Neither wilderness medicine as a distinct area of medical practice nor search and rescue (SAR) theory or practice is part of the standard curriculum for medical students or nursing students in the UK. This is despite the fact that when wilderness medicine is incorporated into a formal curriculum or taught alongside it as short courses, it generally receives very positive feedback. Other authors have noted that students undertaking education and training in wilderness medicine topics find the experience both enjoyable and applicable to their future role as doctors (McGraw and Gluckman, 2005; Fielding 2011). In addition, with the advent of the sub-speciality of pre-hospital emergency medicine (PHEM) in the UK, it is anticipated that doctors will have a more prominent role in the provision of all pre-hospital care services in the future (Intercollegiate Board for Training in Pre-hospital Emergency Medicine, 2014). The Faculty of Pre-hospital Care of the Royal College of Surgeons of Edinburgh has also developed a competence-based system inclusive of practitioners of all professional backgrounds. The authors felt that an understanding of SAR procedures would assist future doctors and allied health professionals working as part of, or alongside, a SAR team (Cooper et al, 2011), and felt that a practical exercise would be an effective way to expose participants to the difficulties in practising medicine in remote environments. It has also been noted that of particular perceived benefit is the exposure of student practitioners to high-fidelity accident scenarios (Fielding, 2011; Mazoyer and Hardern, 2011). Previously, authors have also noted the current paucity of undergraduate medical training in relation to the initial management of patients suffering traumatic injuries and those suffering from other acute events (Smith et al, 2007; Mastoridis et al, 2011). An extensive search of the literature revealed only a small number of articles discussing the provision of education in the area of wilderness medicine to medical students; no articles were found discussing the provision of a SAR exercise for this population.
Over the 2 years since its inception, Warwick Wilderness Medicine Society (WWM) has built up its capacity to develop and deliver training to its members. This is done by utilising and developing the skills within the society, as well as through members attending outside training. Traditionally, as with many university societies, the membership and aims of wilderness medicine societies can vary year on year depending on the skills, time commitments and motivations of committee members. WWM found itself in a similar situation and the committee decided to develop a training programme from first principles.
For an individual to provide effective pre-hospital care in a remote environment they must first be able to maintain their own safety in often difficult environments (Donelan, 2002), and must then be able to practise medicine in a manner appropriate to that environment. Often WWM training, like much wilderness training, addresses either one or the other of these aims. By 2013 WWM had reached a level where the committee felt a SAR scenario could be feasibly organised for 17 participants, with the aim of bringing together the pre-hospital medical management, packaging and transport of casualties in a remote location. The overall aim of this exercise was to not only teach new SAR skills, but also to integrate the two important aims mentioned above, in a way that would be highly educational, inspirational and fun for all participants. This article is an express attempt to disseminate some information learnt from our experiences to assist student interest groups and other education providers in developing their own programmes and training sessions.
Participants
Participants in our exercise were all members of the University of Warwick Wilderness Medicine Society. They were all enrolled on the four-year graduate entry MBChB programme which leads to registration as a medical practitioner in the UK. As graduate entry students, all participants came from various backgrounds, having completed a variety of primary degrees, although the majority of these degrees were science based. Some participants had also completed the optional Pre-hospital Trauma Care module as part of the MBChB course.
Faculty
There were six faculty for the weekend. One was a final year medical student (also a paramedic practitioner), one a junior doctor, three were penultimate year medical students (two of whom were Mountain Leader Award qualified) and all of whom had significant mountain experience and had attended and run multiple wilderness medical training events before. Finally, there was one non-medic who was Mountain Leader Award qualified.
Equipment for the training sessions and SAR exercise were provided by WWM and also from the organisers' personal equipment due to financial limitations. A brief kit list is supplied in Table 1. In addition to this, participants were advised to carry the normal personal equipment needed for a day on the hills. The training day was divided into two periods, a morning skills training and refresher, and an afternoon/evening SAR exercise. During the former period the participants were divided into four groups and rotated through skills stations relevant to the pre-hospital management of a trauma patient. The skills stations can be seen in Table 2.
| 4 x two-way radios |
| Primary survey (30 minutes) |
Search and Rescue exercise
Briefing
The 17 participants were briefed on the exercise scenario—reports of a plane crash in a remote location—and asked to undertake the four stages of a SAR operation: locate, access, stabilise and transport (Cooper et al, 2011). The evacuation plan for the casualties was rendezvous at a set location on the hill top for extrication via a fictitious rescue helicopter.
The participants were provided with maps of the area and then asked to divide the available equipment between themselves, and develop a deployment and search strategy. This style of briefing was chosen to empower the participants, encourage participants' ownership of the exercise and to develop organisational structure. At all times, three members of the faculty were present during the planning stage to assist where required.
Deployment of participants
The participants split themselves into three teams. The first of these teams was to act as a hasty party and carried with them minimal medical equipment. The role of this team was to conduct a Type I search as defined by Cooper et al (2011): to perform a rapid search of high-probability areas and to gain information on the search area. They were deployed in a blue-lighted rapid response vehicle to the closest road to the search area.
The other two teams were deployed from the starting location after a 20-minute delay, imposed by the faculty, arriving at the start of the walk-in approximately 30 minutes after the first team. These teams carried more extensive medical and extrication equipment and were to liaise with the first team at the search area and undertake a Type II search: an efficient search covering a large search area (Cooper et al, 2011). All teams were issued with a radio to enable communications with the other teams. The larger team was accompanied by a member of the faculty who also acted as the search coordinator liaising with a fictitious rescue helicopter.
While the exercise was designed to replicate, as accurately as possible, the experience of members of a SAR team responding to an incident, it had to be treated as a priority second to that of maintaining the safety of the participants. For example, mountain rescue teams in the UK may deploy two responders to rapidly reach a casualty and administer pain relief ahead of the arrival of other members of the team with further equipment for treatment and evacuation (Yarwood, 2010). Such an approach was not left open to the participants in the exercise as it was felt a group of two participants was an unnecessary risk. The location of the search area was specifically chosen to allow for all participants to be observed by members of the faculty from the adjacent hill without intrusion. All of the participants were accounted for on arrival at the search area. From then on all participants and faculty remained within sight of each other. This remained true for the descent after the exercise and all individuals were accounted for upon their return to a pre-planned rendezvous point. The faculty, all experienced mountaineers, also ensured the safe deployment and recovery of the simulated casualties and the other faculty members.
Simulated patients, evacuation and the students' management of patients
All simulated patients were dressed in flight jumpsuits with helmets and with improvised parachutes attached; old sheets and parachute cords were used for this purpose.
Casualty one
Casualty one was positioned to be discovered first. This casualty was a full body resuscitation mannequin. A member of the faculty was positioned nearby to guide the resuscitation efforts of the participants, but remained out of sight during the search. The mannequin was lying face down and had to be moved before resuscitation could begin (Figure 1). Resuscitation efforts were allowed to continue for 10 minutes before the faculty member encouraged a discussion among the participants regarding the likely outcome from a blunt force traumatic cardiac arrest and the clinical guidelines relating to pre-hospital resuscitation in multiple casualty situations and remote environments. This discussion ended in the termination of resuscitation attempts, and allowed these participants to assist their colleagues managing the other patients.
‘The authors believe that the exercise presented here shows that focused teaching followed by a high-fidelity exercise is an effective way to teach wilderness medicine and PHEM skills to medical students’
Casualty two
Casualty two was a 20-year-old female who was initially unconscious. She required basic airway manoeuvres and upon correct airway management she responded to painful stimuli. Further examination identified suspected chest wall, pelvic and right leg injuries. This casualty required airway support with basic manoeuvres, spinal immobilisation and application of a pelvic binder and a box splint to the lower limb prior to evacuation.
Casualty three
Casualty three was a 24-year-old male who initially presented with symptoms of a dislocated left shoulder. The patient subsequently became agitated and complained of abdominal pain with their radial pulse eventually becoming impalpable. This patient required spinal immobilisation, supportive treatment with intravenous fluids once radial pulses were lost, close monitoring and rapid evacuation.
Casualty evacuation
After stabilisation and treatment of the casualties, the participants were required to package and evacuate the resuscitation mannequin to the helicopter landing site. On safety grounds the mannequin was used rather than the volunteer patients for this part of the exercise.
Seven students worked in rotation carrying the patient, giving them an idea of the difficulties associated with transporting a casualty over uneven terrain for extended distances. At the helicopter rescue point at the hill's summit, the SAR exercise was concluded. This was approximately 3 hours from the initial deployment.
Feedback
Feedback was obtained from all 17 participants opportunistically in an informal manner, and also in the form of the Dundee Ready Education Environment Measure (DREEM) tool (Roff et al, 1997), which was sent to participants as a survey 3 days after the training day. However, too few responses were received to allow structured and statistical interpretation of the results. The feedback received was overwhelmingly positive and the high-fidelity nature of the exercise was particularly praised by a number of participants. The transportation of the mannequin over the 500 metres of challenging terrain to the helicopter landing site was found to be a particularly useful exercise by the students. However, students felt that when the faculty members were not in close proximity to the actors the realism of the exercise started to diminish. A number of participants feedback stated that they felt the scenario would be better if taken more seriously by participants. Additional feedback stated that more defined team roles before deployment would have been useful for some participants and that no assumptions should be made about the ability of the students to manage the casualties and that all skills required should be taught earlier in the weekend.
Discussion
The faculty felt participants managed the scenario effectively. The casualties were located within approximately 45 minutes of the search commencing and were appropriately managed. The faculty perceived that the high-fidelity nature of the scenario allowed students to experience the practical challenges associated with medical practice in a remote environment—for example, wind speeds, cold temperatures and distances between casualties and team members. This caused the participants to experience and overcome difficulties with tasks such as: simulated insertion of cannulae, using tape and bandages, managing giving sets for infusions, and maintaining comfortable body temperatures of both casualties and participants.
The feedback received from the session was very positive, with only some areas for potential improvement. This is in keeping with the findings of other authors who have found that simulations are generally very well received in wilderness medicine teaching (Mazoyer and Hardern, 2011). A number of areas for improvement were raised from feedback received from participants and from the debriefing and informal discussions among the faculty. Three key learning points are summarised below along with some proposed strategies to mitigate these factors in future exercises.
Firstly, participants identified that they may have benefited from more clearly defined team roles. This limitation could have been averted through the following actions. Team roles could be allocated beforehand by faculty members during the briefing session. This could have been reinforced by identifiable clothing, similar to those used in in-hospital trauma teams. Secondly, participants felt the scenario would be more productive if it had been taken more seriously by the participants. While this is essentially an issue only solved through the attitudes of the participants, their attitudes towards the scenario may be changed by having more senior clinicians as faculty, and perhaps by having the faculty members providing closer supervision and feedback during the scenario.
Lastly, a number of participants identified that there had been inadequate refresher skills training prior to deployment of the search teams in this exercise. This identification of training needs included the management of a patient beyond the primary and secondary surveys, and non-medical skills such as the use of a map and compass and radio communication procedures. In our exercise we undertook one day's worth of skills training prior to the search and rescue scenario. This could be extended to two days of skills training followed by an evening exercise.
We also feel that we performed some aspects of the planning and execution very well, and identified issues key to the successful execution of the search and rescue exercise. Three of these key points are identified below.
An essential piece of prior preparation was to contact the local authorities in the search area. Having a discussion prior to the exercise with the local police force, to gain their permission to deploy the search and rescue team in a vehicle fitted with blue lights and sirens, and also to inform them that there will be radio traffic in the area, was essential to avoid false alarms from members of the public.
We felt that the availability of appropriate medical and logistical items was essential to increasing the realism of the exercise, this included providing the simulated patients with flightsuits and ‘parachutes’. Provision of a sufficient amount of medical equipment allowed the participants to undertake simulated patient care to a high level, and also to gain experience using various pieces of equipment. The provision of handheld radios also increased the real world safety of the exercise and added the element of radio communications and team coordination to the scenario.
The ability to use volunteer patients previously unknown to the participants helped promote a professional attitude towards patient care. While working with these volunteers, we noted that in our case, the use of non-medical volunteers allowed them to react appropriately to medical interventions and required these interventions to be adequately explained to reassure the patient. However, additional briefing and preparation of volunteers was required to allow for realistic simulations of their illnesses and injuries.
Conclusions
Medical practice in remote environments and search and rescue work is challenging and generally not addressed in medical degrees in the UK, despite pre-hospital emergency medicine now being a recognised sub-specialty. However, doctors interested in adventure sports, international expeditions and work in the PHEM sub-specialty may find themselves in a position where they need to manage initial SAR efforts and treat patients in difficult environments. The authors believe that the exercise presented here shows that focused teaching followed by a high-fidelity exercise is an effective way to teach wilderness medicine and PHEM skills to medical students. In addition, this exercise also provides practical experience of the challenges involved in working outdoors, something not easily conveyed in a classroom. Further to this the authors have shown that such scenarios can be effectively run for students by students, as long as the faculty as a whole are sufficiently experienced medically and in terms of outdoor skills. We do recognise, however, that this exercise would have benefited from the input of physicians with specific experience in search and rescue activities.
There is little guidance in the literature about how to develop a student wilderness medicine society and how to run student-led wilderness training events. This is despite there being approximately 20 wilderness medicine student societies in the UK, and many more internationally. Furthermore, from our experience, many members of such student societies often express a desire for information on this topic each year at the National Student Wilderness Medical Conference in the UK. This is the first such article aiming to assist these societies in planning and running more realistic training exercises for their members. The authors would welcome further discussion around student-led initiatives in the sub-specialty of PHEM and the developing area of wilderness medicine.