Nantahala Outdoor Center | 35.3313° N, 83.5930° W | January 12, 2019
“What is the best way to move someone?”
Randy Manuel glances around at his students shivering in the crisp, early-morning air. It’s Day One of Wilderness First Responder (WFR) training, and we just completed our first exercise outside (and the first of many, many acronyms) BEAM: Body Elevation and Movement. A few people mutter hesitant responses to Randy’s question.
“The best way to move a person in the backcountry,” he says, “is the way that’s working. In our world, there isn’t a whole lot of ‘this has to be done this one particular way.’ We’re out in the woods—do whatever works best in the moment.”
Randy speaks with a rhythmic, down-home Appalachian drawl made for the movies. His easy-going demeanor and mountain-folk mannerisms help the more shy students to relax. It is immediately apparent that we are going to learn a lot of really important stuff this week, but we’re also going to have a lot of fun.
I promise it won’t be boring! Randy Manuel is a man of many professions and talents: experienced EMT, thorough instructor of wilderness medicine, and the best sense of humor this side of the Mississippi.
In the Solo Southeast classroom at the Nantahala Outdoor Center, we take turns introducing ourselves. Of the 16 people here, almost all of us are from North Carolina and Georgia, except for Lily — a lifelong New Yorker with a funny accent who immediately wins everyone’s respect when she tells us she hiked the entire Appalachian Trail a few years back. Andrew, a 19-year-old freshman at Virginia Tech, is the youngest person in the room. Chad, a music teacher from Atlanta, is the “old man” (in his mid-40s) of the group. The rest of us are young professionals, working in conservation, firefighting, education, science, and wilderness therapy. It comes as no surprise that we all love the outdoors—our shared hobbies and passions include backpacking, kayaking, mountaineering, trail running, rock climbing, and mountain biking.
I want to interview everyone in the room. These are my people!
Over the next few days, Randy delivers a crash course in the intricacies of the human body, and all the horrible things that can happen to it. Faced with the daunting task of handling life-threatening situations, the WFR protocol arms us with a set of systems. We learn how to check heart rate, respiration rate, and blood pressure. We learn how to evaluate a patient’s skin and pupils and level of consciousness. We learn these six measures are our vital signs.
We cover topic after topic: Sprains. Strains. Fractures. Seizure. Stoke. Heart attack. Shock.
With each new subject, Randy tosses out a short story or one-liner. A stroke is “the brain’s version of a heart attack.” Shock is “a momentary pause in the process of dying.” Skin is “the best Gortex you’re ever going to get!”
We learn a few new vocabulary words:
Occlusive (adj.)
An occlusive dressing is an air- and water-tight trauma medical dressing used in first aid. These dressings are generally made with a waxy coating so as to provide a total seal, and as a result do not have the absorbent properties of gauze pads.
Crepitus (noun)
A grating sound or sensation produced by friction between bone and cartilage or the fractured parts of a bone.
Ischemia (noun)
An inadequate blood supply to an organ or part of the body, especially the heart muscles.
Dyspnea (noun)
Difficult or labored breathing; shortness of breath.
Can you hear me now? Lily listens for the rush of blood through Sara’s arm as the blood pressure cuff (sphygmomanometer) releases.
After learning how to use blood pressure cuffs and stethoscopes (while it’s unlikely we would have these tools in the backcountry, it’s still worthwhile for us to be familiar with them) Randy pulls up a photo of a car crash – a rolled pickup truck in a ditch. He proceeds to tell us the story of his team responding to this accident, and a pertinent mistake they made during the rescue.
“We’re an experienced team — and we still missed a big thing. But we saw our error and we got the patient out safely,” he says. “So if an experienced team can make a big mistake, what are the chances that you guys — brand new first responders — are going to make some mistakes?” He looks around the room, nodding at each of us. “Yeah, you’re going to make mistakes. And that’s okay, as long as you learn from them.”
Never | Always. “These two words don’t often apply in our world,” Randy says. “Unless we’re talking about diabetes. Never give a diabetic patient insulin. Always give sugar.”
Randy’s reassurances act as a balm for much of the morbid content we cover, but he can’t completely distract us from the despondent nature of the material. After a drawn-out discussion about life-threatening back injuries, Andrew poses this question: “so if someone has major trauma to their spinal cord—that’s it? They’re just done?”
I understand the frustration in his voice. Even with all this training, what could we possibly do to ameliorate such a dire situation?
We learn the range of motion test and the protocol for spinal precautions. We learn the terms mechanism of injury and hands on stable.
When we reach traumatic brain injuries, Randy doesn’t crack a joke or tell a story. He serves this one straight up.
“This topic gets depressing fast,” he says. “We’re in way over our heads on this one.”
While scenarios involving a broken back or a busted head sound awful, nothing makes me cringe more than arterial bleeding. It’s not that blood makes me queasy — blood is blood, whatever. The distinctive, cruel characteristic of this particular trauma comes in the form of an impossible race against the clock. A person can suffer a major head trauma, end up in the hospital several hours later, and still make a full recovery. But if an artery is compromised, you have three minutes to act before the patient bleeds to death. Three minutes. 180 seconds.
You’ve got to be kidding me.
When I ask Randy about the locations of our major arteries, he points to over a dozen different spots on the body: neck, chest, bicep, wrist, stomach, legs. A wave of despair slams into my mind like a mental freight train. How can we possibly survive anything? How are we even alive at all?? What is the point of trying to save anyone when human beings are so baffling breakable?
Randy, the ever-empathetic teacher, takes our existential strife in stride. “We’re remarkably fragile at times,” he says. “But we’re also remarkably durable.”
Conceptual physics meets backcountry. With Chad acting as the patient, Randy teaches us how to set a broken femur using a long tree branch and few pieces of rope.
Rinse and repeat. Lily practices applying pressure irrigation (a technique for cleaning wounds) on an “abrasion” on my left hand.
One rope to rule them all. Randy enjoys a free ride after showing us how to create an improvised litter out of a single rope.
The medical knowledge is important, but memorizing terms, acronyms, and protocols won’t do us much good if we can’t implement them in a real-life situation. Each day includes running through different scenarios—from sprained ankles to head injuries to a lightning strike. We learn how to differentiate between shock and traumatic brain injury, how to deliver rescue breaths, how to tie a tourniquet, how to clean various wounds, and how to set broken bones.
The ultimate test comes when Randy asks us to organize ourselves into an incident command system (noun):
A standardized approach to the command, control, and coordination of emergency response providing a common hierarchy within which responders from multiple agencies can be effective. It is a fundamental form of management, with the purpose of enabling incident managers to identify the key concerns associated with the incident—often under urgent conditions—without sacrificing attention to any component of the command system. [Source: FEMA]
Robert volunteers to take the Incident Commander position which has direct parallels to his job as the Operations Coordinator at Great Appalachian Valley Conservation Corps. We stuff our packs full of gear—tarps, medical supplies, water, food, and extra clothing. While this exercise is a drill (our “patients” will be wilderness medicine instructors sporting fake injuries and ailments) we take it seriously.
Ready. Robert runs through protocol for the rescue, and the different roles and responsibilities of each team member.
Set. Sara, acting as the Assistant Incident Commander, takes notes and waits for the distress call over the radio.
Go. After receiving sparse details from the radio call, the team prepares to mobilize.
After the radio call comes in, Robert gives a quick, final overview, and off we go—down the hill, into the cold, rainy afternoon. Along the Nantahala River, we find three people “in distress”. The two other teams go to the unresponsive patients, while my team huddles around the conscious patient who is sitting up, complaining of pain in her arms. Immediately I feel clumsy and awkward. With drizzling rain and the temperature hovering just above freezing (and because this is an exercise, not the real deal) we don’t cut off the patient’s jacket to splint her “broken” arm. And even though I know my patient’s arm is not really broken, she is legitimately cold.
As my team tends to our patient, I receive questions and directions from Robert, Sara, and Lily. I try to stay focused and efficient, resisting the urge to feel helpless and inadequate.
Just over an hour later, we file back into the classroom, sort through soaking wet gear, and revive our numb fingers and toes. While we successfully “rescued” the three patients, we made some mistakes (just as Randy promised.) Robert leads the group discussion to review what we did right, what we did wrong, what we could improve, and what we learned. I feel a staggering sense of ineptitude—I should have done 100 things differently.
At dinner, I vent my frustrations to Robert and Chad. “This is important to me,” I say. “I want to be good at this!”
Robert reassures me that the only way to become good at this (or anything) is through practice. “The fact that you’re taking it this seriously means you will be good at it.”
Spending every day immersed in scenarios that highlight the fragility of human life leads to many late night conversations. After we finish practicing the patient assessment system yet again, and reviewing acronyms, we crack open beers and discuss our own experiences. One woman broke her pelvis. One guy broke his femur. One of the most bright and bubbly people in our group tells us that she lives with severe depression. Another woman talks about the medication she takes for social anxiety. A recent death in the family. A bad car accident. Cancer. Heartbreak. Divorce. Addiction. No topic is off-limits here.
On the first day, as we went around the room, I thought these are my people simply because we all love the adventuring in wild places. Now, after a week together, I think these are my people on a much more fundamental level: they possess an innate willingness to be open, honest, and vulnerable.
This group, and the things we have learned together this week, remind me that living bravely requires more than a surface-level desire for adventure, and reaches far beyond exploits in the wilderness. Each one of us must own our past experiences, accept our shortcomings, embrace our strengths, and learn from every challenge we undertake—including this course. While we now have a much better understanding of all the things that can go wrong in the woods (or anywhere), we cannot allow fear to hinder us. We have to accept the inherent vulnerability of venturing into the unknown. No matter how well we stock our medical kits, or how much training we complete, we may encounter situations we feel unprepared to face. We will doubt ourselves. We will make mistakes.
But we will do the best we can.
To learn more about Wilderness First Responder training in western North Carolina (and other courses in wilderness medicine) check out Solo Southeast.