In early June, I took my biannual Wilderness First Responder (WFR) and CPR recertification courses. Between refreshers of the patient-assessment system and rescue breaths, I thought about the instances over the past eight years when I’ve had to apply my training.

As a new WFR in 2011, I remember being intimidated by the number of medical scenarios for which I’d been “trained.” For those who feel similarly, or those interested in the operations of an organization like mine, which has guided a cumulative 625 clients on 85 trips, I thought I would share my experiences.

I guide backpacking trips and specialize in high routes and long-distance trails. My clients tend to be between 30 and 60 years old and of above-average fitness, and they skew male by a two-to-one margin. My trips are three to seven days long, and I run them mostly in the Mountain West, though sometimes in Alaska and the eastern woodlands.

If you will were leading, say, monthlong canoe trips in Minnesota’s Boundary Waters Canoe Area Wilderness with at-risk teens, your experiences would probably be different.

For the sake of confidentiality, I have changed the names of clients in the following text.

Evacuations

I’ve had to organize four medical evacuations.

Ethan strained his knee while crossing a wet, rocky moraine in Alaska. We self-evacuated by pack-rafting down the Little Delta River.

Jennifer experienced an intestinal blockage, which had happened to her six months earlier, too. We slowly walked her out to a nearby trailhead, and her partner drove them to a nearby hospital.

Paul suffered a deep cut on his heel when a nearby boulder shifted, wedging his foot. I thought I could see his Achilles tendon. He heroically self-evacuated, which involved a 25-mile hike with 5,000 vertical feet of gain, and then drove himself to the hospital.

Finally, Vic severely strained his lateral collateral ligament (LCL) when he stumbled on a washed-out trail and hyperextended his knee. A helicopter evacuation was necessary, due to our location on California’s Upper Kern River, where we were separated from the nearest trailhead by 20 miles and a 13,000-foot pass.

The prospect of another evacuation (or worse) makes me anxious, sometimes to the degree that I think about closing my program. Thankfully, they’re the exception, and most of our medical issues are easily manageable.

Run-of-the-Mill Injuries

Most scenarious I deal with are relatively simple and fall into four categories.

Foot Issues

The worst blisters I’ve ever seen belong to Guy. He developed hot spots on the first afternoon, but we didn’t address them until camp. There, I found deep quarter-size blisters on both forefeet and swore to never make that mistake again. Guy was remarkably tough, though, and still managed to finish a seven-day John Muir Trail thru-hike.

Maceration is common on wet trips. Most clients are familiar with my recommended treatment, and guides are good about forcing clients to stay on top of it.

Aches, Pains, and Overuse

Few of my clients arrive already trail hardened. Most are professionals, have families, and are involved in their community, so their training time is limited and thus mostly restricted to short but intense exercise (e.g., running, HIIT workouts). They’re unaccustomed to spending long days on their feet and carrying an overnight kit.

To prevent and address ensuing aches and overuse injuries, I recommend carrying a personal supply of ibuprofen, and I moderate a client’s efforts early on so they don’t fall apart after the turnaround. Sometimes I ask each client to specify their biggest physical complaint and assign a pain rating (out of ten) to it, which gets better results than simply asking, “How does everyone feel?”

Hydration and Nutrition

I have no notable stories about dehydration. My best prevention tactic is periodically asking clients when they last peed. When seven clients report peeing at lunch or even more recently, but one person reports last peeing at the trailhead, it’s clear who needs to drink more.

Nutrition seems best managed by watching for changes in a client’s personality or performance. A lack of calories could explain why, say, a normally pleasant client seems slightly agitated or why a front-of-the-pack client drops behind on a climb.

Two clients of mine have tried to follow strict keto diets, and both bonked hard after a few days on the trail. It seemed as if their bodies lacked the necessary fuel for full functionality, so they were shadows of themselves. The solution was having them trade their jerky and pork rinds for the chocolate and Fritos that other clients had.

Insect Bites

Five years ago, Bob, Samantha, and Adam all contracted Lyme disease after a May trip in the Blue Ridge Mountains. Thankfully, they were quickly treated. On our more recent West Virginia trips, we alerted clients of this risk, recommended precautions (e.g., repellents and permethrin-treated clothing), and tried to steer clear of tick-infested areas like meadows. We didn’t find a single tick, but I can’t say whether these measures made a difference, as it was unseasonably cold and wet.

Strains, Sprains, Breaks, and Cuts

Rhett hyperextended his knee slightly on Stanton Pass, in the Sierra, when we tried to push over it just before dinner. To further illustrate our erred judgement, an hour later Bill scraped his shin on sharp talus. We should have just saved the pass for the next morning when we wouldn’t have been tired.

On an off-trail descent, Matt badly sprained his ankle, which we taped for extra support. Interestingly, the incident occurred after the most difficult section.

After Paul (mentioned above, who cut his heel) was badly injured we divvied up his gear and rapidly began descending a tight canyon that involved multiple crossings of a small creek. One client, Bill, was carrying his own backpack as well as Paul’s nearly empty pack, which made for an unwieldy load. He slipped during one of these crossings and landed hard on his hand. We splinted it later that day, when it became clear to Bill that he could not just simply walk off the pain. A post-trip X-ray revealed that he’d broken two or three metatarsals.

There’s a lesson here: after an emergency, check your own level of panic and that of the group, and bring it back to near normal to avoid a subsequent emergency.

Altitude Sickness

On our Mountain West trips, trailheads are often at 7,000 to 8,500 feet, and all the trails climb higher. I learned quickly that clients often need to acclimate more cautiously, especially if they live at sea level. In 2011, on two of my three trips, clients developed acute mountain sickness. The number of altitude-related issues has declined, because most clients now arrive at least two days early, giving them more time to acclimate and work through the initial symptoms (e.g., headache, fatigue, restless sleep). But such instances still occur—last year, Rick from Seattle responded badly and had to be walked out, despite having acclimated properly.

Giardia and GI Distress

My guides and I carry a group supply of Aquamira water-treatment drops, which in my program have achieved excellent results. Only five clients have developed giardiasis, always after returning home and always after drinking unpurified water (intentionally or accidentally).

Katie and Elizabeth developed flu-like symptoms, presumably contracted from another client or another traveler. The solution was over-the-counter medications and rest—and a day hike for everyone else—which gave them an opportunity to recover and finish the trip.

Trends

I don’t keep a detailed record of every blister, sprain, and evacuation. Anecdotally, at least, I think our safety record has steadily improved, which I attribute mostly to:

More stringent vetting of clients, to ensure that we have groups of similarly abled people and that every client is reasonably qualified for their trip

More experience around clients, enabling us to recognize telltale warning signs and to know the limits of our clients better than they do

Greater familiarity with the terrain, conditions, hazards, and common itineraries of our go-to locations

What do these factors have in common? They’re all preventative. Unforgivably, in my opinion, the NOLS WFR curriculum omits any discussion about ways in which medical situations can be avoided—it’s entirely reactive.