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WFR Scope of Practice Draft

Document Date: May 21, 2010
Document Source: Wilderness Medicine Institute of NOLS
Tod Schimelpfenig
Posted:  May 20, 2010

The group of wilderness medicine providers working on scope of practice documents have completed a draft of a Wilderness First Responder (WFR) Scope of Practice (SOP) Guideline to accompany the Wilderness First Aid (WFA) SOP published last fall.  We’re circulating the WFR SOP draft to provide an opportunity for public commentIn 1999 a number of prominent wilderness medicine course providers made copies of their curriculum available and participated in a discussion that resulted in the Wilderness Medical Society Wilderness First Responder Recommended Minimum Topic List. 1  This has remained the most prominent published document defining the WFR.  David Johnson MD of Wilderness Medical Associates and I have been talking for several years about curriculum consistency in wilderness medicine.   We decided in the winter of 2009 that it was time to move forward on this question and to approach this project by first defining what a WFA and WFR should know and what they should be able to do, their “scope of practice.”
It’s not a curriculum, set of lesson plans or supporting text.  There are plenty of these available to those who wish to teach.  We have no enforcement ability or agenda and our work is non-binding.  We do hope it sets some boundaries and clarifies these credentials.
The process of circulating and discussing drafts among the working group has been educational and collegial.   We don’t all agree on every detail of the document – we’re a bunch of opinionated medical geeks – but we have been able to achieve a consensus.
The field of wilderness medicine has been accused of designing courses without any basis in medical evidence.  I disagree.  There is evidence, and we use it. 2 Granted, much of it is tradition, expert opinion or educated guess, but this “level of evidence” abounds in first aid.  Good science on whether a technique actually changes the outcome is often lacking, especially in a wilderness context.  We have to extrapolate an urban study to the wilderness.  We have to use our experience, as biased as it may be.   We’re well aware of the ongoing arguments over the effectiveness of various first aid skills.  The SOP reflects our distillation of this material into a set of practical and relevant skills that we can reasonably expect a lay medical provider to perform in the field and that will help, and not harm the patient.
One of the challenges of wilderness medicine is the many different contexts of practice.  Hikers and paddlers will have different injury/illness profiles, as will adventure racers, outdoor programs and rock climbers.  There are consistent themes; soft tissue and athletic injury, flu-like and GI illness are common.  We also know we carry our medical history with us, and that people can have cardiac, respiratory and other medical events in the wilderness.  The SAR reports show us the rare severe injury events.  Those who argue that wilderness leaders need only rudimentary medical skills don’t appreciate this breath of need.   
Our focus is on the first aid.  Of greater importance are the fundamental outdoor skills, leadership and judgment that are the foundation of prevention and ultimately more powerful medicine that the first aid we can practice in the wilderness.   
We’ll gather input through the summer and meet at the Wilderness Medical Society meeting in Snowmass in July to discuss next steps.  I’m asked whether a standard curriculum or wilderness medicine program and instructor accreditation are next.  I don’t know.  I do know, as Steve Donelan wrote recently in the WEM Journal,  “Even an evidence based, standardized curriculum cannot guarantee that students will learn. Whether our classes are effective in preparing students for real emergencies still depends more on how we teach than on what we teach.”3
Wilderness Medical Society Curriculum Committee.  Wilderness First Responder: Recommended Minimum Course Topics. Wilderness & Environmental Medicine, 10, 13-19.1999.
Islas T.  What kills us in the woods.  Syllabus, 25th Annual Meeting of the Wilderness Medical Society. Snowmass, CO.; July 2008,
Donelan S.   Classroom and Reality: What Should We Teach in Wilderness First Aid Courses? Wilderness & Environmental Medicine, 21, 64–66 (2010)