This past Fall, I was invited to participate in a workshop at the annual AORE (Association of Outdoor Recreation Education) conference addressing the increasingly controversial matter of first aid training for wilderness leaders. The workshop was spurred by my recent publication on the topic in Wilderness and Environmental Medicine (available through the “publications” link on my website).
To say that this topic is “controversial” would be an understatement, although the controversy is really not informed by much data. For the providers of wilderness experiences, especially those based in non-profits such as universities, the costs of maintaining WFR certification for their leaders are not trivial. For the providers of WFR training, such courses are truly their lifeblood, supporting what is becoming a huge industry.
The workshop included several of the major providers of WFR training programs, all of whom are fine individuals who clearly are passionate about their mission and believe that they are providing a vital service. Similarly, the SRO groups from college and university wilderness programs were mindful of the costs but anxious to be sure that they were doing the right thing for their participants.
Good intentions notwithstanding, the discussion at this workshop convinced me even more that the wilderness “medicine” education industry is very much overdue for significant scrutiny. For example, all of the providers present acknowledged that there were absolutely no data speaking to the meaningful retention of any of the competencies taught in such courses. There are ample reasons to question this, many of which we addressed in the publication referenced above. The vast majority of folks taking WFR courses are not operating in the medical field in their daily work, and epidemiologic data are quite clear that their exposure to medical problems in the course of their wilderness work is actually very minimal. We know from studies of layperson competency in CPR skills that retention of such material by those not using it is negligible. If a reasonably structured, basic skill such as CPR cannot be meaningfully retained by laypersons, one has to wonder about the vast number of “protocols” being thrust upon them in the course of a typical WFR program!
Beyond the retention issue, the matter of the skills themselves has never been carefully examined. For example, much was made during the discussion phase of the workshop regarding the various “asthma protocols” taught by the many providers. Most of these are little more than common sense, with the addition of some recommendations regarding the use of asthma inhalers or injectable epinephrine. Use of the latter without prescription, of course, is outside the “scope of practice” of any WFR provider operating outside the framework of an established EMS system, and is illegal in every jurisdiction in the United States. Beyond this, however, any client with asthma which is being treated according to acceptable standards in the US today should have an “asthma action plan”, which details precisely the indications for use and acceleration of medications during an episode. Use of such plans, which are vastly more sophisticated and personalized than some random WFR “asthma protocol”, should be the basis of any approach to a client having difficulty with his or her asthma. Amazingly, none of the providers of WFR training participating in the workshop had heard of this concept, including one who had asthma himself and seemed quite proud at not having his own asthma action plan!
Rather than devoting time during a WFR course to memorizing some esoteric pulmonary physiology, which will almost assuredly be forgotten the next day, how much better to teach about asthma action plans, and the need in the pre-trek medical screening process to insure that clients with asthma have updated plans and have reviewed the coming trek with their providers?
Unspoken explicitly, but clearly present in the room, was a faint antipathy toward the opinion of “doctors” in any of this. Indeed, the opinion seemed to be that front line wilderness experience trumped whatever medical knowledge someone might bring to the table. No one seemed concerned in the least that a group of first aiders with minimal professional oversight could be developing approaches to asthma which ignored the clearly established standards currently being promulgated by groups of physicians who have devoted their professional lives to the disease!
As our study demonstrated, there are currently absolutely no governmental regulatory requirements speaking to the need for specific first aid training for providers of wilderness experiences. The likelihood that this would ever happen is nil. Thus, the only thing which is keeping this unregulated industry going strong is the honest concern by wilderness educators that it is right and necessary. As data gradually demonstrate that this is not the case, WFR programs may gradually be reigned in. In the meantime, the possibility also exists that some will run afoul of state medical practice statutes, something which could hasten the needed reexamination of the industry.