Abstract
To the Editor:
We are happy that our study has stimulated some much needed reflection on the matter of education in wilderness first aid and related topics. These letters nicely illustrate some of the problems we tried to highlight in the manuscript.
We applaud Ms Pope and the American Canoe Association (ACA) for their ongoing efforts at developing requirements for their instructors that are evidence-based and practical. We have actually had some discussions with Ms Pope and the ACA in regard to this.
The first aid needs of water sports instructors and guides are an excellent example of the futility inherent in developing a “wilderness medicine” curriculum that would be applicable to the broad array of outdoor educators and leaders. The epidemiology of injuries likely to be encountered by ACA instructors is unique, and it is eminently sensible for them to have first aid training specific for these injuries. It is difficult to see the relevance of much of the content of the typical wilderness first responder course for canoeing instructors. Incorporating some water sports-specific competencies into an existing structured program such as the American Red Cross's Wilderness First Aid course is a very responsible approach. Along a similar vein, one of us (Dr Welch) is currently working with the Association for Challenge Course Technologies (ACCT) to develop a wilderness first aid course specific to the needs of the challenge course practitioner.
The ACA's requirement for age-specific CPR certification is a nice reminder of another epidemiologic fact. Witnessed drowning is one of the only plausible scenarios in the backcountry in which CPR is likely to be effective.
We appreciate Mr Moss's supportive comments as well. We agree with him that our publication will make it difficult for a plaintiff's attorney to argue for the existence of a “standard” requirement for first aid training in the outdoor industry. Although providers of wilderness first responder training would have us think otherwise, their proprietary “protocols” provide no legal protection for laypersons undertaking activity that in most jurisdictions would constitute the practice of medicine. Some graduates of “Wilderness First Responder” programs have told us about being taught to develop relationships with licensed physicians as a source of prescription medications. Such practices not only put the “first responder” and his or her patient at risk, they also constitute clear violations of most state medical practice acts, placing the prescribing physician in a nearly indefensible position.
The enormous expense of many Wilderness First Responder courses today, including tuition, travel, and time away from other pursuits, is rightly a concern for volunteer organizations. It is difficult to see the “value added” from these expenses. Mr Moss also is quite correct in highlighting the absurdity of much that is occurring in this field currently. Automated external defibrillators (AEDs) in the backcountry are but one example of such silliness. Finally, he is right to stress the correct definitions of terms such as “first aid.” We are amused at the number of programs advertising that they teach wilderness “medicine.”
Mr Nicolazzo, the director of a commercial wilderness first aid training program, provides more of an unreferenced essay or advertisement than a direct response to our article. His letter is useful, however, as an illustration of the types of problems with which this unregulated industry is replete.
Mr Nicolazzo makes a number of statements, which, while frequently heard in the context of wilderness first responder programs, do not hold up to careful scrutiny. The call for a “firm foundation in normal anatomy and physiology” is a simple example. Setting aside the complete implausibility of a layperson achieving anything approaching a “firm foundation” in these topics in a few hours, there is no evidence-basis for the statement. Ankle sprains constitute one of the most common causes of backcountry evacuations for injury. One could spend hours instructing laypersons on the multiple articulations in the ankle mortise, but the likelihood that this would make them better able to provide field treatment is nil. References to the “rather high level of quality” in wilderness first responder courses and the role of competition in producing “increasingly better curriculum, materials, and delivery methods” are completely unsubstantiated anecdote. These and similar assumptions in his letter are precisely the sorts of statements that are overdue for careful, rigorous analysis.
The letter includes suggestions reflecting either hubris or naiveté. An example of this is the suggestion that the “WMS board” undertake “lobbying … to legalize effective treatments that are currently illegal” such as “epinephrine use.” Helping a client who is carrying epinephrine that has been validly prescribed to administer the drug as ordered is not illegal in any jurisdiction and requires little if any training. Making a diagnosis of anaphylaxis in an individual without a prior history, and providing a specific dose and route of epinephrine constitutes the practice of medicine. The idea that state medical licensing authorities would endorse this practice by nonprofessionals without oversight after a brief unstandardized course is ludicrous. Even if regulatory bodies were open to such a drastic change in practice, there is absolutely no risk-benefit analysis to justify it.
The entire wilderness “medicine” education industry is overdue for very thorough scrutiny. A multitude of unregulated providers are offering education of uncertain quality in the use of techniques that have not been subject to any real evidence-based analysis to students who are unlikely to retain them in order to treat conditions with which they probably will never come into contact. This is being done at an incalculable cost to outdoor programs, which often subsist on a shoestring, but which are told that such training is essential for their safe operation. It is about time to rethink this entire boondoggle, beginning with the type of careful epidemiologic analysis called for by Ms Pope, Mr Moss, and Dr Forgey.