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Far From The ER With Jeff Burke, Dr. Will Smith, & Dr. AJ Wheeler

Updated: Jun 1, 2022

TED 60 | Wilderness Medicine

Over the course of the last few years, National and Regional Parks have been flooded with new visitors who may not be accustomed to or trained in wilderness survival. As more and more people head into the backcountry, more and more people get into trouble in the backcountry. This episode features Jeff Burke, Dr. AJ Wheeler, and Dr. Will Smith, who discuss their work in backcountry medical rescues. They join host Alaina Rajagopal to talk about what goes into a medical rescue, the different types of medical rescue, scene safety, and more. Listen until the end to learn how you can stay safe in your outdoor adventures and what to do if you come across a medical emergency in the wilderness.


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Far From The ER With Jeff Burke, Dr. Will Smith, & Dr. AJ Wheeler

Wilderness Protocols And Empowered BLS In The Backcountry

Please keep in mind that the content of this episode does not constitute medical advice but is purely for the purpose of education. This episode was supported by the National Geographic Society’s Emergency Fund for Journalists. This is the very last episode of season two of the show. We talked with a few very special guests about remote and wilderness medicine. I will introduce our first guest, Jeff Burke, who was previously a guest on this show and wrote the episode about a cardiac arrest at a ski resort in Jackson Hole, Wyoming. I am happy to have Jeff back on with two new guests to tell us more about what it is like working in the backcountry. With that, Jeff, take it away.

What is it like to practice medicine in an avalanche path or a ravine riverbank? What does that look like, or say, a mass casualty incident in which 17 climbers get struck by lightning at 13,000 feet? It is not like you are down the road from the hospital and can shove a bunch of folks into a Chevy suburban arriving quickly to definitive care. Medical intervention has to start somewhere, even if it is miles from the nearest road.

With that, welcome to the deep water pool of wilderness medicine. The impetus for this episode was born from a previous episode, in which we broke down a successful heart attack recovery of Jim Hays that began halfway up the Jackson Hole Mountain Resort. It was episode 43, How Medical Response Saved a Life at Jackson Hole.

Distilled to its essence, the rescue was an accomplishment thanks to a mixture of basic life support tools, training, tactics, and let’s not forget, luck. It is an amazing story, so please do not hesitate to read it if you have the time. After participating in that first episode, I wanted to pursue how lucky we are to have skilled, dedicated people come to find us in the backcountry and high mountains.

I have been a ski patroller in Jackson Hole for a long time. When I think about all the moving parts to conducting even small, backcountry rescues, the aspects that interest me are the decision-making, risk assessment, and execution of emergency medical responses far from the trailhead. Without going too far down the rabbit hole of medicine in extreme areas and/or tactical under fire rescue in, say, Syria, I wanted to hear some perspectives of some rescuers higher up the food chain, the Wilderness Docs.

We have a fast-growing active outdoor population that adventures both near and far in the greater Jackson area. For my part, I have had the privilege of working under the medical direction of Saint John’s Emergency Medical Physicians Group, a cadre of ER docs, physician assistants, and Saint John’s nurses who rotate through the Teton Village Clinic each summer and winter, several of whom are also on search and rescue.

We are here to speak with Dr. Will Smith and Dr. AJ Wheeler, both of whom have extensive pre-hospital experience and provide medical direction for not only the mountain resort but also Jackson Hole Fire/EMS, Grand Teton National Park, Teton County Search and Rescue, and Bridger Teton National Forest. Both physicians are active members of Teton County Search and Rescue. The Jim Hays heart attack episode was a worst-case scenario.

Ground zero for this event was a ski traverse nearly halfway up the resort. Happily, that story had a positive outcome, yet ski patrols and search and rescue organizations have call-outs in all kinds of settings with myriad scene safety considerations, ingress and egress limitations, timing, weather windows, approaching nightfall, prolonged winter storms, and resource management. The factors that influenced backcountry rescue operations are numerable.

With that in mind, what medicine gets practiced? For many series of life-threatening scenarios, wilderness docs play an active role in the calculus and execution of medical intervention that is nowhere near the emergency department. That takes a certain physician. We can do a little digging here. What led each of you to practice medicine in the great outdoors?

I grew up in Ohio. A young one who was into athletics and mostly running got into school. I have always loved the outdoors, hiking, camping, backpacking, and the mountain environment. As fate would have it, I went to residency in Milwaukee, Wisconsin, where I met Will. Dr. Smith and I started to dip our toes into wilderness medicine by giving free lectures at an REI on first aid kits and altitude illness. I got lucky enough to follow Dr. Smith out here to Jackson and live in the mountains. It seemed like a logical extension with the things I love to do to take emergency medicine, out of the hospital, into the backcountry and start working with search and rescue.

It is a slightly different story for me. I grew up here in Wyoming and on a 22,000-acre cattle ranch down in Southeast Wyoming. I got to love the outdoors in a trial by fire. I was out fixing fences with my dad. In my senior year of high school, I took an EMT class, and that is where I caught the medicine bug. I continued to work through undergrad and did not get into medical school the first year I applied, so I became a paramedic. I continued to practice those paramedic skills and did ski patrol but I still had that love and passion.

It continued through my emergency medicine residency, like AJ mentioned, where we started hanging out doing adventure races, those REI lectures, and then we both ended up here in Jackson. Here has been a great opportunity to continue to expand, not just the skills inside the emergency department but a great backcountry wilderness setting to continue to practice those skills. That is definitely where I have got more passion for getting out there and making a difference.

Let’s paint a quick picture. When there is a report of a backcountry emergency adjacent to the Jackson Hole Mountain Resort, most often, two patrollers will make the initial move out of bounds to see what happened. This starts a chain of events in which the sheriff’s office and subsequently Teton County Search and Rescue are notified that we are reconning a possible inter-agency mission and that we could need further assistance depending on the severity of the emergency. Normally, this looks like a search and rescue helicopter crew who, with the aid of the ship, can fly deep into a canyon with medical personnel and tools, and help ground workers like ski patrol, fly out a person who cannot walk and/or move.

It is also a handoff to the next higher level of care, which might be a local hospital or a larger tertiary care center. When we arrive as a rescue team, we secure the scene as best we can. We present the situation and package the patient as best we can. The ship then flies into our coordinates, and there is a physician who can potentially help with pain management and/or invasive treatments somewhere during the course of the egress. A lot of it seems to be about buying time in the field so as to optimize critical care downstream. Can you speak to that?

One of the important things to recognize when we are talking about search and rescue is that this is not just a helicopter EMS service. We are search and rescues or helicopters, not equipped like a full HGMS ship. We are resource limited. When we are responding to assist with a rescue at Jackson Hole Mountain Resort or somewhere else in the backcountry around here, we only have a small amount of medical equipment we can carry because we have to carry technical rescue equipment and bring rescuers to the scene. Our medical equipment is mostly geared towards being able to address life threats, immobilized patients and transport them, and moving into higher levels of care when we need to.

AJ hit on it. It is trying to figure out what you should do there and then versus the importance of getting them out of that environment, mitigating or stabilizing the environment. One of my hats is also as an Army Reserve doc. I have had combat deployments over in the Middle East but whether or not it is bullets flying at you, an avalanche slope, it is a bear, those are all real dangers. Taking care of patients in each one of those dangerous situations, you have to mitigate those facts.

Sometimes it is more important to get that person out of there before you start doing the high-level medical care. That is one of the traps that more advanced medical providers get into, and especially as docs, because we have got so many tools and toys that we can play with but sometimes the more important thing is to get that patient out rather than using those. Stabilize them, and you can do that later.

As advanced medical providers, sometimes it is more important to get that person out of there before you start doing high-level medical care.

You are both charged with having another skillset when you become involved with mountain rescue, especially in the snowy mountains. It is an ancillary skillset but one in which that requires its own set of hard skills, mountain craft, and earned risk versus reward decision-making, whether terrain and snowpack are variables that do not exist in the emergency department. Wilderness docs need to acquire substantial backcountry awareness to be effective. What would you, guys, care to weigh in on that?

Field experience is super important. Functioning as Medical Directors and as members of search and rescue, being able to experience what search and rescue members are going through, being in the field, and understanding that. Having that knowledge when you are not actually in the field and knowing what your providers are trying to do and what they might be coming up against in the field is super important.

That is why being a member of search and rescue is helpful but like in the ER, when you are trying to manage a difficult airway, you have to know the risks ahead of time and be able to anticipate those. We have to know the risks of the environment we are going into from avalanche strain, technical high-angle rescue, and with the addition of the complicating medical care and patient condition. It is a fun puzzle to solve.

It is sometimes a little silly or crazy but it is the challenge. Working day in, day out of the emergency department gets to be the same but when you are out there in what I would like to call the term the technical rescue interface, that is where the ambulance stops at the end of the road. That is where you will use those backcountry technical rescue skills to get that patient out.

As a Medical Director, sometimes we are on the scene and providing that care. Sometimes we are remote, helping people make some of those advanced medical decisions. Sometimes there is no communication. One of the big things is helping prepare those that are going into those fields with the right skills and training so that they are able to take care of the patients if we are not there or they cannot get a hold of us. Those medical protocols and guidelines in these remote, austere wilderness environments are key for patient care.

Let’s go back to when you were talking about scene safety a minute ago. When we learn about wilderness medicine, we learn that the first question you ask approaching a patient is, “Is the scene safe?” In a test scenario, you can usually address this but in a real-life scenario, the scene is almost never completely safe. As you mentioned, there are bullets, bears or other risks. Can you talk more about scene safety and the realities of practicing medicine in avalanche territory, flood zones, bear territory, and war zones?

For me, as a ski patroller, we do a lot of things that are snow-based, and then even in the summer with some of the other on-mountain situations. The 30,000-foot view is, generally speaking, weather considerations, the snowpack, and the terrain. A lot of it does not have to be necessarily rocket science. You show up on a scene after an avalanche has happened, and you can see typically what has transpired. You can see the avalanche, the right places where you can go or shouldn’t be going, or how to enter where you don’t put yourself or any of the other rescuers in any type of danger.

In the summer for us, a lot of the, “Is the scene safe?” When there is high angle rescue, ropes, and redundancy in the rope systems. There are a lot more things that are going on. We practice a lot with that. You do a lot of systems checks, and you have put those into place to make sure that everybody who has a part can do it and has control of the part that they play in this puzzle. You are confidently doing your part of the mission.

Scene awareness, awareness of what is going on around you, practicing things so that you know it is second nature when you are doing it in the scene, and trusting the people around you that they are doing their part of the overall pie.

As a lower-level person in the food chain, I show up and paint a scene as best I can, so that people higher up the food chain can have a clear idea of what has transpired and what they can do to get this person to more definitive care.

Dr. Smith, Wheeler, any thoughts on that?

Scene safety is always something not generally a completely safe scene when you are in any of these environments because there is an injury or illness that has already happened. By the nature of the wilderness or remote environment, you have to take those into account. Training proficiency and having a good team because what it takes to get these patients safely out of the backcountry and in these environments is the team that you are with.

I am not a fan of the safety-first paradigm. There is a great article out there by Seth Hawkins, another wilderness medicine practitioner, about changing that up to the safety third, which may have been initially spearheaded by Mike Rowe on his TV series. It brings light to what Dr. Smith pointed out, which is search and rescue providers cannot always have a perfectly safe scene.

We have a job to do, and we are going to always look to mitigate the risks around that job as much as possible, which makes hard decisions for us sometimes. You have to acknowledge that what we do is not always safe. You risk a lot to save a lot sometimes. Sometimes, you have to make those hard decisions but pushing safety to the third position or that perfect safety to that third position and recognizing that you are working hard to mitigate risk is important.

That answers the next question I was going to ask you but along the same topic, we know that these rescues are extremely dangerous for the rescuers and a lot of cases. On one of my local mountains, a rescuer died a couple of years ago searching for a lost hiker. How does the risk to rescuers play into the decisions on what type of rescue happens when it happens? How long the search goes?

TED 60 | Wilderness Medicine
Wilderness Medicine: Our medical equipment is mostly geared towards being able to address life threats, immobilize patients and transport them, and move into higher levels of care when we need to.

A lot of the decision-making is based on people who have had more experience and seeing the different varieties of nuance and differences between what are normally similar rescue situations. For example, you can have someone who has got a knee injury but they are in a dangerous spot above a cliff or other terrain challenges that make something that is a normally mundane rescue very complex or complicated. When you have more serious injuries, coupled with lots of egress challenges, everybody has to elevate their game a little. You have a lot more decisions that need to be made quickly and definitively, and you have confidence that you know what you are doing.

For example, when we have had people who have been injured and brought a toboggan into them, the rescuers have to pass complicated rock features. I remembered years ago. I had stopped. We called for a 300-foot rope because the two patrollers that were bringing the toboggan in were above us, and there was no room for them to make an error.

We brought the rope, we put them on belay, and as they were coming down to us, it got less and less snow-covered. They were even knocking a few little rocks nearby, and had they come in without any type of redundancy or backup, that situation could have been much worse. I am sure both of the doctors have their own experiences where things have developed more complications over time.

One of the things we use a lot is the Incident Command System or ICS. It helps designate some of those roles. You have an incident commander who is actively making the decisions of go, no-go with input from the rest of the team. A lot of times, you will have a safety officer that is more focused on those safety concerns, the risk reduction possibilities, whereas you got the operations section, and it is working on trying to get the mission done.

Sometimes that can get us into a tunnel vision of getting it done at all costs but there might be a way to reduce the risk or do it another way. A lot of times, we use helicopters but even though the helicopter is risky in itself, it reduces the overall risk of admission. You might be able to do a helicopter rescue with three people and get the rescue done in 30 minutes versus if you do a ground rescue and you are going to need 30 to 50 people 8 hours through the night, the helicopter is ultimately the less risk.

Looking at some of those risk stratification and risk mitigation are definitely important to try and make it as safe as possible. Sometimes there are points where the risk is too great. We need to wait until the following day or two to drop some avalanche bombs, so we do not get more rescuers hurt because then we are going to have more patients ultimately.

Will and I take your question very seriously because it hits very close to home. We unfortunately also lost a team member in a helicopter accident several years ago. One of our members was killed in a helicopter crash. Thankfully, the pilot and another SAR member survived. We are lucky to have them with us still but when we are looking at sending our team members out in the helicopter, at night or into avalanche terrain, we definitely weigh those risks very seriously.

Several years ago, there was a call out to Teton County Search and Rescue. A young man had slipped on a relatively exposed traverse while climbing Cody Peak in late May. He was sporting alpine boots without hiking soles. He lost his footing and sped down a large backcountry bowl in spring morning conditions, which is to say, hard and fast. He suffered bilateral Tib-Fib breaks. By the time ski patrol had been notified, Teton County Search and Rescue and Dr. Wheeler were mobilizing.

Patrolman Al Walker and myself were headed up the aerial tram as Dr. Wheeler got dropped off at the start of the Cody hike outside of the resort. If I remember correctly, TC-SAR was not set up for the short-haul with their helicopter, which is typically only eight months out of the year because it was transitioning to the next contract.

We were going to have to move the injured party down the mountain to find a spot where the helicopter could land and pick up the patient. This was less than ideal as the LZ location was still sloped, and it would be difficult to load the patient into the helicopter. Luckily, Grand Teton National Park Rangers were doing their short-haul training with a different helicopter. For their summer season, at the time of the incident, they were able to wrap that up and respond to assist by dropping Ranger Chris Harder at the scene.

For the record, the short-haul is defined as transporting one or more persons suspended beneath the helicopter and is usually employed when ground-based operations are prohibited by cliffs, forests, canyons, rivers, snow, and glaciers. Typically, the duration of the flight is as short as possible to a suitable landing zone where the patient may be transferred to a higher level of medical care. Dr. Wheeler arrived first and was the de facto side commander. Patrolman Alex Walker and I arrived on skis as Dr. Wheeler provided pain management drugs. We lowered the victim to a flatter spot on the bowl while using a skid, which is a relatively lightweight extrication device. Think of a backboard roll-up.

During this time, the helicopter finished its required training evolution and picked up Ranger Harder, who flew under the helicopter with the litter, which is a rigid titanium basket stretcher for transporting injured persons. One of the factors that made the rescue so smooth was that all the agencies involved trained routinely with the same short-haul protocols. It does not sound like much but when rescuers are dangling 150 feet below a helicopter to pluck an injured person from the middle of the Teton mountain range, there is simply more at stake. Let’s talk a bit about risk versus proficiency and training, which means, a lot of the time, there is a helicopter involved.

I definitely think it is true that you do not often rise to the occasion but you sink to the level of your training. When we are talking about the short-haul, we focus on training on what we call our typical terrain. We are trying to get into terrain that we think is representative of areas that we are going to be doing rescues so that when tensions are high, and you are going to a rescue, it is not something you have never done before. It is something you have trained on.

The training, we can contrive these controlled situations in that terrain, make sure that we are making sound decisions throughout that training, and not have the concern of a patient who is waiting on you, timing factors or weather and those kinds of things that would increase that risk. It decreases that risk versus benefit ratio.

Part of it is the inter-agency cooperation that we have here in the valley as well. With Dr. Wheeler, myself, as well as some of the other emergency medicine physicians being able to do medical oversight to coordinate the care between Grand Teton National Park, the ski patrol of search and rescue or Fire/EMS, everybody is on the same page, whether or not that is with the technical rescue or that is with the patient care, it allows everybody to have that same common operating picture.

We were doing some training up in Rock Springs. Plan A was to have some ski patrollers be high up in our Rock Springs bowl area. The weather wasn’t quite right, so we changed to plan B. Everybody is fluid. Everybody has got good communication. We were able to pull off the training but a slightly different location with better weather and factors to make it overall safer. That inter-agency cooperation and communication are all key when it comes to the day when we have to play it out and help save somebody.

It is true that you do not often rise to the occasion, but you sink to the level of your training.

What factors play into whether you use a short-haul or another modality of transport?

The scheme I typically use is patient condition is always one of the first things we are looking at. Isolated extremity injury, an ankle sprain or a broken wrist is different urgency than a pelvis injury, spinal cord injury or shortness of breath in the backcountry. That patient urgency can sometimes drive the decision as to the mode of rescue that we are going to look at. Layered on top of that, we start to look at the weather conditions, “Is it even possible to safely fly a helicopter?” Ultimately, the terrain that we are going into, “Is it a wide-open meadow?” That is a great LZ. “Is it a steep treed slope?” A short-haul may be the only way to move somebody who is immobile.

For our readers, LZ is Landing Zone.

Basic life support protocols keep things simple for many of us with limited degrees of medical training, you have both helped to craft collective protocols shared by several of the institutions throughout the valley, much to our benefit, I would submit. Can you touch on the breakdowns of tools, tactics, and prioritizations as they relate to the backcountry events?

From a strategy versus tactics standpoint, we have developed our strategies for backcountry rescue and then try to identify tactics that we can use to develop that strategy, and then tailor the tools and our medical equipment to those tactics to fit into the wilderness and backcountry realm. Even the AED that we carry, we are looking for an AED that is not only capable and small but we want to have the ability to see the leads for decision-making in certain backcountry situations. It has to be environmentally tough, work with blowing snow and cold and freezing conditions. Over time, we have worked hard to hone our tools to fit into the wilderness light and fast tactics needed to develop our strategy.

Being on the different medical food chains, being down at the bottom with basic life support, and being up towards the top with the ALS with all the tools and tricks if we are in the emergency department. As we mentioned before, a lot of times in these environments, we have got the basic skills to keep ourselves safe but then also a limited amount of medical gear and equipment. A lot of times, even though AJ and I might be physicians, we might not have that many more tools that EOS providers have. It’s a lot of the decision making. There was a cardiac arrest. We had one of the climbing rangers up in Grand Teton, Scott Guenther, short-hauled into the Maverick.

A gentleman was three hours skinning up one of these backcountry peaks. He started having chest pain, and we started the rescue response. Looking at the totality of the situation, we decided it would be a location that would best be accessed by a short-haul medical emergency. Thinking about, “What tools do we take with us? We cannot take the whole kitchen sink. I have got a medical bag that is 40 pounds but I am going to be able to take 5 pounds of gear.” Again, thinking about what saves a life.

The AED is one of the things we took with us. We were planning on getting the patient extracted as quickly as we could but as soon as we got on the scene, the patient had gone into cardiac arrest. From plan B to plan C, and now, D, E, and F, there are always these backup plans as you are going to these missions. Part of that is the flexibility. Also, planning ahead and being able to get this patient out, and ultimately, he survived. That is a great example of that a chain of survival that we sometimes see, although not quite what you see in the front country.

To that point, often, the time at which it takes to get to a patient and get them out is what leads to increased survival. With the cardiac arrest that we had discussed in a previous episode, you guys were able to get him into an emergency department very quickly and off the mountain. In Europe, their survival rates are very high after avalanches because their definitive care is much easier to reach because they are close to definitive care. Whereas in backcountry Canada, it is much more difficult to get people to definitive care in emergency departments. Have you noticed that in your care at all or in the work that you have done? Sometimes time to definitive care makes a difference or what do you see as some of the major factors?

I got back from a winter in France. They have helicopters flying all over the place. A lot of the ski areas are way up high in the mountains. They have actual helicopter companies that work to transport people from almost any location to definitive care quickly and efficiently. They have the PGHM, which is the Peloton Gendarmerie Haute Montagne, which is a professional search and rescue that is all over France. They have the same equivalent in Switzerland, Germany, and Italy. Piggybacking off what Will said, having to bring qualified personnel into this area and getting them to definitive care fast brings those numbers up. They have that advantage with a lot of air support.

When you start talking about wilderness EMS systems of care, you have to start looking at all those variables. Looking at what happens in Europe, their survivability, resources, and distances is different than what we have here sometimes in the US in certain locations and in Canada and other parts of the world. One of the great textbooks that are out there is a textbook by Seth Hawkins if you are looking at knowing how to optimize your wilderness EMS care.

One of the differences about wilderness medicine, where you are improvising your backpack into a splint or where you are out there and happened to be taken care of, versus a wilderness EMS systems care, whether or not that is ski patrol or search and rescue, where you have that duty to act, you got a patch on your shoulder, a radio, and a response system. For AJ and myself, being Medical Directors for these wilderness EMS systems of care, those are all the things that you have to look at like, “When should you have termination protocols? When does it make sense? When does it increase the risk?” There are lots of differences out there but still trying to do the best patient care.

It is interesting to compare and contrast Europe versus North America, the US, and Canada. The EMS paradigm and the search and rescue paradigm are very different. Search and rescue in most of North America is a volunteer. In the US, most search and rescue are volunteer organizations. Helicopters and equipment are much less common and geographically much more spread out. Response times can be hours versus in the Alps could be minutes to rescue, and because of that, we have different strategies and ways of managing these things.

One good example of one of the strategies we employ commonly is in Grand Teton National Park, we have had several instances of climbing falls with head injuries in the mountains. The Rangers respond and are able to get a Ranger on the scene, and clearly in an emergency department, assessing a trauma patient, decreased GCs, you would manage ABCs, and airway comes first.

You are looking at, “Do I need to manage this, this airway? What can I do?” In this situation, however, the technical rescue is the thing that is going to slow us down in getting to that definitive care the most. If the rangers or Will and I happened to be on scene and managed that airway, that is going to impact the rest of that rescue and slow that significantly.

TED 60 | Wilderness Medicine
Wilderness Medicine: Inter-agency cooperation and communication are all keys when it comes to the day when we have to play it out and help save somebody.

The technical pieces for the rescue, as well as the technical pieces of the medicine being employed at that point, would significantly delay being able to short-haul that patient out. What we have done multiple times is that the rangers package those patients up and provide some O2, and position them well to protect their airways as best as possible. They are short-hauled out to the rescue, where they set up a miniature ER. Once that patient reaches that point, that is the right spot to start then to employ airway management and some of those more advanced techniques before handing off to either the ground ambulance or HCMS for the next transport.

In the past, you have mentioned honing good basic life support training for many rescuers along that chain of command and putting off Advanced Life Support or ALS to keep things simple in the field. Along with the other partners in your group, you guys all foster a robust culture that hammers home simple protocols to patrollers, rangers, paramedics, and search and rescue members. Why are solid BLS skills so essential? What are the nuances of when to pull the trigger in performing more invasive lifesaving skills?

It is true that good ALS care is only effective when it is provided on a solid foundation of great BLS care. One of the rules that Will and I have learned over the years must be very tactical on when we do employ ALS skills in the field. The majority of the stuff we do are directing BLS skills in the field and then directing our advanced providers or ourselves as to when those appropriate times to do an ALS intervention. It is typically only when it is absolutely necessary.

Perhaps the exception would be pain control. I do think that we are getting better and better at providing pain control and being more humane to people when we are able to rescue them. Outside of that realm, we are doing very little to manage airways, splinting people, and very little IV management because it is very difficult to maintain in the backcountry. Focusing a lot on those BLS skills, adequate splinting installation, and hypothermia management, which are so important for those patients.

A lot of what we have learned and transferred from different treatment realms is what the military in Iraq and Afghanistan has learned as far as tourniquets in these immediate life threat reversal interventions. Most of the time, it is getting the patient out of that technical, tactical, remote, wilderness or austere environment. The new tiers of difficulty for the military, like Africa and the Pacific, call these tyrannies of distance.

Prolonged field care is the concept of thinking about where TCCC or Tactical Combat Casualty Care is that first hour of care and getting them to the trauma center. Now that prolonged field care is thinking about those hours or days, that is a lot more similar to what we may be dealing with in these search and rescue wilderness environments.

They have got some good mantras in there. Looking at the good, better, and best, you know you are not going to be able to take your whole ICU out to the patient field, so, “What is the good?” It is the AED with the view screen, it is unlimited airway oxygen supplies, pain control, and then where you are going to intervene with those skills. Make a conscious decision as to where in that extraction paradigm you are going to be doing those specific interventions. It has got some good crossovers that have been helpful for us to do what is right for that patient at that right point in time with the rescue.

Dr. Smith, I also liked what you said in a conversation you had with Jeff before we did this episode where you said that what saves a life is good CPR, early recognition, and defibrillation. That applies to people who do not necessarily have medical training and people who do have medical training. That was a great point to make. Early recognition, good CPR, and then if you have an AED, defibrillation.

The chain of survival that we have learned about for the American Heart Association is why we see AED scan in airports and all these different places, that basic life support skillset, and now we are seeing the STOP THE BLEED campaign and the kits that are next to them, tourniquets and wound packing. Those are a lot of the same interventions that we do at a terrain platform to the same thing we would be doing in the backcountry. Some of that patient care carries over with the same priorities.

The outdoors is anything but perfect when it comes to weather resources, information, and personnel. Before you can even begin to assess the patient, you often have to find the patient and then deal with the external factors I mentioned. For example, Dr. Smith, you were involved in an overnight search and rescue for a snowboarder caught in an avalanche on Taylor Mountain, West of Teton pass in which the reporting party witnessed the avalanche but was unable to locate her partner with an avalanche transceiver. It is a handheld electronic device that is typically worn under the jacket with a harness around the chest, and it emits a signal. If you are buried, others in your party can switch their receivers to receive and use the search mode to locate their partners buried below the snow surface.

Avalanche and weather conditions were impeding the rescue ops that night and, at one point, were suspended throughout the evening and resumed the following morning with heli bombing for rescue or safety, which is simply hovering over avalanche paths and dropping explosive charges onto the slope to mitigate the hazard.

Those are always tough decisions. Using that incident command, one person needs to make that decision of go or no-go with some input from others. We were able to get out there and do a hasty search to try and see if there was somebody with a high chance or probability of survival. Once we were able to do that, the night and the dark coming in, the chance of survival was very low to zero. The rest of the rescuers were very high. Those are the decision points that we try and look at balancing all the factors that we are able to, and then go in the next day. Sometimes that is a recovery, and that is some of the mantras that we know there are going to be patients that are going to survive regardless of what we do.

There are going to be patients that die regardless of what we do, and then, in that case, that patient was already deceased. There is that small subset of patients where we were able to get in there and do that immediate reversal of a life threat. That is what we strive for but realizing that there are going to be patients that are not able to survive. The rest of the team is so great.

These imperfect conditions are standard fare in the field of medicine. How does each of you moves forward making decisions with basic life support measures?

One of the mantras that I like to use is ideal to real care. I know the ideal care situation is if it was on the side of a road, we call 3 ambulances, 2 firetrucks, and a big extrication crew. Sometimes the real care that we are able to provide in the backcountry is much more limited to that. It is understanding those differences.

Looking at the priorities, we mentioned earlier in real situations where the weather is bad or it is late and getting dark. We know that ideal care would be to provide pain control and spend time splinting a patient. The reality is that we have fifteen minutes to get that patient into the helicopter and be en route back to the landing zone to extricate them.

What saves a life is good CPR, early recognition, and defibrillation.

The decision often becomes, “We are prioritizing transport first because if not, we are all spending the night here.” It is not ideal for the patient. It is a hasty packaging. We are certainly still trying to prioritize patient care, making sure we are not harming patients and missing something important. We are pushing other things to the side to be able to accomplish the mission within the constraints we are given.

Are there any new protocols coming down the pike in wilderness medicine?

The prolonged field care guidelines that the military is looking at, those have come out on It is where the military puts a lot of its joint trauma systems, some of its consensus guidelines, and papers. That prolonged field care, so that good, better, best concept looking at the mantra of rock, truck, house, and airplane. As you are potentially treating a patient, what can you carry on your back? What can you carry in a vehicle that is potentially going with you and for search and rescue that may bear our helicopter or one of our razors?

In those situations where they may be in the middle of Africa and waiting for extraction, they may be taking care of a patient and then in a house or in an airplane for hours on end. Some of those are some of those things. has all those that are open source to the public, best practices that are out there that are coming up and being more focused.

When you look at the level of providers that we work with as medical directors, you have wilderness first aid, wilderness first responder, OEC, Outdoor Emergency Care, and then Emergency Medical Technicians and EMTs. The background to those courses is fairly limited. The time you are spending in that education, while significant, leads them to be very protocol-driven. Those protocols tend to be very black and white at that level. As you advance to AEMT, paramedic level providers, and nurses in the field, the broader education behind those providers allows them to have more breadth of scope in their protocols and more leeway to make decisions.

One of the tasks that Will and I have taken and with our education is trying to take all of our providers and help them understand the decision framework that we, as physicians, employ when we are in that wilderness environment and by working with our providers and helping them understand that decision-making gives them more options and leeway in the field. We have radio failure protocols and talk to our providers about the what-ifs. We can run them through those scenarios and feel confident that they are going to make decisions in a similar way that we would if we were on the scene.

Walk me through a typical rescue. What would that look like for each of you in your different positions?

We could start with a basic one. For example, there is a rescue in one of the adjacent canyons outside of the Jackson Hole Mountain Resort, in which we have to leave the resort into the backcountry. We would send a small little hasty party out to assess the situation and get a scene size-up and number of patients. One of the things that we focused on that an old climbing ranger told us was to do the mid-scale. It was the mechanism, the injuries, and the vitals. That way, we can send a quick, succinct picture that Dr. Smith and Wheeler can be like, “This is what happened. These are the injuries. These are the vitals.”

Before they even get on the ship and come help us, they already have a good idea of what they are looking at. For my part as a first responder, we try to show up and paint a quick picture so that people up the chain of command have a good idea of what they are going to be doing before they even leave the hangar.

One of the most important vital signs that we often look at is mental status. If you have a patient that is unresponsive, that may be from lots of different causes but that is more of an emergency versus a patient with normal mental status. A lot of times, by the time we are able to access that patient, their ultimate disease course or progression have taken place. Mental status is one that we use a lot to help guide us on what we want to do.

To go into that the anatomy of a search and rescue call, when someone, at least in our area, is in the backcountry and gets injured, typically that call starts with them reaching out to 911. Our emergency dispatchers are amazing when they recognize that the call is in the backcountry. They are usually able to follow that call if it is at the resort or close to the resort, to the mountain station at Jackson Hole Mountain Resort or directly to the Teton County Search and Rescue board, which is a group of 7 or 8 of us that will receive a page. We need to call dispatch if there is a potential rescue.

Will and I are both parts of that mechanism. We will often, early on, hear the very basics of what is going on. If somebody called and said they were in this location and that they were hurt or needed rescue, our initial decision right at that point is, “Is this a rescue or not? Are we paging the rest of the team? Are we getting other agencies involved?” Sometimes it is not. Sometimes it is somebody who is lost, and we need to get in touch with them. More often than not, it is a rescue. We wind up paging our team and reaching out to other organizations that might have people closer.

Jackson Hole Mountain Resort is a great example of that. The patrol there is awesome at responding to out of bounds backcountry injuries and helping us with that by getting somebody on the scene early. We start to employ that risk mitigation and those deeper decisions on, “How are we going to access this patient, given their location?” That is the behind the scenes walkthrough of the anatomy of how we organize our search and rescue here.

What is something that our readers can do to avoid becoming wilderness victims?

Companion rescue is paramount in the backcountry for the most part. If someone in your party is swept away in an avalanche, you are the rescuers, at least at first. Personal responsibility is very real when there is no ski patrol headed out when you are binding breaks, let alone your leg. We owe it to ourselves and others in our party to be versed in basic first aid and some semblance of self-evacuation in the event of broken gear or worse. For the record, backcountry gear, which includes telemark, split boards, and alpine touring, has gotten dialed in over the last decade but it is still not infallible.

TED 60 | Wilderness Medicine
Wilderness Medicine: Make sure you are going with good people and have the right training before you get out, whether or not that is the avalanche skills or the first aid skills.

Take a wilderness first aid class. Take avalanche courses. Go with good people. If you can, find good mentors that have good backcountry habits. Nobody is perfect but I was lucky to go out with good people. I have been lucky in my life. I have made lots of mistakes but I have been blessed with having good mentors in the backcountry.

The big thing is prevention, and we always talk about that. Having the right training before you get out, whether or not that is the avalanche skills or the first aid skills. Make sure you are going with good people. There is a very common theme. Make sure you have shared with any loved ones, friends or family when you are expected back and when to push the big red button and call for help. We always had variations when we started going to these backcountries. There is always a buffer zone but the technology with cell phones, with personal locator beacons, X spots, and in-reaches. There is a lot more communication that can be done.

Sometimes it is erroneous communication and sometimes erroneous signal. We go out for those but it has definitely helped with two-way communication to and from a party to know what is going on. Those are all the components, and then something does happen, I have the number one rule that I use for my kids, “Don’t freak out.” Being able to take a deep breath, assess the situation, and then do what you need to do. Those are my big tips.

I have a very similar take. Our Teton County Search and Rescue Foundation or nonprofit arm, which focuses on our preventative search and rescue, has the motto of, “Be prepared, be practiced, and be present.” Be prepared and have the right equipment for the environment you are going in. Be practiced. You need to know how to use that equipment and then, as Dr. Smith pointed out, be present. Staying calm, which is certainly easier said than done but calm is contagious. If you are able to use your most important tool, your brain, by staying calm, you can make good decisions and make sure that you do not make a bad situation worse.

What is one thing that you would recommend our readers can do if they come across a wilderness injury or a search and rescue scenario?

As someone like me with limited medical training, the best thing you can do if you do have to push the red button, if you have communication, calmly paint a very succinct, good picture. A lot of people ski with cell phones. If you know how to find your coordinates, if you can give them your location and a very distinct or succinct description of what your injuries are and where you are, you are going to help your cause go a long way.

There is no doubt that cell phones and GPS have dramatically changed what search and rescue is. By far, the most useful thing that you can know is how to use your cell phone to provide your GPS coordinates for search and rescue. Once we know where you are, it is easier to come and assist.

We use the acronym LATE, Locate, Access, Treat, Extricate. Once we get in that first part of the search and rescue LATE acronym done, I would say, “Do not freak out.” Use your mind, slow down, figure out what you need to do, come up with a plan, and again, do not freak out.

Can you recommend any resources for our readers who might be interested in becoming wilderness medical providers?

I would defer to Dr. Smith and Dr. Wheeler. I know the Wilderness Medical Institute is connected with NOLS but I am sure those guys can speak a lot more to that.

There are lots of different wilderness medical teaching agencies out there. I am now the Medical Director for Wilderness Medical Associates International. I had the privilege of taking over from Dr. David Johnson for that organization. There are numerous ones out there. Look in your local area for what is available, looking at what already local resources you have in place but there are several ones out there. There are different levels that were mentioned. Wilderness first aid, wilderness advanced first aid, and wilderness first responder is the biggest one that is out there. It goes into that medical decision-making of being out there in the field and sometimes in a prolonged situation, you know what to do.

You can move up to wilderness EMT. You can be a wilderness paramedic or other wilderness advanced practice provider and then get up to wilderness physician. As you get higher up, there are not as many card-carrying certifications out there but it is more that it is going to be medical decision-making and preparation as far as being able to work you up through those skill levels.

My recommendation will be if your general plan is day trips and wilderness first aid courses through one of the companies that Dr. Smith mentioned. If you are doing multi-day trips, a wilderness first responder is great. That level or above is appropriate for search and rescue providers. As we mentioned earlier, throughout the country, in the US at least, search and rescue is mostly a volunteer organization. Volunteering with search and rescue organizations is a great way to learn more about this as well. Most of those organizations are either paying for you to take a course or internally teaching wilderness medicine in some scope.

If you are a medical provider of any sort, the Wilderness Medical Society is a great resource and has a lot of interesting courses for different types of scenarios.

I have been a member for quite a long time.

There's no doubt that cell phones and GPS have dramatically changed what search and rescue is.

Do any of you guys have any final comments, stories or anything would like to add or share?

I am going to put in a plug for our search and rescue podcast, The Fine Line. If you want to hear some more stories about what search and rescue and the Tetons in our region alike, it is a great podcast.

For plugging other places to go listen to, Seth Hawkins and David Fifer do RAW Medicine. They also do a lot of wilderness medicine topics and things. Steve Rush has a PJ Medcast podcast. It has got a lot of good information. A lot of these things that crossover between the military to the wilderness to other austere settings, there are a lot of lessons learned that could be shared.

Thank you all so much for joining us. I appreciated all of the knowledge that you were able to share. That is it for this episode. Thank you as always for reading. Our guests were Jeff Burke, Dr. Albert Wheeler, and Dr. Will Smith. This episode was written by Jeff Burke and was sponsored by the National Geographic Society’s Emergency Fund for Journalists. If you liked what you read, please give us a like, rating, or comment. This was the last episode of season two of The Emergency Docs. Please consider subscribing or following us on Instagram if you would like to be notified when we start season three. Until next time and next season.

Important Links

About Jeff Burke

Jeff Burke is a freelance writer based in Jackson, Wyoming, and has written about outdoor and mountain culture for over 20 years. His work has appeared in Skiing, Outside, Climbing, Backcountry, Backpacker, Men’s Journal, Nat Geo Adventure, Alpinist, Powder, Mountain, UFC Magazine, and Wall St. Journal, as well as many other regional publications and websites.

Additionally, he’s provided technical copy, commercial scripts, press releases, and blog content for outdoor manufacturers such as Arc’teryx, Scarpa, Gregory, Polartec, G3, Flylow, GU, Black Diamond and Mammut. In 2015, He was hired by Teton Gravity Research film company to write the narration and storyline for the feature length documentary “Born to be Wild” for Jackson Hole Mountain Resort’s 50th anniversary.

Jeff Burke is also a year-round ski/mountain patroller for the Jackson Hole Mountain Resort.

About Dr. AJ Wheeler

Dr. Wheeler is Co-Medical Director and active member of Teton County Search and Rescue and Co-Medical Director of Grand Teton National Park EMS and Bridger Teton National Forest. Dr. Wheeler also works actively with Jackson Hole Ski Patrol and Grand Targhee Ski Patrol whose medical direction is obtained through his Emergency Medicine Group.

He also is associate faculty at the University of Utah and works closely with the Wilderness Medicine Fellowship there to provide an experience in Search and Rescue and Research into Wilderness Medicine.

About Dr. Will Smith

Dr. Smith practices Emergency Medicine in Jackson Hole, Wyoming and is a Clinical Assistant Professor for the University of Washington School of Medicine. He serves as Medical Director for Wilderness Medial Associates International and several other organizations.

Locally, he serves as the Co-Medical Director for Grand Teton National Park, Teton County Search & Rescue, Bridger Teton National Forest, and Jackson Hole Fire/EMS. Dr. Smith also serves as a Colonel in the U.S. Army Reserve Medical Corps. COL Smith has practiced medicine around the world on 6 continents, from the 'Baghdad ER' to Easter Island.

His combat experience combined with his pre-hospital EMS experience as a Paramedic, and his technical Search and Rescue skills have led to numerous speaking engagements at Wilderness and EMS conferences/seminars around the world.

Dr. Smith has also been appointed to several national committees (American Heart Association), authored numerous book chapters and consensus guidelines on Wilderness and Rescue Medicine, and serves as a Subject Matter Expert for DARPA. He has founded and runs Wilderness and Emergency Medicine Consulting (WEMC), LLC. More information can be found at


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