IntroductionThe purpose of this study was to investigate the psychometric properties of the remote first aid self-efficacy scale (RFA SES). The RFA SES is a 30-item self-report scale developed in response to emerging evidence showing that self-efficacy is predictive of performance. MethodsTrained alumni from Wilderness Medical Associates (WMA) training courses and less trained students from Laurentian University (LU) were recruited via email to complete an online questionnaire at 2 different periods (T1 and T2). The questionnaire included demographic questions, the 30-item RFA SES, the 10-item Connor-Davidson resilience scale (CD-RISC), and the 10-item generalized self-efficacy scale (GSES). Data analysis included assessment of the dimensionality, reliability, and validity of the scale. ResultsThere were 448 alumni from WMA and 1106 students from LU who participated in the study. The RFA SES demonstrated a clear unidimensional structure. The mean interitem correlation was 0.75 at T1. Test-retest reliability (T1 to T2) was high for both the LU group (intraclass correlation [ICC]=0.90) and the WMA group (ICC=0.92). Moderate correlations were found between RFA SES and CD-RISC (r=0.42, P<0.001), a general measure of resilience, and the GSES (r=0.48, P<0.001), a general measure of self-efficacy. Wilderness Medical Associates participants showed higher mean scores than LU students at T1 (t [569]=16.2, P<0.001). ConclusionsThe RFA SES is a unidimensional, reliable, and potentially valid scale. Further research should focus on item reduction followed by additional tests of reliability and validity.

The Wilderness Medical Society convened a panel to review the literature and develop evidence-based clinical practice guidelines on the treatment of anaphylaxis, with an emphasis on a field-based perspective. The review also included literature regarding the definition, epidemiology, clinical manifestations, and prevention of anaphylaxis. The increasing prevalence of food allergies in the United States raises concern for a corresponding rise in the incidence of anaphylaxis. Intramuscular epinephrine is the primary treatment for anaphylaxis and should be administered before adjunctive treatments such as antihistamines, corticosteroids, and inhaled β agonists. For outdoor schools and organizations, selecting a method to administer epinephrine in the field is based on considerations of cost, safety, and first responder training, as well as federal guidelines and state-specific laws.

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Objective To assess the individual and community health effects of task shifting for emergency care in low-resource settings and underserved populations worldwide. Methods We systematically searched 13 databases and additional grey literature for studies published between 1984 and 2019. Eligible studies involved emergency care training for laypeople in underserved or low-resource populations, and any quantitative assessment of effects on the health of individuals or communities. We conducted duplicate assessments of study eligibility, data abstraction and quality. We synthesized findings in narrative and tabular format. Findings Of 19 308 papers retrieved, 34 studies met the inclusion criteria from low- and middle-income countries (21 studies) and underserved populations in high-income countries (13 studies). Targeted emergency conditions included trauma, burns, cardiac arrest, opioid poisoning, malaria, paediatric communicable diseases and malnutrition. Trainees included the general public, non-health- care professionals, volunteers and close contacts of at-risk populations, all trained through in-class, peer and multimodal education and public awareness campaigns. Important clinical and policy outcomes included improvements in community capacity to manage emergencies (14 studies), patient outcomes (13 studies) and community health (seven studies). While substantial effects were observed for programmes to address paediatric malaria, trauma and opioid poisoning, most studies reported modest effect sizes and two reported null results. Most studies were of weak (24 studies) or moderate quality (nine studies). Conclusion First aid education and task shifting to laypeople for emergency care may reduce patient morbidity and mortality and build community capacity to manage health emergencies for a variety of emergency conditions in underserved and low-resource settings.

INTRODUCTION:A disparity exists between the skills needed to manage patients in wilderness EMS environments and the scopes of practice that are traditionally approved by state EMS regulators. In response, the National Association of EMS Physicians Wilderness EMS Committee led a project to define the educational core content supporting scopes of practice of wilderness EMS providers and the conditions when wilderness EMS providers should be required to have medical oversight.METHODS:Using a Delphi process, a group of experts in wilderness EMS, representing educators, medical directors, and regulators, developed model educational core content. This core content is a foundation for wilderness EMS provider scopes of practice and builds on both the National EMS Education Standards and the National EMS Scope of Practice Model. These experts also identified the conditions when oversight is needed for wilderness EMS providers.RESULTS:By consensus, this group of experts identified the educational core content for four unique levels of wilderness EMS providers: Wilderness Emergency Medical Responder (WEMR), Wilderness Emergency Medical Technician (WEMT), Wilderness Advanced Emergency Medical Technician (WAEMT), and Wilderness Paramedic (WParamedic). These levels include specialized skills and techniques pertinent to the operational environment. The skills and techniques increase in complexity with more advanced certification levels, and address the unique circumstances of providing care to patients in the wilderness environment. Furthermore, this group identified that providers having a defined duty to act should be functioning with medical oversight.CONCLUSION:This group of experts defined the educational core content supporting the specific scopes of practice that each certification level of wilderness EMS provider should have when providing patient care in the wilderness setting. Wilderness EMS providers are, indeed, providing health care and should thus function within defined scopes of practice and with physician medical director oversight.

Wilderness First Aid is a common certification for outdoor recreationists, educators, and trip leaders. A panel of educators, researchers, and clinicians evaluated 15 core and eight elective WFA practices for strength of recommendations based on the quality of supporting evidence and balance between the benefits and risks/burdens according to the methodology stipulated by the American College of Chest Physicians. The strength of the evidence for these 23 WFA practices varies widely because of scant published research to date. When no evidence existed, the panel based recommendations on a consensus of the panelists for risk/benefit and best practices. This review clearly points out the need for conducting greater research to strengthen the level of evidence in numerous WFA topics and for educational strategies that improve retention of core knowledge, as well as skill application for the lay first aid provider.

We appreciate the opportunity to comment on the excellent Wilderness Medical Society practice guidelines for spine immobilization in the austere environment.1Quinn R. Williams J. Bennett B. Stiller G. Islas A. McCord S. Wilderness Medical Society practice guidelines for spine immobilization in the austere environment.Wilderness Environ Med. 2013; 24: 241-252Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar We commend the authors for their presentation of the evidence, and we generally agree with their well-considered recommendations. However, we have some concerns, mainly about the proposed algorithm, “Recommendations for spine clearance and immobilization in the austere environment” (Figure 2 of the article). The authors correctly point out that spinal “immobilization” falsely implies that the spine can be immobilized using current techniques. We believe that the newer terms “spinal protection” and “spinal motion restriction” are more accurate. We agree that a vacuum mattress should be used rather than a backboard for spinal protection. We are surprised that the authors recommend cervical traction during extrication. They mention the dangers of traction with the use of cervical collars. We also would have liked to see the authors address the issue of comfort in patient packaging. For example, is there evidence that patients should be transported in the supine position for spinal protection? Practical experience suggests that transporting patients in the lateral decubitus position can be more comfortable and poses no additional risk. The authors emphasize the lack of evidence that spinal immobilization confers benefit, and they highlight the known risks. If one concludes that spinal immobilization has no benefit, no patient should be “immobilized.” There would then be no need for the proposed algorithm. We agree with the authors that many injured patients are immobilized unnecessarily, causing significant harm, but we do not believe that spinal motion restriction is useless. For nonambulatory patients, there is no reasonable alternative to stretcher transport with spinal protection. Ambulatory patients seldom, if ever, require special measures to protect the spine. In practice, they may be subjected to unnecessary stretcher transport with associated risks in many austere settings. The authors present convincing evidence that “appropriately trained personnel can safely use the NEXUS criteria2Hoffman J.R. Mower W.R. Wolfson A.B. Todd K.H. Zucker M.I. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group.N Engl J Med. 2000; 343: 94-99Crossref PubMed Scopus (969) Google Scholar or Canadian C-spine Rule”3Stiell I.G. Wells G.A. Vandemheen K.L. et al.The Canadian C-spine rule for radiography in alert and stable trauma patients.JAMA. 2001; 286: 1841-1848Crossref PubMed Scopus (870) Google Scholar in the prehospital setting to guide selective immobilization of the cervical spine. If the guidelines had been limited to the cervical spine and had stopped with the 1A recommendation to use the NEXUS criteria or the Canadian C-spine Rule, we would have no objection. Our main objection to the untested algorithm developed and presented by the authors is to the specific additional criteria they propose as requirements for spinal protection. We are concerned that there might be patients who would benefit from spinal protection to whom it would be denied using these criteria. Because the algorithm has not been validated, there is no way of knowing how it would perform in practice, unlike NEXUS and the Canadian C-Spine Rule. The criteria for spinal range of motion seem to apply only to the cervical spine. Traditionally, for conscious patients, the decision to protect the thoracolumbar spine has been based on the physical examination, specifically on the presence of neurologic findings or tenderness to palpation. We are not aware of evidence concerning the benefits or harms of this practice. We wonder if the authors have evidence to support their proposed algorithm other than “careful and meticulous review of the literature…in combination with the collective expertise of the authors…” We are especially interested in the basis for the 2 new binary decision points, “significant spine pain or tenderness (≥7/10)” and “voluntarily able to flex, extend and rotate spine (cervical or thoracolumbar) 45° in each plane, regardless of pain.” These decision points seem quite subjective and would be difficult to apply in the field. We believe that most field providers would be very reluctant to apply flexion and extension in the field, even if there were evidence that it would be helpful. The risk of unnecessary immobilization could be decreased by including all or parts of a validated instrument, the Canadian C-spine Rule. The Canadian C-spine Rule includes “sitting position,” “ambulatory at any time,” and “delayed onset of neck pain” as criteria for low-risk patients who need only be “able to actively rotate neck 45° left and right” to avoid radiography.3Stiell I.G. Wells G.A. Vandemheen K.L. et al.The Canadian C-spine rule for radiography in alert and stable trauma patients.JAMA. 2001; 286: 1841-1848Crossref PubMed Scopus (870) Google Scholar Patients who will not need radiography certainly do not need stretcher transport for spinal protection. We call on the authors to revise the algorithm by using validated criteria rather than untested novel decision points to prevent ambulatory patients from being placed on stretchers. Drs Zafren, Smith, and Kovacs declare no conflict of interest. Dr Johnson owns a company that provides instruction in wilderness medicine. Wilderness Medical Society Practice Guidelines for Spine Immobilization in the Austere EnvironmentWilderness & Environmental MedicineVol. 24Issue 3PreviewIn an effort to produce best-practice guidelines for spine immobilization in the austere environment, the Wilderness Medical Society convened an expert panel charged with the development of evidence-based guidelines for management of the injured or potentially injured spine in an austere (dangerous or compromised) environment. Recommendations are made regarding several factors related to spinal immobilization. These recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks or burdens for each factor according to the methodology stipulated by the American College of Chest Physicians. Full-Text PDF

The Epinephrine Roundtable took place on July 27, 2008, during the 25th Annual Meeting of the Wilderness Medical Society (WMS) in Snowmass, CO. The WMS convened this roundtable to explore areas of consensus and uncertainty in the field treatment of anaphylaxis. Panelists were selected on the basis of their relevant academic or professional experience. There is a paucity of data that address the treatment of anaphylaxis in the wilderness. Anaphylaxis is a rare disease, with a sudden onset and drastic course that does not lend itself to study in randomized, controlled trials. Therefore, the panel endorsed the following position based on the limited available evidence and review of published articles, as well as expert consensus. The position represents the consensus of the panelists and is endorsed by the WMS. In 2014, the authors reviewed relevant articles published since the Epinephrine Roundtable. The following is an updated version of the original guidelines published in Wilderness & Environmental Medicine 2010;21(4):185-187.

People, both laypersons and healthcare providers who live, work, travel, and recreate in the outdoors have specialized medical training needs not met by traditional first aid programs. They care for patients in remote locations, in challenging weather, with questionable communication and support, limited equipment, and the need to make independent decisions on patient care and transport. As a result, medical and outdoor specialists developed wilderness medicine courses in an attempt to meet these needs. Initially the content for these courses was written independently and was opinion-based. Subsequently it has evolved based on evidence and experience. This process has led to a consensus about content and scope of practice (SOP)for wilderness first aid (WFA) providers amongst the leading training organizations.