Welcome to the Wilderness Medicine Training Center's 2021 Fall Newsletter. As usual, we cover a lot of ground: We present guidelines for assessing and evacuating outdoor program participants due to behavioral or psychological distress—and updated our SOAP notes accordingly. We also discuss (in detail) the assessment and treatment of venomous snakes and include four new case studies to check your understanding.

Our digital handbooks—designed for phones and tablets—contain significantly more information than the print version and are available in English ($25), Spanish ($20), and Japanese ($25). Buy one now; it's always with you (as long as you keep your device charged), and updates are free for life; the next update is scheduled for January 2022. And, don't forget our digital SOAP notes for only $5 (currently only available in English).

COVID Vaccines

Unfortunately, the pandemic is still with us, and the overall situation remains fluid. Given the high infection rate of the Delta variant and the potential for break-through infections, we strongly recommend that everyone attending an in-person course be fully vaccinated and have a negative PCR test within three days of the course start. The admission criteria and PPE requirements for in-person courses vary to comply with federal, state, and company requirements with specific requirements outlined in each registration form.

Check your WMTC certification status online

2019 graduates and their employers can check their certification status on wildmedcenter.com by going to Resources > Certification Database and entering your last name in the search window.

Updated Patient SOAP Notes

We updated our Patient SOAP notes for 2022 to include, among other things, assessment and evacuation checkboxes for Behavioral & Psychological Problems; please read the article in this newsletter titled Behavioral & Psychological Distress. Download a pdf copy of our 2022 SOAP Note here.

We are acutely aware that there are few recertification courses available this fall and that WFR & WEMT graduates need their certification to work. To address this issue currently certified graduates of an approved wilderness medicine provider may register for Part 1 of our WFR & WEMT Recertification course. Once they complete the online portion of the course, they will be issued a provisional WFR or WEMT certification; the certification expires one year from the time they registered for Part 1. To complete the certification process and receive a full three-year certification, they must complete the Part 2 practical session before their provisional certification expires. You may substitute Part 2 of a WFA or WAFA for Part 2 of our WFR & WEMT Recertification course. (Remember: You must register for and complete Part 1 of the WFR & WEMT Recertification course not Part 1 of a WFA or WAFA to recertify.)

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To register for Part 1 of our hybrid WFR & WEMT Recertification course:

1. Go to our website Course Schedule
2. Scroll down (or use the hyperlinks at the top of the page) to the WFR & WEMT Recertification section.
3. Click or tap on the "Part 1 Hybrid" tab.
4. Click or tap on the "Register for Part 1" button to access the course registration form.
5. Submit the registration form and pay for the course. It takes a maximum of 24 hours to manually process a registration; please be patient as our staff confirms your eligibility and mailing address. If you don't receive an email confirming your registration within 24 hours, please check your junk mail; if it's not there please contact our office.
6. You can register and pay for a Part 2 practical now or later by following the directions below. You do not have to complete Part 1 before registering for Part 2 but you MUST complete Part 1 in order to attend Part 2.

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To register for Part 2 of our hybrid WFR & WEMT Recertification course:

1. Go to our website Course Schedule
2. Scroll down (or use the hyperlinks at the top of the page) to the WFR & WEMT Recertification section. (Remember: You may substitute Part 2 of a hybrid WFA, WAFA, or WFR for Part 2 of our WFR & WEMT Recertification course.)
3. Click or tap on the "Part 2 Hybrid" tab to see a current schedule of Part 2 practical sessions.
4. Click or tap on the name of the course sponsor whose dates and location best meet your needs. A new page will open with details of the course you are interested in.
5. Click or tap on the "Proceed to Registration" button to access the course registration form.
6. Submit the registration form and pay for the course. It takes a maximum of 24 hours to manually process a registration; please be patient. If you don't receive an email confirming your registration within 24 hours, please check your junk mail; if it's not there please contact our office.

Outdoor trips may induce emotional distress or trigger a mental health challenge or crisis in participants that expresses itself as a growing inability to cope with the daily problems and activities presented during the trip. While most healthy people can adapt to mild stress and return to their baseline relatively quickly, chronic, moderate, or severe stress may overwhelm their coping mechanisms and result in distress or crisis. Field staff benefit from assessment guidelines that help them decide if a participant is in distress and compensating (and how to support their process in the field) or unable to compensate and should be removed from the trip for professional assessment and care.

For many people, stress is inherent in outdoor trips. To avoid a mental health crisis, trip leaders need to identify and evaluate early stressors. The mental health pyramid depicts three levels of stress and their associated evacuation levels. Ill and Injured are mental health terms. While caregivers should be aware of the clinical terms, they should use "Severely Overwhelmed" or "Red;" "Overwhelmed" or "Orange;" or "Distressed" or "Reacting" to avoid negative labeling. Trip leaders can utilize colors or non-clinical terms to check in with participants daily or after a potentially stressful event or activity. Conduct rapid check-ins using a circle format with individual follow-up as necessary. For example, "Let's go around the circle and see where everyone's stress level is right now using colors."

• Green = No distress
• Yellow = Distressed and actively compensating
• Orange = Overwhelmed and unable to compensate
• Red = Severely overwhelmed and potential danger to self or others

Participants in outdoor trips who self-identify as distressed, overwhelmed, or severely overwhelmed should be encouraged to seek out and speak with staff or the trip leaders privately. Similarly, if staff or trip leaders observe any behaviors that indicate a participant may be in distress or crisis, they should speak privately with the individual. Depending on the participant's story and presenting signs/symptoms, the participant may remain in the field or evacuated. 

Signs & Symptoms of Potential Behavioral & Psychological Distress

• Does not participate in group discussions or decision-making.
• Has little or no interest in maintaining friendships or participating in daily activities.
• Withdrawn, seeks solitude whenever possible.
• Shunned by group members.
• Constantly fidgets and appears anxious or afraid.
• Seems easily annoyed, irritable, or unusually critical.
• Seems distracted, speaks unusually slowly, or rambles.
• Appears sad or unhappy, exhibits episodes of crying.
• Poor appetite or overeating.
• Shares beliefs that other group members find unusual or bizarre.
• Sudden or noticeable change in daily functioning.
• Exhibits disruptive behavior.
• Unusually emotional.
• Exhibits ongoing conflict with group members or staff.
• Exhibits ongoing irrational behavior.
• Complains of numerous unexplained physical ailments.
• Exhibits an inability to cope with daily problems and activities.
• Self-identifies as distressed (yellow), overwhelmed (orange), or severely overwhelmed (red).

Support

Participants in distress but actively compensating (yellow) may remain in the field if supported and their daily functioning monitored. Support participants by:

• Creating a calm, safe environment
• Carefully listening to their story and concerns
• Involving them in problem-solving and self-care
• Helping them build stronger relationships with staff or trip leaders and group members
• Working with them to create practical step-by-step solutions with measurable (visible) outcomes

Evacuation

If any of the following conditions are met, the trip leader should contact their program director for assistance. In most cases, the affected participant should be evacuated and seen by a mental health professional; closely monitor them during evacuation.

• Field staff—or those providing patient care­—are uncomfortable with the situation.
• Patient exhibits an ongoing or growing inability to cope despite interventions and support.
• Patient's behavior negatively affects other trip members' experience.
• Patient has prescribed Rx meds for a mental health condition and is not taking them.
• Patient appears to have the potential to harm themselves or others.
• Patient wishes they were dead or expresses suicidal thoughts.

Venomous snakes are found worldwide, and it's vital to research local snakes for identifying marks, hunting patterns, and habitat before venturing into their territory as avoidance equals prevention. Snakes are deaf to most airborne sounds—they do not have external ears—and have poor eyesight; however, their sense of smell is excellent, as is their ability to detect ground vibrations. Venomous snakes are classified according to their fangs and venom delivery systems. Because venom is metabolically expensive for snakes to produce, roughly 25% of strikes do not envenomate.

Viperids (Vipers & Pit Vipers)

Due to the location of their venom glands, all vipers have a characteristic broad-shaped triangular head with elliptical pupils (that may appear round is poor light) and some have a distinctive rattle on the end of their tails. Pit vipers have small heat-sensing pits below and behind their nostrils with an approximate sensing range of 14 in (vipers do not have heat-sensing pits). The range of their sensory detection apparatus is roughly 20 ft. Both vipers and pit vipers are ambush predators with thick, muscular bodies. They have hollow hinged fangs that fold into a bone pocket in their jaw when not in use. The fangs are connected to venom sacs, and venom release is under the snake's control. Most snakes in this family give birth to live young. More than 200 species of snakes within the Viperidae family include all rattlesnakes, cottonmouth (water moccasin), copperhead, adder, bushmaster, desert horned viper, baboon viper, jararaca, long-nosed viper, palm viper, puff adder, saw-scaled viper, and white-lipped tree viper.

Elapids

Elapid fangs are short (compared to viperids) and usually fixed in place with a groove or slit-like opening in the tooth. Most Elapidae have long, slender bodies and, unlike members of the Viperidae family, are active hunters; most lay eggs. Some elapids—like the spitting cobra—are capable of projecting their venom in a spray up to five feet away from forward-facing holes in their fangs. Sea snakes, all cobras, black mambas, brown snakes, coral snakes, death adders, green mambas, tiapans, kraits, and tiger snakes are part of the elapid family.

Colubrids

The Colubridae family is the largest snake family with over 2500 species. While many colubrids are technically considered venomous, very few are dangerous to humans. Their fangs are located towards the back of the snake's mouth, forcing the snake to chew on its prey to deliver its venom. Members of the Colubridae family known to be fatal to humans include boonslangs, bird snakes, Argentine blackheaded snake, South American culebra de cola corta, and twig snakes.

Venom & Antivenom​

Snake venom is a complex cocktail often containing hundreds of pharmacologically active molecules; the exact recipe varies among families and even individuals of the same family. Regardless of the type of snake, there are three broad categories of venom syndromes: neurotoxic, hemotoxic, and cytotoxic. Venom capable of causing significant disability or death in humans will elicit at least one sign or symptom from one or more triad.

Antivenom is available for each symptomatic triad; however, the specific components vary regionally according to the chemical compensation of the venom. Snakebite patients may present with a symptom of one triad early and later develop signs and symptoms of another. Early administration of antivenom is the definitive treatment for all snake envenomations. It is vital to know the location and contact information of clinics, hospitals, and medevac units with antivenom before you depart on a trip into snake country.

Field Assessment of Snake Bites

Look for and document the signs and symptoms of cytotoxic, hemotoxic, and neurotoxic syndromes; if possible, document the progression with photographs; even seemingly unrelated S/Sx may be important. Together with the geographic region, the results help physicians determine the type and amount of antivenom to administer to the patient. At the same time, pictures of the progressive development of the envenomation are helpful; it is not necessary to know the species of snake. Reassess symptomatic patients every 15-30 min or as evacuation permits. Reevaluate asymptomatic patients regularly during the evacuation; if no S/Sx develop within 24 hours, the patient was bitten by a non-venomous snake or received a dry bite from a venomous snake.

Because the timeline of the development of cytotoxic signs and symptoms is critical to antivenom dosing: Look for small puncture wounds ± minimal bleeding at the site, then circle the bite site and write the time it occurred with a permanent marker on the patient. Look for local and progressive cytotoxic signs and symptoms: These include pain (typically severe), tenderness, swelling, and tissue destruction (blisters, increased bleeding, bruising, ulceration, etc.). Use a permanent marker to mark the leading edge of pain and tenderness with "P" for pain and "T" for tenderness and then the time. Mark skin changes (flushing, cyanosis, bruising, and swelling) with "S" for skin and the time. Dotted lines are usually reserved for documenting resolving S/Sx, ofter after the administration of antivenom. NOTE: The patient's airway can be obstructed by excessive swelling.

• ​Look for local and systemic hemotoxic signs and symptoms: Local S/Sx include continuous bleeding from the site after 30 min, bruising, blood-filled blisters, and progressive swelling (left photo). Systemic S/Sx include the development of small red or purple spots on the skin (petechiae, center photo), bleeding from the gums (right photo) and other mucosae, coughing up blood, vomiting blood, tarry stools, blood in urine, pulmonary edema, and blindness.

• Eye pain from spitting cobra venom.
• Assess and monitor for anaphylaxis (low risk).
• Rhabdomyolysis is possible. Monitor for significant tissue damage (bruising, swelling, petechiae) with muscle pain and dark urine.

Field Treatment of Snake Bites

• Antivenom is the definitive treatment; the dose is based on the clinical presentation and progression of signs and symptoms, not the type of snake. There are no absolute contraindications for administrating antivenom to patients with a symptomatic snake envenomation. If resources and training permit, administer in the field before transport.
• Remove jewelry, and begin a Level 2 Evacuation of all symptomatic and asymptomatic snakebite patients to antivenom: neurotoxic signs and symptoms are often delayed; and, while cytotoxic and hemotoxic signs and symptoms typically appear within minutes, however, they can also be delayed for hours. Choose the fastest evacuation option: If walking is faster, walk. Accurate identification of a snake species can be very difficult for lay people; unless you are well acquainted with a specific species and get a clear view of the snake (from a safe distance), assume all snake bites to be venomous. Go here to visit a website illustrates just how difficult it is to identify a venomous snake. Remember, that identification of the species is not necessary for antivenom treatment.
• Upgrade the to a Level 1 evacuation if any systemic signs and symptoms develop.
• When conditions permit, minimize patient activity, elevate the affected bite/limb (60º if the patient is lying on their back) above the patient's heart to reduce pressure on swollen tissues, and loosely immobilize the bitten limb to reduce movement without constricting tissues.
• Treat eye pain/damage from spitting cobra venom in the same manner as any caustic chemical by flushing with saline or water for at least 15 min; topical anesthetic eye drops (tetracaine) may be necessary to reduce pain and permit flushing. Monitor for corneal erosion. After flushing, remove clothing. Thoroughly wash both clothing and the patient's body with soap and water to prevent re-exposure from dried venom.
• Intubation or cricothyroidotomy may be necessary to maintain the patient's airway due to excessive salivation or foam from neurotoxin or swelling from cytotoxic bite in the face or neck. Prolonged rescue breathing may be required for those in respiratory arrest secondary to a potent neurotoxin.
• If rhabdomyolysis is suspected, force fluids to help clear excess protein (myoglobin) and protect the patient's kidneys.

DO NOT

• DO NOT cut, suck, or use electricity or chemicals on the bite.
• DO NOT use a venom extractor.
• DO NOT apply a tourniquet or constricting bandage.
• DO NOT give NSAIDs for pain.

Did you assess and treat the snakebite correctly? Was there anything you would do differently in the future? Click here to find out.

What should you think is wrong with Josh and what should you do? Click here to find out.