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Title: Wilderness Survival, Preparedness and Prevention


1
Wilderness Survival, Preparedness and Prevention
  • Matt Hamonko MD, MPH, FAAEM, FAWM

2
Rule of 3s
  • 3 minutes without air
  • 3 hours without shelter
  • 3 days without water
  • 3 weeks without food
  • 3 months without hope

3
Air
  • Barrier to survival water
  • Solid
  • Liquid

4
Air
  • Cause of Avalanche related mortality
  • Avalanche related deaths in Utah
  • 1989 -90 to 2005-06 season
  • 56 deaths
  • 85.7 caused by asphyxiation
  • 8.9 caused by asphyxiation trauma
  • 5.4 caused by trauma (most head injuries)

Mcintosh SE, Grissom CK, Olivares CR, Kim HS,
Tremper B. Cause of Death in Avalanche
Fatalities. Wilderness and Environmental Med.
200718293-97.
5
Air
  • General recommendations for avalanche survival
  • Moving snow yell, escape off the slab, release
    skis, keep pack on, swim
  • Slowing snow expand chest, make an air pocket
    with one hand and extend the other hand towards
    the surface
  • Air pocket may extend survival time up to 90
    minutes
  • Stopped snow relax

Tremper B. Staying Alive in Avalanche Terrain.
2nd ed. Seattle, WA Mountaineer Books
2008. Mcintosh SE, Grissom CK, Olivares CR, Kim
HS, Tremper B. Cause of Death in Avalanche
Fatalities. Wilderness and Environmental Med.
200718293-97.
6
Air
Grissom CK, Radwin MI. Technological Advances in
Avalanche Survival. Wilderness and Environmental
Med. 200213(2)143-52.
7
Air
  • Avalung Study
  • 8 subjects
  • cases 8 subjects using Avalung
  • Controls 7 subjects breathing in 500 ml air
    pocket
  • Duration of burial, O2 saturation, heart rate,
    respiratory rate, end tidal CO2 and inspired CO2
  • Trial stopped at subjects request, 60 minutes or
    O2 saturation measured below 85

Grissom CK, Radwin MI. Technological Advances in
Avalanche Survival. Wilderness and Environmental
Med. 200213(2)143-52.
8
Air
  • Avalung study
  • mean burial time 58 minutes with Avalung, 10
    minutes in controls (p 0.001)
  • O2 saturation decreased to 90 in study group and
    84 in control group (p 0.018, baseline O2 sat
    96)
  • ETCO2 increased to 45 mm Hg in the study group
    and 54 mm Hg in the control group (p 0.018,
    baseline ETCO2 32 mm Hg)

Grissom CK, Radwin MI. Technological Advances in
Avalanche Survival. Wilderness and Environmental
Med. 200213(2)143-52.
9
Air
  • Avalanche Prevention
  • Safety course
  • Shovel
  • Probe
  • beacon

Silverton, NA, McIntosh SE, Kim HS. Avalanche
Safety Practice in Utah. Wilderness and
Environmental Med. 200718264-70.
10
Air
  • Water Submersion Survival
  • Fundamentals maintain respirations and minimize
    heat loss
  • Stay relaxed
  • Turn your head to breath
  • Remain in a curled position
  • Breath rhythmically as body bobs to the surface
  • Avoid swimming long distances (heat loss)

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
11
Air
  • Prevention
  • Avoid false confidence in swimming lessons
  • CPR instruction
  • Flotation devices
  • Buddy swimming
  • Know the depth of the water
  • Prevention
  • Recognize drowning risks
  • Avoid alcohol and drugs
  • Be aware of currents
  • Proper training and maintenance of SCUBA diving
    equipment

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
12
Air
  • Cold Water Submersion
  • Phase 1 cold shock 0-2 minutes
  • Hyperventilation, gasping, arrhythmia
  • Phase 2 cold incapacitation 5-15 minutes
  • Loss of motor control
  • Phase 3 onset of hypothermia 30-60 minutes
  • Phase 4 circum-rescue collapse

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
13
Air
  • Cold Water Submersion
  • Face the direction from where you came
  • Put arms up on ice
  • Kick legs vigorously
  • Bring body into horizontal position
  • Kick and pull forward
  • Crawl or roll away from hole

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
14
Air
  • Vehicle Submersion Study
  • Automobile with intact passenger compartment
  • 63 seconds before water reached bottom of windows
  • 150 seconds for total time to submersion
  • Opening door while floating decreased submersion
    time from 150 to 30 seconds
  • After water reached base of windows subjects were
    unable to exit until the vehicle was submerged
    (pressure on door and window)

Geisbrecht GG, McDonald GK. My Car is Sinking
Automobile Submersion, Lessons in Vehicle Escape.
Aviat Space Environ Med. 2010 81(8) 779-84.
15
Air
  • Vehicle Submersion Study
  • Vehicle exited easiest during flotation phase
    SEATBELT-WINDOWS-CHILDREN-OUT
  • As the vehicle sinks it will assume a vertical
    engine down position
  • The chance of survival if the vehicle is totally
    submerged and on the bottom is negligible
  • Electronics should work for up to 3 minutes
    submerged

Geisbrecht GG, McDonald GK. My Car is Sinking
Automobile Submersion, Lessons in Vehicle Escape.
Aviat Space Environ Med. 2010 81(8) 779-84.
16
Shelter
  • Choosing the location
  • Avoid areas exposed to wind and water
  • Avoid valley bottoms and deep hollows (i.e. cold
    air sinks)
  • Avoid terraces that retain moisture
  • Camp near water but not to close ( i.e. insects)
  • Check for insect nests and dead trees above
  • Avoid spurs leading to water and game trails

Wiseman J. SAS Survival Handbook. 2nd ed. Miami,
Fl. Harper Collins 2003.
17
Shelter
  • Shelter building key points
  • Depends on materials available, tools available,
    and what you are shelter from
  • Consider how long you intend to stay
  • Consider the number in the party
  • Take your time and avoid sweating
  • Ensure adequate ventilation
  • Regularly clear entrances
  • The smaller the shelter the warmer it will be

Wiseman J. SAS Survival Handbook. 2nd ed. Miami,
Fl. Harper Collins 2003.
18
ShelterFire
  • The fire triangle air-heat-fuel
  • Practice, practice, practice..
  • Preparation
  • Tinder, kindling, fuel
  • Choose the fireplace
  • Sheltered
  • Clear away a 2 meter in diameter perimeter
  • Build the fire on a platform if the ground is wet

Wiseman J. SAS Survival Handbook. 2nd ed. Miami,
Fl. Harper Collins 2003.
19
ShelterFire
  • Tinder
  • Required only a spark to light
  • Birch bark, dried grass, wood shavings, down,
    waxed paper, cotton fluff, pine cones, pine
    needles, inner bark
  • Survival kit natural cotton soaked in vasoline
  • Kindling
  • Raise the flame from the tinder
  • Dry twigs, soft woods, resin containing woods

Wiseman J. SAS Survival Handbook. 2nd ed. Miami,
Fl. Harper Collins 2003.
20
ShelterFire
  • Fuel
  • Dry wood
  • Heavier/harder woods burn longer and hotter
  • Hickory, beech, oak
  • Soft woods burn fast and spark
  • Cedar, alder, hemlock, spruce, pine, chestnut,
    willow
  • Damp woods produce smoke
  • May be advantageous for repelling insects and
    signal fire

Wiseman J. SAS Survival Handbook. 2nd ed. Miami,
Fl. Harper Collins 2003.
21
ShelterFire
  • Firelighting
  • Strike anywhere matches
  • Lens
  • Flint and steel
  • Battery
  • Fire bow
  • Hand drill
  • Hand drill

Wiseman J. SAS Survival Handbook. 2nd ed. Miami,
Fl. Harper Collins 2003.
22
ShelterFire
23
Water
  • Requirements
  • Physical and cognitive performance is decreased
    at 1 dehydration
  • Exhaustion and collapse is likely at 7
    dehydration
  • The body can lose over 2 liters/hour by sweating
  • Minimum water loss per day is approx. 2.5 liters
  • Minimum recommended water intake per day to
    sustain physiological function is 1.5 liters
  • Should consume 1 liter/kg weight loss
  • Time to death after total water deprivation 6-14
    days

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
24
Water
  • Finding water
  • Valley bottoms
  • Above high water line on coast
  • Rain water collection
  • Game trails
  • Straight, low flying birds at dawn and dusk
  • insects

Wiseman J. SAS Survival Handbook. 2nd ed. Miami,
Fl. Harper Collins 2003. Auerbach P.
Wilderness Medicine. 5th ed. Philadelphia, PA
Mosby-Elsevier 2007.
25
WaterDisinfection
  • Infectious agents
  • Bacteria, viruses, protozoa, parasites

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
26
WaterDisinfection
  • E. coli
  • Shigella
  • Campylobacter
  • Vibrio cholerae
  • Salmonella
  • Yersinia enterocolitica
  • Aeromonas
  • Hepatitis A
  • Hepatitis E
  • Norovirus
  • Poliovirus
  • Miscellaneous (more than 100 types)
  • Giardia lamblia
  • Entamoeba hystolytica Cryptosporidium
  • Blastocystis hominis
  • Isospora belli
  • Balantidium coli
  • Acanthamoeba
  • Cyclospora
  • Ascaris lumbricoides
  • Ancylostoma duodenale
  • Taenia spp.
  • Fasciola hepatica
  • Drancunculus medinensis
  • Strongyloides stercorlaris
  • Trichuris trichiura
  • Clonorchis sinensis
  • Paragonismus westermani
  • Diphyllobothrium latum
  • Echinococcus granulosus

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
27
WaterDisinfection
  • Water quality key points
  • Clarity is not an indication of purity
  • Cloudiness indicates higher risk of impurity
  • Human and animal activity in the watershed is
    highly indicative of microbe pollution
  • Streams do not purify themselves
  • Settling effect of lakes may make them safer than
    streams
  • Groundwater is general safer than surface water

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Derlet
RW, Carlson JR. Coliform Bacteria in Sierra
Nevada Wilderness Lakes and Streams What is the
Impact of Backpackers, Pack Animals, and Cattle?
Wilderness and Environmental Med.
200617(1)15-20.
28
Water Disinfection
  • Sierra Nevada 5-year Coliform risk factor study
  • 364 samples analyzed
  • Coliforms present
  • 4/47 wild site samples (9)
  • 5/42 day hiker site samples (12)
  • 20/111 backpacker site samples (18)
  • 70/111 pack animal site samples (63)
  • 51/53 cattle site samples (96)
  • Backpacker vs. cattle/pack animal area (p 0.05)

Derlet RW, Ali Ger K, Richards JR, Carlson JR.
Risk Factors for Coliform Bacteria in Backcountry
Lakes and Streams in the Sierra Nevada Mountains
a 5-Year Study. Wilderness and Environmental Med.
200819(2)82-90.
29
WaterDisinfection
  • Terms
  • Clarification reduce turbidity
  • Disinfection kill or destroy nearly all disease
    producing microorganisms except spores
  • Purification removal of organic or inorganic
    chemicals and particulate
  • Sterilization destroy all forms of microbial
    life including spores.

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
30
WaterDisinfection
  • Boiling
  • Kills or inactivates all enteric water borne
    pathogens
  • Old recommendation boil for 10 minutes and add 1
    minute for every 1000 ft. in elevation
  • New recommendation bring to a boil (/- for one
    minute) and altitude is inconsequential
  • WHO bring to a boil
  • CDC boil for one minute

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
31
WaterDisinfection
  • Sedimentation
  • Allow large particles to settle
  • May reduce microorganism load by 90
  • Not recommended as sole form of disinfection
  • Coagulation-flocculation
  • Chemical induced clumping and stirring (i.e.
    alum)
  • Removes 60-98 of bacteria, 65-99 viruses,
    60-99 giardia, 95 helminths
  • Not recommended as sole form of disinfection

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
32
WaterDisinfection
  • Filtration
  • Rated by ability to retain particles of
    particular sizes
  • 0.2 µm enteric bacteria
  • 2.0 µm Giardia and Cryptosporidium cysts
  • 20 µm Helminth eggs and Larvae
  • Inadequate for 100 virus removal
  • 99.99 virus removal rate in 2008 published study

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Gerba CP,
Naranjo JE, Jones EL. Virus Removal from Water by
a Portable Water Treatment Device. Wilderness and
Environmental Med. 200819(1) 45-9.
33
WaterDisinfection
  • Halogens
  • Depends on chemical (i.e. iodine or chlorine)
    concentration, contact time, temperature,
    contaminants and pH.
  • 1-10mg/L for 10-60 minutes considered effective
  • Optimum pH 6.5 to 7.5
  • Cold temperature decreases reaction rate
  • Contaminants may deactivate or physically block
    effect
  • May not be effective or practical for some spores

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
34
WaterDisinfection
  • Betadine (Povidone-Iodine) Study
  • Betadine 10 solution
  • Tested at concentrations of 1100, 11,000 and
    110,000
  • Coliform E.coli
  • Effective bactericidal activity 5 log reduction
    (99.999 kill)
  • 1100 solution effective, 11,000 solution
    effective after 15 minutes of exposure

Heiner JD, Hile DC, Demons ST, Wedmore IS. 10
Povidone-Iodine May Be a Practical Field Water
Disinfectant. Wilderness and Environmental Med.
201021(4)332-36.
35
WaterDisinfection
  • Ultraviolet Light
  • All water borne enteric pathogens are susceptible
  • Required clear water
  • Requires a power source

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
36
WaterDisinfection
  • General Recommendation
  • Use a 2 step process
  • 1 filtration, sedimentation or
    coagulation/flocculation
  • 2 halogen, ultraviolet light

37
Food
  • Non-obese adult male can live 60-70 days in a
    clinical setting with no food
  • All body fat and 1/3 of lean body mass gone
  • Significant loss of muscle strength after 5-10
    weight loss
  • Greater than 50 loss of lean body mass is
    predictive of death
  • Daily recommended wilderness minimum calorie
    intake men 2900 Kcal, women 2200 Kcal

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
38
Food
  • Recommended macronutrient composition
  • 50 carbohydrates
  • 35 fats
  • 15 protein
  • Consider vitamin depletion when
  • Diet is restricted to less than 1200 to 1600 Kcal
    daily
  • Eating habits are disrupted
  • Increased energy expenditure

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
39
FoodProcurement
  • Insects (most reliable source of animal food)
  • Avoid insects feeding on refuse
  • Avoid brightly colored insects (usually
    poisonous)
  • Avoid grubs on the underside of leaves (usually
    poisonous)
  • Preparation
  • Most may be eating raw
  • May also boil, roast, grind into powder
  • Remove legs, wings, hairs

Wiseman J. SAS Survival Handbook. 2nd ed. Miami,
Fl. Harper Collins 2003.
40
FoodProcurement
  • Insects (most reliable source of animal food)
  • Grasshoppers (40-50 protein)
  • Termites (keep for months when roasted)
  • Butterfly and moth larvae (37 protein, 13.7
    fat)
  • Earthworms
  • Beetles and beetle larvae (head, legs, wings not
    digested)
  • Snails (boil for five minutes to remove shell)

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
41
FoodProcurement
  • Mammals, amphibians, reptiles, fish
  • Finding game tracks, feeding signs, droppings,
    rooting, scents, burrows, dens
  • Killing game
  • Snares trap
  • Deadfalls trap
  • Spear trap
  • Nets (birds and fish)
  • Noose
  • Weapons (bow and arrow, sling shot)
  • Fishing

Wiseman J. SAS Survival Handbook. 2nd ed. Miami,
Fl. Harper Collins 2003.
42
FoodProcurement
  • Plants
  • Indicators of toxicity
  • Milky or discolored sap
  • Beans, bulbs or seeds within pods
  • Spines, fine hairs, thorns
  • Dill, carrot, parsnip or parsley like foliage
  • Almond scent
  • Grain heads with pink, purple or black spurs
  • Three leaved growth pattern

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
43
FoodProcurement
  • The Universal Edibility Test
  • Test one part at a time
  • Separate plant into basic components
  • Smell for strong or acrid odors
  • Do not eat for 8 hours prior to test
  • Place plant on elbow/wrist for 15 minutes if
    irritation occurs discard
  • Prepare the plant part how you plan to eat it

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
44
FoodProcurement
  • The Universal Edibility Test (continued)
  • Touch the prepared part to your lips for 3
    minutes
  • Place the plant part on tongue for 15 minutes
  • Chew the plant part and hold in mouth for 15
    minutes DO NOT SWALLOW
  • If no irritation swallow the plant part
  • Wait eight hours, if ill effects occur induce
    vomiting and drink water
  • If no ill effects eat ¼ cup of plant, wait 8 hours

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
45
Survival Preparedness and Prevention
46
Survival Preparedness and Prevention
  • Zion National Park Search and Rescue statistics
    for the 2008-2009 season (N 86)
  • Gender 64.12 male
  • Age 26.36 between the age of 20-29
  • Location 34.92 in mountains or foothills below
    5,000 ft.
  • Activity 52.33 while hiking or day walking
  • Contributing factors 32.69 falls, 22.12
    fatigue physical conditioning, 21.15
    insufficient info and errors in judgment, 9.62
    insufficient equipment /clothing/ experience,
    5.77 darkness, 2.88 heat

47
Survival Preparedness and Prevention
  • Zion National Park public health cross sectional
    study
  • April-May 2010
  • N 519
  • Younger individuals were more likely to carry
    cell phones (P0.009), GPS units (P0.001) and
    greater than 2 liters of water (p0.001)
  • Older individuals were more likely to carry food
    (p0.02)
  • 90 checked the weather, 91.9 first aid kits,
    77.5 map, 37.0 compass, 24.9 GPS, 4 locator
    device, 75.9 cell phones

48
Survival Preparedness and Prevention
  • Search and Rescue (SAR) Studies
  • 12,337 SAR operations in U.S. National Parks from
    2003 to 2006 with 522 fatalities
  • 3,912 cases associated with day hiking
  • 18 activated by cell or satellite phone call
  • Utah 2001-2005 1190 SAR operations
  • 185 cases associated with insufficient clothing,
    or experience, 81 associated with adverse weather

Heggie TW, Heggie TM. Search and Rescue Trends
Associated with Recreational Travel in US
National Parks. Journ of Travel Med. 200916(1)
23-7. Heggie TW, Heggie TM. Search and Rescue
Trends and the Emergency Medical Services
Workload in Utahs National Parks. Wilderness and
Environ Med. 200819164-71.
49
Survival Preparedness and Prevention
  • Search and Rescue Studies
  • Shenandoah National Park 2003-2007
  • Most operations associated with trauma to the
    lower extremities while hiking rather than
    medical illness
  • Yellowstone National Park 2003-2004
  • 38 of operations related to hiking or walking
  • 77.4 of trauma were soft tissue and 56 involved
    the lower extremities
  • 8.3 of operations were related to dehydration,
    hypovolemia or hunger (most common non-traumatic
    cause)

Forrester JD, Holstege CP. Injury and Illness
Encountered in Shenandoah National Park.
Wilderness and Environ Med. 200920318-26. Johnso
n RM, Huettl B, Kocsis V, Chan SB, Kordick MF.
Injuries Sustained at Yellowstone National Park
Requiring Emergency Medical System Activation.
Wilderness and Environ Med. 200718186-9.
50
Survival Preparedness and Prevention
  • Canadian Study (Banff, Yoho, and Kootenay
    National Parks) 2003-2006

Finlay JW. Epidemiology of Mountain Search and
Rescue Operations in Banff, Yoho, and Kootenay
National Parks, 2003-06. Wilderness and
Environmental Med. 200819(4)245-51
51
Survival Preparedness and Prevention
  • NOLS packweight and injury study

Hamonko MT, McIntosh SE, Schimelpfenig T, Leemon
D. Injuries Related to Hiking with a Pack During
National Outdoor Leadership School Courses A
Risk Factor Analysis. Wilderness and
Environmental Medicine. 201122(1)2-6.
52
Personal Survival Kits
  • Recommended Components
  • Fire-building strike anywhere matches, candle,
    cottonvaseline, knife, metal match
  • Shelter-Building parachute chord, tarp, folding
    saw
  • Signaling equipment headlamp, whistle, notebook,
    pencil, signaling mirror, orange tape

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
53
Personal Survival Kits
54
References
  • Mcintosh SE, Grissom CK, Olivares CR, Kim HS,
    Tremper B. Cause of Death in Avalanche
    Fatalities. Wilderness and Environmental Med.
    200718293-97.
  • Tremper B. Staying Alive in Avalanche Terrain.
    2nd ed. Seattle, WA Mountaineer Books 2008.
  • Grissom CK, Radwin MI. Technological Advances in
    Avalanche Survival. Wilderness and Environmental
    Med. 200213(2)143-52.
  • Silverton, NA, McIntosh SE, Kim HS. Avalanche
    Safety Practice in Utah. Wilderness and
    Environmental Med. 200718264-70.
  • Auerbach P. Wilderness Medicine. 5th ed.
    Philadelphia, PA Mosby-Elsevier 2007.
  • http//www.umanitoba.ca/faculties/physed/research/
    people/giesbrecht/Thin_Ice.pdf
  • Geisbrecht GG, McDonald GK. My Car is Sinking
    Automobile Submersion, Lessons in Vehicle Escape.
    Aviat Space Environ Med. 2010 81(8) 779-84.
  • Wiseman J. SAS Survival Handbook. 2nd ed. Miami,
    Fl. Harper Collins 2003.
  • Derlet RW, Carlson JR. Coliform Bacteria in
    Sierra Nevada Wilderness Lakes and Streams What
    is the Impact of Backpackers, Pack Animals, and
    Cattle? Wilderness and Environmental Med.
    200617(1)15-20.
  • Derlet RW, Ali Ger K, Richards JR, Carlson JR.
    Risk Factors for Coliform Bacteria in Backcountry
    Lakes and Streams in the Sierra Nevada Mountains
    a 5-Year Study. Wilderness and Environmental Med.
    200819(2)82-90.

55
References
  • Gerba CP, Naranjo JE, Jones EL. Virus Removal
    from Water by a Portable Water Treatment Device.
    Wilderness and Environmental Med. 200819(1)
    45-9.
  • Heiner JD, Hile DC, Demons ST, Wedmore IS. 10
    Povidone-Iodine May Be a Practical Field Water
    Disinfectant. Wilderness and Environmental Med.
    201021(4)332-36.
  • Heggie TW, Heggie TM. Search and Rescue Trends
    Associated with Recreational Travel in US
    National Parks. Journ of Travel Med. 200916(1)
    23-7.
  • Heggie TW, Heggie TM. Search and Rescue Trends
    and the Emergency Medical Services Workload in
    Utahs National Parks. Wilderness and Environ
    Med. 200819164-71.
  • Forrester JD, Holstege CP. Injury and Illness
    Encountered in Shenandoah National Park.
    Wilderness and Environ Med. 200920318-26.
  • Johnson RM, Huettl B, Kocsis V, Chan SB, Kordick
    MF. Injuries Sustained at Yellowstone National
    Park Requiring Emergency Medical System
    Activation. Wilderness and Environ Med.
    200718186-9.
  • Finlay JW. Epidemiology of Mountain Search and
    Rescue Operations in Banff, Yoho, and Kootenay
    National Parks, 2003-06. Wilderness and
    Environmental Med. 200819(4)245-51
  • Hamonko MT, McIntosh SE, Schimelpfenig T, Leemon
    D. Injuries Related to Hiking with a Pack During
    National Outdoor Leadership School Courses A
    Risk Factor Analysis. Wilderness and
    Environmental Medicine. 201122(1)2-6.
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