During my first year of medical school, I attended a three-day wilderness medicine conference in Roanoke, VA. My main takeaway was that I knew way less than I thought about spending time outdoors, let alone surviving in the wilderness with “just an inconvenient night out” as Peter Kummerfeldt, one of our first lecturers and an outdoor survivalist instructor, would be apt to say multiple times during the 2019 Wilderness Medical Society (WMS) medical student rotation in February. Before the conference I had been tent camping and day hiking many times, but I had very limited knowledge when it came to carrying an injured or ill person out of rough terrain using only what I had, tying simple knots, or the best items to carry with me to prevent and manage medical and traumatic problems when I went backpacking.

 So, for three years in a row I returned to the conference, learning a little more each year. It was during my third conference that I learned about the WMS Wilderness and Environmental Medicine rotation in Thomas Jefferson National Forest. As someone who still didn’t feel competent in the majority of the Wilderness Medicine conference classes I had attended, and also as a medical student with limited time to get outdoors, I knew I was in for a solid month of learning.

Twenty-four of us, both medical students and residents, were all quickly thrown into the elective, spending the majority of the day learning, both indoors and outdoors, then taking the evenings to decompress when there wasn’t an after-dinner lecture, practicing our knot-tying, playing different games, and casually bonding while reinforcing content and procedures we learned that day. This type of “forming, storming, norming and performing,” is achieved especially well when living and learning together as we did during this month-long course.

We were outdoors throughout much of the course, whether rain, snow or shine, learning various tasks regardless of weather condition. During the first week the weather was perfect, and many of us completed a navigation race in short sleeves. There was a fair amount of cold and mud though, and it ironically snowed the day before our wildfire rescue scenario. Determining and avoiding fire lines with streams of melting snow running all around requires some extended imagination.

By far the most intense (and possibly my favorite) week was the Wilderness First Responder (WFR) course. The skills I learned, not just in medical treatment but also in team leadership and how to function fluidly in a group dynamic, will follow me for the rest of my career.

The WFR course is filled with scenario after scenario, first as a small group of four with a designated team leader. Group leaders changed and groups increased in size with each new scenario until at the end we would all work within one large team. We also took turns playing the role of “patient,” and as the days wore on each new “patient” upped the ante in performance, which in turn upped the performance of the teams. It’s surprising how hairy (and sometimes hilarious) things can get when you have ten medical students running around trying to safely maneuver an intoxicated and screaming “patient” with an open femur fracture and upper arm laceration into a litter 45-feet up a steep incline.

One unexpected lesson in these scenarios was learning to step back and remain hands-off when in the role of leader. As students and residents, many of us are still accustomed to being the cog in patient care. As leader I had to physically grab my wrist behind my back to keep from jumping in and stabilizing a C-spine. If I was on the ground holding pressure on an abdominal wound, I couldn’t properly direct another team member where I wanted the litter or make sure someone else had called ahead to ensure the helicopter would be ready to receive us.

But we all learned and by day four we flowed, if not like a well-oiled machine, at least like a bicycle with two good wheels. We were ready for the Night Scenario, a sort of culmination to the four days of training and scenarios in the WFR course. For this we would function as one large team, conducting a mass search and rescue within the 450+ acres the lodge was located on, triaging the patients and then administering medical management. An Incident Commander was selected to run the show, and each of us was assigned a role. Structure and preparedness were essential. With headlamps on we stuffed what we thought we’d need in our bags: splints, tourniquets, water, bandages, maps, and more.

At 6:30 pm we received our report: an airplane had gone down somewhere on the property, and we were given a general idea of direction from an eye witness. With two-way radios in-hand, we dispatched our search and rescue teams only to hear over the staticky intercom ten minutes later that there had actually been a mid-air collision, and there was likely another crash site in the vicinity with 12 victims total.

As part of the triage group my teammate and I searched slowly through the surrounding woods with our flashlights, calling out every 100 feet. It was eerily quiet, and the shouts of other searchers echoed back to us until the first screams of the victims being found cut the silence. One was continuously blood curdling.

“Group 5, this is group 2. We’ve located seven patients.”

“Group 2, this is group 5. What are their triage colors?”

Among the seven patients was a mother and her baby. Mom was labelled green (mild injuries), but her baby had been labelled black, meaning baby had not survived the crash. My teammate and I looked at each other, each mouthing the word “whoa.” Even in simulation the information carried weight.

We worked from 6:30pm to 1:30am searching, triaging, medically stabilizing, and transporting 14 “patients” back to the main lodge. Twelve had been reported, but reports can be wrong, bystanders can get involved, and situations change. Being in the thick of it, time flew by.

Some of the trickiest parts of search and rescue involve simply moving the patient safely, without injuring them or yourself in the process. We all immediately think about the life-saving maneuvers that need to be employed - throw that tourniquet on quickly, secure the airway. All essential, but once the patient is stabilized, it is unlikely they’ll be walking out on their own power.

Extricating patients from the woods and back to base probably took longer than anything we had to do that night. There were logistics in figuring out how to get them into the litter (one would lose her airway anytime we laid her on her back), haul the litter up the steep terrain they had crashed into, and in determining the trails the patients could be wheeled through.

Finally, at 1:30am we reconvened and debriefed with an overview of the night and how our progression throughout the week had shone. There were failures as well, but every hands-on experience led to a lesson learned, one that hadn’t had to be tested on a real-life emergency. Here are some of the simplest and greatest lessons I learned throughout that week and night, things I would encourage anyone to consider if ever caught in a situation remote from advanced medical care:

1. Be prepared. Whether in your car, backpacking, or traveling internationally there are certain items you should be carrying, and these things are often not applicable to all situations. Each trip requires separate consideration. After the rotation I was able to revise the first aid kit I carry in my car to better reflect what I might actually need in an emergency.

2. If you’re extricating an injured patient from the woods, and they say they can walk out, use your clinical judgement to determine if this is a realistic possibility. Carrying someone for miles can be exhausting.

3. This is a bit of follow-up on the last one, but listen to your patients. They may have something important to contribute. At one point we had several distraught victims who were not injured. Assigning them the task of assisting us help roll another patient on the litter out of the woods allowed other medical personnel to remain behind to continue working, and helped distract the uninjured victims from focusing on the trauma of what they’d just been through. People often want to help in these situations, but they need direction

4. Assign a leader. When the situation gets hectic, having someone established to drive the ship can lead to much swifter problem solving. Many factors play into this such as the size of the group or experience of the leader and others involved. It may not pan out the way any one person wants, but staying calm and communicating without shouting often will lead others to follow by example.

5. Keep your patient warm. With broken bones and bleeding involved, the thought of keeping your patient warm sometimes falls right out of your head, but hypothermia can drop someone fast. Make sure you review their injuries, but actively focus on covering them back up quickly.

There was so much more to this rotation that I could discuss. We went backpacking to Mckafee’s Knob the first weekend off, had the largest bonfire I’ve ever seen with speakers booming throughout the night, and learned to build our own survival kits. We had many other lectures I haven’t mentioned, from people’s experiences building their own non-profit clinic in Peru to being prepared when hiking with someone who has diabetes.

 I was able to meet and get to know so many amazing people throughout the month that came from across the United States and all around the world. We learned together and from one another, forming bonds that, as far as I’m concerned, will last a lifetime. It was an inspiring and one a kind experience, one I would encourage any passionate medical student or resident with even limited knowledge of the outdoors to take advantage of.