This week wilderness medicine!
Mark with Off Grid Medic
What is OFF GRID MEDIC
Q: Mark, tell everyone a little bit about yourself.
A: My name is Mark DeJong, and I’ve been a Paramedic since 1998. My interest in medicine began back in the late 80’s when, as part of a military assignment, I was stationed aboard the USNS Mercy hospital ship in the Philippines. We were tasked with providing medical care to the indigenous people in mostly remote areas. After my honorable discharge I decided to continue my medical training and earned my degree in Emergency Medical Services. Since that time, I’ve served as a field Paramedic, FTO, Lieutenant, Captain and eventually Director of Emergency Medical Services for a very rural county in South Central Georgia. I’ve also served as an EMT and Paramedic instructor at the college level. I’ve always been consumed with spending time in the wilderness, and I was very excited to learn about this mysterious emerging field called “wilderness medicine” about ten years ago. I earned my Wilderness EMT and Advanced Wilderness EMT certifications, then was fortunate enough to be selected as a member of the Advisory Committee at the Appalachian Center for Wilderness Medicine in North Carolina. That’s been a very unique opportunity, in that it provides a clearinghouse for material that is pertinent to wilderness-specific medical activities. After surviving the politics of public service for over twenty years, I decided to shift career gears and focus solely on education—not just for certified or licensed medical providers, but for anyone who has a passion for the outdoors. Four years ago I formed Off Grid Medic, LLC as an educational company with a focus on wilderness medicine. We now travel the country teaching Wilderness First Aid, Wilderness First Responder and Wilderness EMT programs. In fact, I just returned from teaching a WFA and WFR program in Colorado at 10,000 feet. There’s nothing like learning about the physiological effects of altitude while actually experiencing them at altitude!
Q: So, you’ve used the term “wilderness medicine” a few times. What exactly is “wilderness medicine?”
A: Well, the term often suggests thoughts of the shaman, the medicine man, who heals the injured or ill using plants off the landscape and unconventional medical treatments. Part faith healer, part botanist, part doctor, part mountain man. Someone who understands more than any “town doctor” … Sounds a little far-fetched, right? Well, believe it or not, it’s partially true! From an academic standpoint, the term wilderness medicine simply covers medical treatments delivered when separated from definitive care by time, distance or circumstance. More specifically, the National Institute of Health characterizes wilderness medicine as the remote and improvised care of patients with routine or exotic illnesses or trauma, limited resources and manpower, and delayed evacuation to definitive care. These treatments can range from classic first aid treatments all the way to advanced skills such as wound closures, dislocation reductions, creating a rescue plan, practicing preventative measures, oxygen administration, the list goes on…
In emergency medicine, we generally operate within what is referred to as the Golden Hour—the time of onset of a traumatic injury or sudden illness to the arrival time at hospital-level care. Statistics have shown that when a patient arrives at a hospital, or what we refer to as definitive care, within one hour of the onset of an injury, patient outcomes are more favorable than when they arrive outside the Golden Hour. Wilderness care exceeds this time frame and can literally last up to hours, days or even weeks.
Closely related to time, the distance to definitive care is viewed in terms of how far away a patient is when illness or injury strikes. In about 95% of inhabited areas within the United States, someone can usually be at a hospital within about sixty minutes, or one hour. While serving as the EMS Director for a very rural system in South Georgia, our nearest hospital with real interventional capabilities was 38 miles away, and even though we were providing an advanced level of medical care, we often crossed the threshold for wilderness protocols to be used.
Circumstance is more often the deciding factor in determining the applicability of wilderness medical skills. The victim is often alone, or within a small group, lacking the ability to reach an advanced care facility within the Golden Hour, and quite often has no communication with 911 or professional rescuers. A great example of how circumstances can make a difference: a client on a river rafting trip fell from his raft on a section of river less than 100 yards wide. Despite repeated warnings about not attempting to stand in swift water, the man’s leg became pinned between two rocks, resulting in a broken femur. His raft guide pulled him free and paddled to the nearest shore, where a call to 911 was made. His guide, certified as a Wilderness First Responder, constructed an improvised traction splint and protected the victim from hypothermia. An EMS unit arrived within 15 minutes to transport the patient to the hospital, which was about 25 minutes away. Unfortunately, the patient was on the opposite side of the river as the road. Due to his injuries, the inability for him to effectively swim with a traction splint applied, and the Class IV rapids downstream, the patient had to remain in place for almost four hours until a low angle rescue team arrived, assessed the situation, devised a plan, rigged equipment and executed a rescue. So, what should have been a routine 25-minute transport resulted in a prolonged situation lasting almost four and a half hours.
Circumstance can also come into play even when you’re not in the wilderness! Think about natural disasters. After Hurricane Katrina, my family and I were truly on our own for four days without cell service or even roads to drive on. If an injury or illness were to have happened, knowing how to deal with losing communication and being separated from definitive care makes you a huge asset.
Q: So the inability to reach definitive care due to prolonged time, distance or circumstance, coupled with the inability to communicate and having to provide medical care without a stockpile of traditional medical supplies?
A: Exactly. But remember, you don’t have to be in the wilderness to need these skills. Even in a tactical situation, knowing how to improvise what you need from your environment can make the difference between life and death. I have a client in downtown Atlanta, a church actually, that requested a custom program that would not only benefit their missionary staff, but their general congregation as well. Due to their specific location, they are very concerned about an active shooter incident. We performed a needs assessment and developed a program that provided them with the knowledge and tools needed to stretch out that Golden Hour a bit. When the program was over, they were splinting with window blinds and treating hypothermia with choir robes. They are the only church, to the best of my knowledge, that actually has a fully stocked trauma pack hanging under the pulpit.
Q: It sounds like there’s more to wilderness medicine than just medicine. What other skills or abilities do you feel are required to really be proficient?
A: #1 A solid, and ever expanding, knowledge base… formal education is one option, classes and workshops are another. Keep in mind that medicine, and acceptable medical procedures, often change. Consider the evolution of the tourniquet…consider the role of Nexium and antacids in the treatment of allergic reactions… Guidelines change, and the only way to maintain a solid educational base is by keeping current in your training.
#2 General camping skills… safety in the woods is paramount. The ability to spot widow makers, practice knife and fire safety, use a bear bag to hang food while in bear country, recognize and understand changing weather patterns, hazardous animals and plants, the list goes on…
#3 Wilderness survival skills (fire, water, shelter, orienteering skills). A simple question: If you have to stay with a patient for an extended period of time, do you have the skills to maintain your own well-being, in addition to your patient’s? Can you accomplish everything that needs to be done by using your gear, as well as the patient’s gear? Can you develop and execute a plan to safely get your patient to advanced medical care? Personally, I challenged myself and completed Dave Canterbury’s Advanced Pathfinder survival training program back in 2010. One of the biggest things I learned about myself during that program, from a physiological standpoint, is exactly how I react when I’m truly dehydrated or when I don’t have food for three days straight.
#4 The ability to improvise medical care using whatever is available… A hallmark of Wilderness Medicine is learning to provide medical treatments without access to a big, giant medical kit. We can splint with sticks, construct an improvised litter, make our own rehydration salts, make a cervical collar using water bottles and duct tape or even a closed cell foam sleeping pad. At Off Grid Medic, we routinely train students who are already medical professionals. At one program in particular, I was approached by two students, who happened to be a physician’s assistant and a doctor, who explained that they were completely out of their element. Without a clean, sterile working environment, plenty of manpower, proper lighting, medical imaging equipment, heating and air conditioning, they literally experienced a mental block. I had to remind them that, despite the lack of modern equipment, patient assessment is still patient assessment. Hands are still used for palpation; skin color, temperature and moisture are still a vital sign; capillary refill time is still the poor man’s way to assess perfusion; and the patient’s needs don’t change. You simply have to dig a little deeper and think outside the box regarding your interventions.
#5 A firm understanding of medicinal plants is a solid skill to develop. We can make aspirin from willow bark, we can use cattail, or even honey, as an antibiotic ointment, we can use plantain to make a poultice to treat insect bites and certain skin irritations. Although I’m not a botanist, I’ve learned to be very comfortable with nature’s original pharmacy. Again, the list goes on…
Q: Are there any specific equipment needs that you prefer NOT to improvise?
A: Most definitely. I don’t cut corners on commercial tourniquets. The RevMedX parabelt goes with me everywhere. I have a TX-2 in my vehicle, and a CAT in every one of my packs. Although knowing how to improvise a TQ is an invaluable skill to own, there’s nothing more frustrating that watching a patient bleed out because you didn’t want to carry a commercial piece of equipment. I live by the mantra, “All bleeding eventually stops.” There are a few new specialty products on the market as well. The main one that comes to mind is a non-surgical wound closure manufactured by a company called DermaClip. We have tested their products and they perform flawlessly. They’re currently only available by prescription, but an OTC version is expected out this year.
Q: So let’s talk about medical kit mentality for a few minutes. What do you carry in your kit?
A: It’s a simple question with a very complex, situationally-dependent answer, especially for someone with a strong understanding of wilderness medicine. While working the streets, my medical kit consists of about $250,000 worth of high tech equipment, supplies and pharmaceuticals located inside a big metal box, anchored to a truck chassis, and surrounded by blinking red lights. When operating as a contract medical provider, my kit takes up every corner of a 3800 cubic inch StatPacks G3 medical backpack. When spending a night in the backcountry or a weekend on the trail, my medical supplies fit neatly inside a quart-size Ziploc bag.
I’ve taken a long look at the similarities, and differences, in the medical supplies carried on an ambulance and compared those to what is most often needed in the backcountry. The conclusion that I reached was that the mission defines the gear. In emergency medicine, we often use easy to remember abbreviations to keep our priorities straight. Street side, when advanced life support is usually just a phone call away, the priorities are “ABC”, which represents airway, breathing and circulation. In tactical medicine, when gunshot wounds and blast injuries are common, the priorities shift to address life-threatening hemorrhage first, hence “CAB” or “MARCH”. In wilderness medicine, when definitive care may be hours or even days away, we use “ABCDE”, adding disability and environment as potential life-threatening concerns. The ability to get yourself, or your patient, out of a compromised situation while dealing with environmental issues is paramount to a positive outcome. Regardless of the setting, without an open airway, adequate breathing, sufficient circulation, the ability to reach advanced care, and a means to thermoregulate, every injured or ill person will rapidly assume room temperature.
The practice of wilderness medicine presents unique challenges not usually experienced in urban or tactical medicine. You must learn to do more with less, yet still provide quality patient care. To keep myself on track, every kit I assemble revolves around the five “ABCDE” principles.
We must have an open airway to survive. In wilderness settings, where availability of equipment is generally limited due to size or weight, a simple oropharyngeal airway, or OPA, can be used with minimal training to maintain an open airway. In the absence of an adjunct, knowing how to manually open an airway using the head-tilt-chin-lift and modified jaw thrust maneuvers can be the difference between life and death.
Humans must breathe to live. A disposable CPR pocket mask weighs practically nothing, yet enables me to provide rescue breaths without resorting to mouth-to-mouth if needed.
All bleeding eventually stops. The challenge is stopping blood loss before the supply runs out. Every kit should have an assortment of sterile bandages and dressings that can be used to treat anything from busted knuckles to an axe in the foot. I carry sterile 4 X 4 pads, sterile rolled gauze and a tourniquet. Note the word “sterile”. Infection is a real concern in the backcountry, and it’s much easier to prevent than it is to treat. Since a sterile environment is nearly impossible to duplicate in the wild, my kit is heavy on treating circulation issues.
Disability, or loss of mobility, can present in several forms: A broken leg, a sprained ankle, a suspected spinal injury or a medical condition that leads to an altered mental status are all great examples. Wilderness areas provide me with a wide assortment of splinting materials. I can craft a splint for an arm, a lower leg and a femur from the landscape. If needed, a litter can be easily constructed to carry out an injured patient. In a pinch, I can even make an improvised cervical collar using leaves and extra clothing. Since my options are so plentiful, and my training so thorough, I choose not to carry splinting materials in my wilderness kits.
We cannot control nature’s behavior. We must be able to thermoregulate not only ourselves, but our patients as well. Dehydration, heat exhaustion, heat stroke, exertional hyponatremia, hypothermia, and frostbite are legitimate concerns that must be addressed in the backcountry. We also need to be able to address issues related to snakes, bees, ticks and mosquitoes, as well as any harmful plants we may be exposed to. Regardless of the season, I always carry an emergency blanket, salt packs, sugar packs, honey packets, a means to filter water, a potent tube of insect repellent and at least 100mg of diphenhydramine.
A few items always migrate into my kit that don’t fit into a particular category. Aspirin has been clinically proven to assist in treating a heart attack, and acetaminophen is considered the pain reliever of choice in wilderness medicine. NSAIDS, such as ibuprofen, are generally excluded due to an increased risk of stroke and blood clots. A small pair of tweezers and a sewing needle have been invaluable to me during tick season.
All medical kits, regardless of size or complexity, should assist you in opening and maintaining an airway, providing ventilations if needed, limiting blood loss, immobilizing a suspected fracture and treating environmental concerns. I am a firm believer that the more you know, the less you have to carry. If you are not comfortable with your current level of medical training, seek out a course that improves your level of knowledge and competency. Already have a medical kit? That’s great, but do you really know how to use everything in it? Is it full of items you really don’t need for your situation? When is the last time you inventoried the contents? When is the last time you thought your way through the contents? The wilderness is a wonderful place, but can turn into a nightmare for those who are untrained and underprepared for a medical situation.
Q: So you offer Wilderness First Aid, Wilderness First Responder and Wilderness EMT programs. Can you walk us through what all is covered in each program, and who each program is designed for?
A: Our 18-hour entry-level WFA course is designed for anyone who spends time in the wild or has an interest in improving their basic medical skills. Don’t let the course title mislead you...our WFA program goes way beyond first aid. This interactive program provides students with opportunities to learn and practice hands-on skills through a balanced mix of scenarios and outdoor classroom time.
The American Safety and Health Institute serves as the certifying agency for our WFA program. Certification is valid for two years. This program is recognized by the Georgia Peace Officers Training Council for 18 hours of Continuing Education and has also been approved by the Boy Scouts of America. From scouting organizations to hard-core adventurers, our WFA program fills the need for basic level medical training. The curriculum includes Basic Anatomy and Physiology; Patient Assessment Skills; Bleeding Control Techniques; Recognizing and Treating Soft Tissue Injuries; Bone Injuries and Splinting; Strains and Sprains; Head and Spinal Injuries; Burns and Thermal Injuries; Recognizing and Treating Shock; Medical Emergencies in the Backcountry; Bites, Stings and Envenomations; Environmental Hazards and Concerns; Emergency Carries and Improvised Litters; and Medical Kit Mentality
Our Wilderness First Responder (WFR), program, referred to as the “Gold Standard” in wilderness medical care, is primarily intended for non-medical professionals who are traveling in the backcountry and serving as wilderness guides, outdoor instructors or educators, Search and Rescue (SAR) team members, ski patrol, medical personnel for adventure races/events, missionaries, expedition medical team members, etc. The scope of practice for a WFR is to prevent and identify medical problems, initiate reasonable and prudent field management and identify red flag signs and symptoms necessitating evacuation for potentially life-threatening problems. Our WFR program is offered as a stand-alone 80-hour program, or as an additional course following completion of an Off Grid Medic Wilderness First Aid program. This particular program has been approved for 22 hours of continuing education credit from the Georgia Peace Officers Training Council. Our WFR curriculum includes Expanded Anatomy and Physiology; Expanded Patient Assessment Skills; Expanded Vital Signs; Alternative Wound Closure Techniques; Bleeding Control and Shock Management; Improvised Traction Splints; Indications and Use of Medical Oxygen; Basic Airway Adjunct Indication and Use; Burns and Thermal Injuries; Medical Emergencies in the Backcountry; Dislocation Reduction Techniques; Rotary Aircraft Ground OperationsEmergency Carries and Improvised Litters;
Medical Kit Mentality; and Incident Command for Wilderness Operations.
Our 5-day Wilderness Medic (WEMT), program is designed for currently licensed or certified EMTs, Paramedics, RNs, PAs, and Physicians who have an advanced understanding of street-side medicine but desire a better understanding of wilderness treatment protocols and procedures. This fast-paced course is conducted outdoors at all times and includes both didactic and psychomotor components. This course includes both day and night scenarios. A moderate level of physical exertion can be expected during these activities. Successful completion of this course upgrades current physicians, PAs, RNs, and emergency medical responders (EMRs) to the WFR level, and current EMTs and Paramedics to the Wilderness EMT (WEMT) level. The Georgia Department of Public Health serves as the certifying agency for our WEMT program. Certification is valid for two years. Prerequisites: Valid Provider-level CPR and current licensure as a Physician, PA, RN, EMT or Paramedic. This course is approved by the Georgia Department of Public Health, Office of EMS and Trauma, and the Georgia Peace Officers Standards and Training Council for 40 hours of Continuing Education. Our curriculum includes: Medical Emergencies in the Backcountry; Medical Care Outside the Golden Hour; Alternative Wound Closure Techniques; Fractures and Improvised Splinting;
Environmental Emergencies; BIAD Applications in Remote Care; Medical Leadership and Expedition Planning Considerations; Tourniquets and Hemostatic Agents; Dislocation Reduction Techniques; Rotary Aircraft Ground Operations; Emergency Carries and Improvised Litters; Survival Skills for Remote Providers; Medical Kit Mentality and much, much more!
Q: I’ve seen a lot of pictures and videos from your training programs, and man those injuries look real! What’s the secret ingredient for your moulage, and where did you learn that skill?
A: We’ve all been through those boring classes where the instructor says, “Your patient has an impaled object”, right? And you look and there’s no impaled object. There’s no injury there at all. I know I have. Unfortunately, no one learns anything good from that experience. One of the most effective learning tools is realism, both in how an injury looks and how a patient presents. To ensure the best training, we use crisis actors and theatrical quality silicone moulage for all our injuries. We’ve been able to replicate everything from a gunshot wound to arterial bleeding to an abdominal evisceration to an anaphylactic reaction. We were lucky enough to have an amputee as a crisis actor in Colorado last month and actually pulled off an ultra-realistic above the knee amputation. Facebook and Instagram haven’t banned any of our pics yet, but I always put an educational disclaimer at the beginning just in case. As far as where I picked up the skill, it’s all self-taught. Once you’ve seen enough soft tissue injuries in your career, replicating them is the easy part. I did a training session on moulage techniques for the CERT team at the University of Georgia earlier this year that was a big hit, and I always get the “Dad of the Year” award at Halloween every year.
Q: Where have you taught courses in the past?
Q: How much do your programs usually cost?
Q: How can our listeners find out more about wilderness medicine and the courses you offer?
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