“Wewillimmobilize/treatthe by…(Describetreatmentforallpossibleproblems).”“Ourevacuationplanis....”“Werequestthefollowingsupplies/support…”Anticipatedproblems“Wewillmonitorfor…(Listanticipatedproblemsandresponses).“

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SectionIV

Forms

72

Acknowledgement of Risk Form

ForusewithReedCollegeoutdoorprogrammingthatusesUnitedStatesForestServiceandtheNationalParksServicelandsandrivers.

MuchofthelanguageusedhereinwasadoptedfromtheNationalOutdoorLeadershipSchoolandotherorganizations’acknowledgementofriskforms.

Name:______________________________________ Date:___________________

Activity:________________________________________________________________

InconsiderationofTheReedInstitute,itsagents,employees,trustees,officers,contractorsandallotherpersonsorentitiesassociatedwithit(hereafterreferredtoas“ReedCollege”),Iagreeasfollows:

AlthoughReedCollegehastakenreasonablestepstoprovidemewithskilledstaffandappropriateequipmentfortheactivitythatIamabouttoundertake,Iacknowledgethatthisactivityhasrisk,includinginherentrisksthatcannotbeeliminatedwithoutdrasticallyalteringthecharacterofthisactivity.Thesameelementsthathelpcreatetheuniquecharacterofthisactivitymayalsobethesameelementthatcauseslossordamagetomyequipment,accidentalinjury,illness,orinextremecases,permanenttrauma,disabilityordeath.IunderstandthatReedCollegedoesnotwanttoreducemyenthusiasmfortheactivity,butthinksthatitisimportantformetobeinformedinadvancedabouttheactivities’inherentrisks.Thefollowdescribesmany,butnotall,ofthoserisks.

ReedCollege’soutdoorclassesandrecreationalactivitiesgenerallytakeplaceintheoutdoorenvironmentwhereparticipantsaresubjecttonumerousrisks,bothenvironmentalandotherwise.Activitiesmayvarydependingonthecourseoradvertisedevent,butoftenincludehiking,backpacking,mountaineering,rockandiceclimbing,rappelling,whitewaterraftingandkayaking,seakayaking,canoeing,bicycling,skiing,scubadivingorcaving.Otheractivitiesmaybeundertakendependingupontheintentoftheclassorouting.

Theseactivitiesmayoccurinremoteplacesasignificanttimeanddistanceawayfrommedicalfacilitiesordefinitivecare;thedifficultyofcommunicationandtransportationmaysignificantlydelayevacuationandtransporttoamedicalfacility.

Mealsareusuallypreparedoversmallportablestoves,althoughsometimesgroupsalsocookoveropenfires.ReedCollege’sstandardwatertreatmentprocessuseseitherboilingorhalides,specificallyacommercialformofiodinethatkillsmostvirusesandparasites,butmaynotkillcryptosporidium.Risksgenerallyassociatedwithcampingincludecuts,burns,blisters,diarrhea,flu‐likesymptoms,andfallingtimberorrock.

Travelisbyvehicle,onfoot,raft,kayaks,canoe,sailboat,horseback,skis,snowshoes,andbyothermeans.Thistravelmaybeoverroughunpredictableoff‐trailterrain,boulderfields,downedtrees,rivers,whitewaterrapids,steepslopes,slipperyrocks,snowandice,glaciatedterrain,oceantidesandcurrents,wavesandreefs.Associatedrisksincludecollision,slipping,falling,beinghitbyobjects,strikingobjects,capsizing,anddrowning,inadditiontoenvironmentalrisks.

Environmentalrisksandhazardsincluderapidlymoving,deeporcoldwater;insects,snakesandpredators;falling,rollingorshiftingrock;lightning,avalanches,flashfloods,rapidlychangingweather,andotherunpredictableforcesofnature.Possibleinjuriesmayincludedehydration,sunburn,heatexhaustionandheatstroke,frostbite,hypothermia,highaltitudeillnesses,andothermildorseriousconditions.

Decisionsaremadebytheinstructorsandstudents,oftenwhileimmersedinthewildernesscontext.Thesedecisionsaredependentuponavarietyofperceptionsandevaluationsthatbytheirnatureareimpreciseand

73

subjecttoerrorinjudgement.Studentsmayexperienceunsupervisedtimeduringperiodswheretheinstructorisnotneededfortheirtechnicalexpertise.Atallpointsintimethestudentsareresponsiblefortheirownsafety,andshouldalsotakeownershipforthesafetyofotherstudentsontheexperience.

IamawarethattheproposedReedCollegeactivityincludestheriskofinjuryordeathtomyself.Irecognizethatthedescriptionofrisksgivenaboveisnotcomplete,andthatotherunknownorunanticipatedrisksmayresultinpropertyloss,injury,ordeath.Iagreetoassumetheresponsibilityfortheinherentrisksinthisactivity,boththoseidentifiedinthisdocumentaswellasthosenotidentified.Myparticipationinthisactivityisvoluntary,thatnooneisforcingmetoparticipate,andthatIamparticipatingwithfullknowledgeoftheinherentrisks.IamawarethatthereareotherclassesoractivitiesthatIcouldtakeordoinstead.

IdeclarethatIamgoodenoughphysicalfitnesstoparticipateintheactivityoutlinedabove.IfIhavemedicalconcernsrelatedtotheactivity,IhaveverifiedwithmyphysicianthatIamphysicallyandpsychologicallyabletoparticipateintheexperience.Allinformationonthemedicalformistrueandcompletetothebestofmyknowledge.IauthorizeReedCollegetoobtainorprovideemergencyhospitalization,surgical,ormedicalcareforme.

IrepresentthatIamfullycapableofparticipatinginthisactivitywithoutcausingharmtomyselforothers.Therefore,I,andmyparent(s)orguardian,ifIamaMinor,assumeandacceptfullresponsibilityformeandforinjury,death,andlossofpersonalpropertyandexpensessufferedbymeandthemasaresultofthosedangersandrisksidentifiedherein,andthoseinherentrisksanddangersnotspecificallyidentified,andasaresultofmynegligenceinparticipatinginthisactivity.

I,andmyparent(s)orguardian,ifIamaminor,haveread,understood,andacceptedthetermsandconditionstatedhereinandacknowledgethatthisagreementshallbeeffectiveandbindinguponmyself,myheirs,assigns,personalrepresentativeofestate,andallofmyfamilymembers.

PrintedName

Signature Date

Ifthestudentisunder18,Iamsigningthisasparentorguardiantoreflectmyagreementtoindemnify(thatis,protectbypaymentorreimbursement)Reedfromanyclaimwhichmaybebroughtbyoronbehalfofthestudent,oranymemberofthestudent’sfamily,forinjuryorlossresultingfromthoseinherentrisksoftheactivity,describedandnotdescribedabove,andfromthenegligenceofthestudent.

PrintedName

Signature Date

InAddition:

Waiver and Release

AlargepercentageoftheUnitedStatesForestService,theNationalParksService,andotherfederallandmanagementagenciesdonotallowserviceproviderssuchasReedCollegetobereleasedbytheirstudentsfromliabilityforinjuryorotherlossesoccurringoncertainpubliclands.InthoseareasReedCollegeislimitedtotheattachedAcknowledgementofRiskform.Youractivitymayincludetravelandactivitiesthatisnotonthesepubliclands;ReedCollegeseeksadditionalprotectionforthistravelandactivities.

Pleasereadthefollowingcarefullyandsignbelow:

IhavereadandunderstandtheattachedAcknowledgementofRiskagreement,andconfirmitsrepresentationsandagreetoallitsprovisionsasthoughtheywerefullysetforthinthisdocumentagain.

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Exceptwithrespecttoaninjurythatoccursonpubliclandswhoserulesandregulationsprohibitmydoingso,Iacknowledgeandassumeallrisksofthecourseoractivity,knownorunknown,inherentorotherwise.InadditionIagree,formyself,myheirsandmypersonalrepresentatives,todefend,holdharmless,indemnify,releaseandforeverdischargeReedCollege,anditscurrentandformertrustees,officers,employees,agents,insurers,successorsandassigns(hereinaftercollectivelyknownas“representatives),fromandagainstanyandallclaims,demands,actionsorcausesofactions,whetherknoworunknown,relatingtoorarisingoutoforinconjunctionwithanydamage,deathorotherconsequencestorealorpersonalproperty,anyaccident,illness,personalinjury,deathorotherconsequencesthatmayresultinmyparticipationintheactivities,orparticipationofanyotherparticipant,whethersuchactionisauthorizedasapartoftheactivitiesorwhethersuchdamageorotherconsequenceiscausedbythefaultornegligenceofReedCollegeoritstrustees,officers,employees,oragents.

Clearthinkingisnecessaryforthisactivity,thereforeIagreetoabstainfromtheuseofalcoholornon‐prescriptiondrugsbeforeandforthedurationoftheactivity.AdditionallyIaffirmthatIhavenochroniccondition,disability,orotherhealthconcernsthatwouldmakemyparticipationintheseactivitiesinadvisable.

IagreetosubmitanydisagreementunderthisWaiverandReleasefirsttoconfidentialmediation.Ifconfidentialmediationdoesnotresolvetheissue,Iagreetosubmitthedisagreementtobindingarbitration.ThisarbitrationshalltakeplaceinPortland,OregonandshallbeconductedaccordingtotherulesoftheAmericanArbitrationAssociation.Theprevailingpartyinanyarbitrationshallbeentitledtorecoveritsattorneys’andexpertfeesandothercosts,disbursementsandexpensesincurredbeforeandduringarbitration,asthearbitratormayadjudgereasonable.Further,IagreethatthisreleaseshallbegovernedbyandconstruedaccordingtothestateofOregon.

IunderstandthatthisreleaseisvoluntaryinthatthereareotherclassesoractivitiesthatIcouldchoosetoundertake.Ihavereadthisreleaseandunderstanditfully.IunderstandthatsigningthisreleaseisaconditionofmyparticipationintheactivitiesandthatthisWaiverandReleaseislegallybindingonme.And,Iunderstandthat,amongotherthings,IamagreeingtoindemnifyReedCollegeanditsrepresentativesforinjuries,damagesorlossesthattheymaycauseandgivingupcertainrightstosueReedCollegeanditsrepresentativesforinjuries,damages,orlossesthatImayincur.

IASSUMEALLRISKSASSOCIATEDWITHTHEACTIVITIES,WHETHERORNOTSPECIFIEDINTHISWAIVERANDRELEASE,ANDUNDERSTANDTHATREEDCOLLEGEISNOTAGUARANTOROFMYSAFETYINCONNECTIONWITHMYPERFORMANCEOFTHEACTIVITIES.

Inwitnessthereof,Ihavecausedthisreleasetobeexecutedthis__________dayof__________________,20___.

PrintedName

Signature Date

Theparentorguardianmustsignbelowifthestudentisunder18yearsofage.InconsiderationofReedCollege’sallowingthestudenttoparticipateintheactivity,theundersignedparent(s)orguardianagreetoreleaseReedCollegefromanyclaimtheparent(s)orguardianmayhavebecauseofinjuryorlosssufferedbythestudent,includinginjuryorlossclaimedtobecausedbythenegligenceofReedCollege.Inaddition,theparent(s)orguardianagreetoprotectandindemnifyReedCollegefromanyclaimandrelatedexpensesorfees,broughtatanytimebythestudentorbyanyoneonthestudent’sbehalf,orbyanymemberofthestudent’sfamily,orbyanothercourseparticipant,arisingoutofthestudent’senrollmentorparticipationintheactivity.Theundersignedalsoagreetothetermsofmediationandarbitrationoutlinedabove.ThisindemnityincludesclaimsofReedCollege’snegligence.

PrintedNameofParent(s)orGuardian

Signature Date

Signature

75

Health and Diet Questionnaire ReedOutdoorProgramandEducation(R.O.P.E.)

Thisinformationisforthetripleaders’informationonlyandiscompletelyconfidential

Name:_________________________________Trip:_____________________________________

Phone(school):_________________

EmergencyContact:_______________________________________Relationship:________________EmergencyContactPhone:(___)_________________

R.O.P.ETripInformation

ReedOutdoorProgramandEducationTripscanbemulti‐daywildernessexpeditionsinremotesettings,whereevacuationtomodernhospitalfacilitiesisnotimmediatelypossible.Youmustexpectextremeweatherconditionsrangingfromsnowstormstosleettoextremeheatandhumidity.Suddenenvironmentalchangesaretobeexpectedandanticipated.DependingonwhatactivityyoupursueinyourR.O.P.ETrip,youmayberequiredtocarryaheavyloadupuneven,steepterrain;paddleforextendedperiods;sleepoutdoors;experiencelong,toughdays;andpreparemealsandsetupcamp.Besurethatyouareabletoberesponsibleforyourself.

Participant:PleasecircleYESorNOforeachquestion.Eachmustbeanswered,butkeepinmindthata“YES”answerdoesnotnecessarilymeanyouwillnotbeabletoattendyourR.O.P.E.Trip.

GeneralMedicalHistory

Doyoucurrentlyorhaveyoueverhad:

1.Respiratoryproblems?Asthma? 1.YESNO

2.Gastrointestinaldisturbances? 2.YESNO

3.Diabetes? 3.YESNO

4.Hypertension? 4.YESNO

5.Bleedingorblooddisorders? 5.YESNO

6.Hepatitisorotherliverdiseases? 6.YESNO

7.Neurologicalproblems?Epilepsy? 7.YESNO

8.Seizures? 8.YESNO

9.Dizzinessorfaintingepisodes? 9.YESNO

10.Treatmentormedicationformenstrualcramps? 10.YESNO

11.Disordersoftheurinaryorreproductivetract? 11.YESNO

12.Anyotherhealthcomplaint?__________________ 12.YESNO

13.DoyouseeaMedical/Physicalspecialistofanykind? 13.YESNO

14.Areyoupregnant? 14YESNO

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15.Treatmentorcounselingwithamentalhealthprofessional? 15.YESNO

16.Cardiacproblems? 16.YESNO

Diet

17.Areyouavegetarian? 17.YESNO

Ifyes,howstrictareyou?(willyoueatfishorchicken?Areyouvegan?)_________________________________________________________________________________

_________________________________________________________________________________

18.Ifyouarevegetarianorvegan,pleaselistsomeofthemealsthatyouparticularlyenjoy:__________

_________________________________________________________________________________

19.Pleaselistanyfoodsthatyouparticularlydespise:________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Muscle/SkeletalInjuries

Doyoucurrentlyorhaveyoueverhad:

20.Knee,hip,ankle,shoulder,arm,orbackinjuries(includingsprains)and/oroperations?

Ifso,pleaseexplain:_______________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Allergies/Medications

21.Anyallergies?Toinsectbitesorbeestings? 21.YESNO

Ifyes,pleaselistthem,alongwiththeirseverity:_________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

22.Areyouallergictoanymedications?____________________________ 22.YESNO

23.Areyoucurrentlytakinganymedications? 23.YESNO

Medication Dosage SideEffects/Restrictions

______________________________________________________________________________________________________

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______________________________________________________________________________________________________

______________________________________________________________________________________________________

24.Yearoflasttetanusimmunization:______.Ifyoucannotremember,wasit

withinthepastfiveyears? 24.YESNO

TheReedOutdoorProgramandEducationrecommendacurrenttetanusimmunization

25.DoyouhaveahistoryoffrostbiteorAcuteMountainSickness? 25.YESNO

26.Doyouhaveahistoryofheatstrokeorotherheatrelatedillness? 26.YESNO

Fitness

27.Doyouexerciseregularly? 27.YESNO

Activity Frequency Duration/Distance IntensityLevel

(Easy/moderate/competitive)

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

28.Doyousmoke?Ifso,howmuch?_____________________________ 28.YESNO

29.Swimmingability(CHECKONE):___Non‐swimmer ___Recreational___Competitive

PLEASEREADCAREFULLYANDSIGN

Theinformationprovidedaboveisacompleteandaccuratestatementofanyphysicalandpsychologicalconditionswhichmayaffectmyparticipationinthistrip.Irealizethatfailuretodisclosesuchinformationcouldresultinseriousharmtomeandfellowparticipants.IagreetoinformtheReedOutdoorProgramandEducation(R.O.P.E.)shouldtherebeanychangeinmyhealthstatuspriortothestartofthetrip.Onthebasisofthebackgroundinformationatthebeginningofthisform,andwhatIknoworsuspectaboutmyphysicalandpsychologicalhealth,IamfullycapableofparticipatinginthisR.O.P.ETrip.

IunderstandthatifIhavethepotentialforasevereallergicreactiontobeestings,insectbites,food,poisonoak,orothersubstancesthatmightbefoundintheoutdoor,itismyresponsibilitytobringthepropermedicationwithmeonthistrip.

Participant’sSignature:______________________________________Date:___________________

78

Outdoor Call Guide Reed Outdoor Programs

#1 Stabilize the Situation

Victim:

4. Has been given immediate medical care. 5. Is safe, warm, hydrated and has fuel (food) and on board. 6. Is being reassured and has on-going medical supervision. The group:

• Is safe, warm, hydrated, and has fuel on board. • Has assurance, direction, and supervision. • Is able to help out when possible • #2 Develop a plan, write it down!

Include:

• Document your SOAP note well. • Brief description of incident with pertinent facts. • General condition of group members and of the staff working with the emergency. • Exact location of the group. • Recommendation for treatment and evacuation; note the type of terrain to be covered, the type of support

needed, and helicopter landing sites if applicable. • Relevant qualifications of the staff (WFR, EMT, etc.) • Generate a plan for how assistance or the runner themselves will reconnect with the group. If a person is lost:

9. Time and place at which loss of contact started 10. The area and type of search already completed by the group. 11. Physical condition of the lost individual and supplies that they are believed to be carrying.

#3 Call using a cell phone or send runners for help.

5. The Specialist/WFR should remain with the group when possible. 6. A second Specialist may choose to go out alone, or send students out in a pair or trio. 7. The runners or people making the call need to have a written copy of answers to the above questions, as well as

knowledge about who to call. 8. The runners need to have a plan for joining back up with the group.

Emergency Numbers

Call 911 first if you have a life-threatening emergency! Then contact Will/Reed as soon as is practical. Will and Reed College always need to be apprised of situations where injury results in need for external help, or if an incident generates public concern.

If the emergency is not a threat to life or limb, place calls in the following order:

• Will Symms’s work number (503) 777-7232 • Will Symms’s home phone (503) 998-0812

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• Reed College, Emergency only (503) 777-7533 • Reed College, Non-emergency (503) 771-1112

If you have an emergency and you can’t reach Will immediately, inform Community Safety of your situation and ask that they continue to try to communicate with Will.

Otherpotentiallyusefulnumbersandaddresses:

HoodRiver,OR

HoodRiverSheriff ProvidenceHoodRiverMemorialHospital309StateStreet 13thandMayStreetsHoodRiver,OR97031 HoodRiver,OR97031541‐386‐2098 541‐386‐3911

GovernmentCamp,OR

ClackamasCountySheriff’sDepartment LegacyClinicMountHood WillametteFallsHospital

2223SouthKeanRoad 24988SEStarkSt 1500DivisionStreetOregonCity,OR97045 Gresham,OR97030‐8324 OregonCity,OR97045503‐655‐8218 (503)674‐1580 503‐656‐1631

Estacada,OR

ClackamasCountySheriff’sDepartment WillametteFallsHospital EstacadaMedicalClinic2223SouthKeanRoad 1500DivisionStreet 103SWHighway224OregonCity,OR97045 OregonCity,OR97045 Estacada,OR503‐655‐8218 503‐656‐1631

McKenzieBridge,OR

LaneCountySheriff’sOffice McKenzieWillametteHospital125East8thStreet 1460GStreetEugene,OR97401 Springfield,OR97477541‐682‐4150 541‐726‐4444

Bend,OR

DeschutesCounty911 St.CharlesMedicalCenter63333Highway20#91 12500NeffRoadBend,OR97701 Bend,OR97701541‐388‐6655 541‐382‐4321

Maupin,OR

WascoCountySheriff’sOffice Mid‐CoumbiaMedicalCenter511WashingtonStreet 1700East19thStreetTheDalles,OR97058 TheDalles,OR97058541‐296‐5454 541‐296‐1111

Carson/TroutLake/WhiteSalmon,WA

SkamaniaCountySheriff’sOffice SkylineHospital KlickitatCountySheriff200VancouverAve. 211SkylineDrive 205S.ColumbusAve.Room108Stevenson,WA98648 WhiteSalmon,WA98672 Goldendale,WA98620509.427.5047 509‐493‐1101 509‐773‐4545

MillCity,OR

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LinnCountySheriff’sOffice AlbanyGeneralHospital1115SEJacksonStreet 10466thAvenueS.W.Albany,OR97321 Albany,OR97321541‐967‐3901 541‐812‐4000

Astoria/Seaside,OR

ClatsopCountySheriff’sOffice ColumbiaMemorialHospital ProvidenceSeasideHospital3557thStreet 2111ExchangeStreet 725SouthWahannaRoad

Astoria,OR97103 Astoria,OR97103 Seaside,OR97138503‐325‐8653 503‐325‐4321 503‐717‐7000

CraterLake,OR

KlamathCountySheriff’sOffice MerleWestMedicalCenter3300VandenbergRoad 2865DaggettAvenueKlamathFalls,OR97603 KlamathFalls,OR97601541‐883‐5130 541‐882‐631

Clatskanie,OR

ColumbiaCountySheriff’sOffice GoodSamaritanHospital&MedicalCenter901PortAve. 1015N.W.22ndAvenueSt.Helens,OR Portland,OR97210503‐366‐4611 503‐413‐7711

Madras,OR

JeffersonCountySheriff’sOffice MountainViewHospital ValleyCommunityHospital675NWCherryLane 470N.E.AStreet 550ClayStreetMadras,OR97734 Madras,OR97741 Dallas,OR97338541‐475‐2201 541‐475‐3882 503‐623‐8301

LongBeach,WA

PacificCountySheriff’sOffice OceanBeachHospital3182ndStreetN.E. 1741stAveN.LongBeach,WA98631 Ilwaco,WA98624360‐642‐9403 360‐642‐3181