# Wals



## redcrossemt (Nov 30, 2009)

I'm headed up to Petoskey, MI for a Wilderness Advanced Life Support class next week. It's accredited by Wilderness Medical Associates and hosted by Northern CAIRN. Supposedly taught by the MD president of WMA, and a CEN/RN/WEMT-P-IC/FAWM. I'll let you all know how it goes!


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## medicdan (Nov 30, 2009)

I've head some great things about that class, both in the form through WMA and SOLO. I look forward to hearing your comments-- and how ALS skills and assessment can be performed without many of the toys (monitor, etc), and whether it is practical to hike out patients dependent on medication, oxygen or ventilation.


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## zmedic (Dec 8, 2009)

How much of the class is really ALS and how much of it is training docs and nurses basic wilderness skills that you would learn in an WEMT class?


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## medicdan (Dec 9, 2009)

As I understand, at least at SOLO, a pre-requisite for the course is WEMT certification, or at least WFR.

CORRECTED: It seems the SOLO version AdvancedWEMT covers search and rescue, high/low angle rescue, shelter and litter building, travel medicine, with a little of ALS in the backcountry.


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## redcrossemt (Dec 10, 2009)

Hello all! Just finished up a really fun week of learning up in northern Michigan. It's been snowing and blowing like all heck, which made it all the more realistic and challenging...



zmedic said:


> How much of the class is really ALS and how much of it is training docs and nurses basic wilderness skills that you would learn in an WEMT class?



I would say that there are good and bad things about any "ALS" class that incorporates different levels. Our class was populated by three physicians, one PA-C, two EMTP/RNs, one EMTP student, six paramedics, and two EMT-I/85s (a total of 15 students).

The bad thing about having a "mixed provider" class is that not everyone knows about everything that others know about. The docs and nurses had to learn a lot about scene assessment, patient packaging, etc. We paramedic types had to spend a lot more time on the primary care stuff (think clinic work), backcountry medicine, ENT assessment, etc..

The good thing about the class is that everyone is able to add something, and we all learned different things from each other. It was really a dynamic class, and I thought the discussions and scenarios were much livelier because we had a wide variety of medical knowledge and experience.



emt.dan said:


> As I understand, at least at SOLO, a pre-requisite for the course is WEMT certification, or at least WFR.
> 
> CORRECTED: It seems the SOLO version AdvancedWEMT covers search and rescue, high/low angle rescue, shelter and litter building, travel medicine, with a little of ALS in the backcountry.



The WMA WALS course that I attended did NOT require WFR or WEMT as a pre-requisite, and therefore taught the WEMT cirriculum with a focus on advanced assessment and medications which I will talk about in a second. A few students had taken those classes, but most of us had not. If you had taken WFR or WEMT recently, much of the material would be boring to you. However, it had been a while since the previously certified students took the class, and they reported it was a good and very necessary review of the material.

WMA does not teach SAR or survival skills, except maybe to what would be considered an awareness level. We did spend some time on building litters, but most of the class was focused on backcountry/travel medicine, wilderness first aid skills, and most of all on good decision making. The sponsoring agency's motto is "Giving people the knowledge to make good decisions in bad environments" and I think this is probably the best thing you get out of the class.



emt.dan said:


> I've head some great things about that class, both in the form through WMA and SOLO. I look forward to hearing your comments-- and how ALS skills and assessment can be performed without many of the toys (monitor, etc)



The key to this whole thing is that "ALS assessment" and many of our "ALS treatments" are not often possible and usually won't improve survival from a wilderness/remote medical situation. Instead, we use our advanced knowledge to make decisions about what will improve survival.

Obviously, a week of training is hard to summarize here, but here is a short list of my most important "lessons learned" from the course:

1. We need clarity of the situation, and specifically if there is an emergency or not, rather than a specific diagnosis. To get to this point, it really helps to be at the advanced level, and have a good understanding of pathophysiology. WMA's assessment scheme focuses on identifying current and anticipated problems, and then developing a plan to take care of everything however feasible.

2. We need to be dynamic, creative, and sometimes go against "protocol" to protect life and limb, and ensure our own safety. One of the hardest things for me to do in the scenarios this past week was to identify a spinal injury, and then to walk the patient out of the woods. And the other was to remove a penetrating object from the abdomen. Even though these things may be against what we're taught in EMT school, they might actually make the most sense in the wilderness depending on the complexity of the evacuation, resources available, patient condition otherwise, etc.

3. We need to have a good understanding of primary care medicine. As an EMS provider, we are likely the most familiar with medicine of people we travel in the backcountry with. You are looked at as the group's 'doc' and expected to be able to deal with rashes, coughs, diarrhea, tooth aches, and anything else that might come up. As paramedics, we typically just drive these people to the hospital... As WEMT/WALS providers, we may have to diagnose a fungal infection in the field, and then choose the most appropriate course of action. Prevention is also one of the key jobs of any medical provider on an expedition. Failure to prevent illnesses or making the wrong decision about an illness or injury can lead to huge risks to rescuers and the entire group.

4. And we need to understand environmental emergencies (such as HAPE, HACE, envenomations, etc.) and how to treat them. Often these are the things where ALS matters most - but typically in the form of oral medications and other treatments we may not be familiar with.

5. As far as toys, yes there is an entire workshop portion of the class dedicated to equipment and uses. Improvision and packing equipment and supplies that can solve multiple purposes are important. For instance, you can combine an NPA and a large syringe as a manual suction device. The sam syringe can be used for irrigation when a 18ga IV catheter is attached. Intubation can often be performed without a laryngoscope using a bougie, headlamp, and camp silverware to manipulate the tongue. We also reviewed ways to effectively ventilate patients carried out on litters, such as attaching a BVM to a white resuscitator or similar. IV's can be kept warm and flowing by packaging with the patient and delivering boluses as the rescue contiues, or by using a pressure infuser.



emt.dan said:


> and whether it is practical to hike out patients dependent on medication, oxygen or ventilation.



Well I guess it really depends on the situation. If the patient is able to walk, it may be best to walk. You have to consider how many people and resources you have with you, what more is coming, how complex and time-consuming a litter carry will be, and how long it will take an ambulance or helicopter to reach the nearest evacuation point. I don't think oxygen really has much use in wilderness medicine. If you have it, great; but in almost all of the situations I have been faced with, it is typically something that gets left behind. However, there are things like carbon fiber tanks and Oxymizers that can give you more oxygen from a lighter package if you really need it. I'm not sure what kind of medication a patient might be dependant on, but yes, in certain situations, I could see walking out, for instance, a patient who had an allergic reaction that we needed to continue an epinephrine drip on. Again, though, it depends. If an evacuation team can be to you in short time, and you can meet an ambulance quickly after that, why risk walking the patient? Something else to think about is sheltering in place if resources can't get to you right away. And, then, on top of everything, people will die in the wilderness despite our efforts. It's a remote setting and some just can't be helped due to the time to get to definite care, and our lack of resources.

Anyway, I hope this is a good idea of what WALS is about. Don't expect to spend most of your time talking about sexy ALS treatments and medications. You will focus on basics and good decision making. I thought the course was excellent for any EMTP, RN, PA-C, MD/DO, or other 'advanced' level practitioner who spends time in remote or disaster situations, or provides medical services as part of a SAR or backcountry rescue organization. It also comes with 36 advanced level CE credits, which is nice.

If you have any questions about the course, I welcome you to post here or message me.

If you'd like to discuss a treatment modality or something not directly related to administation or cirriculum of the course, start a new thread.


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