WFA courses are an introduction to WM, not a thorough exploration of the topic. Within the WFA labeled offerings in the United States, there are courses of significantly varying instructional hours. A consumer wishing to take a WFA course, or an administrator attempting to choose a level of training or certification needed for their program’s trip leaders, might be overwhelmed trying to choose from the list of educational companies and offerings returned by a simple online search. Although there is no nationally accepted standard for a WFA, attempts have been made over the years to reach consensus with regard to content.2,4,14-16 The most recent attempt has been led by a group of professional educators and directors known as the Wilderness Medicine Education Collaborative (WMEC). Information on the writing group and their recommendations is found in Box 2.2.

The recommendations of this group are nonbinding, and there are numerous WFA courses offered around the country that are not presented according to the guideline. However, within the professional education providers, topics covered are fairly consistent. A significant and controversial deviation from these guidelines is the WFA curriculum promoted by the Boy Scouts of America (see http://www.scouting.org/filestore/pdf/680-008.pdf for additional details). This curriculum features
most prominently in WFA courses and texts presented by the Emergency Care & Safety Institute (ECSI) bearing the moniker of the WMS, the American Academy of Orthopaedic Surgeons, and the Boy Scouts of America as well as the proprietary Wilderness and Remote First Aid course offered by the American Red Cross.^17,18 Among other topics, these courses are controversial for the ease by which instructors can become certified to teach this curriculum and the breadth of topics covered in a short time frame by the curriculum, characteristics which have been described as both strengths and deficits to such courses.¹⁹

SOLO has also developed a WFA variant termed Wilderness First Aid Afloat (WFAA). This unique marine-oriented course deletes certain elements of WFA such as altitude illness felt to be less relevant for marine applications and significantly expands topics applicable to the water-based environment.²⁰

The most common training format for WFA is a 16-hour course, delivered over 2 days, though other models exist. Some companies provide a three-day WFA, some provide the WFA curriculum in 2 days and include an additional day for cardiopulmonary resuscitation (CPR). There are hybrid courses of study where 1 day worth of content must be covered by the student through online modules before arriving for a two-day course, and there are WFA courses delivered over the entirety of a college semester during shorter class meetings. Even more confusingly, some organizations offer a “basic” WFA class (at around 8 hours) in addition to a “standard” WFA class (at the more typical 16 hours), both resulting in certification in “Wilderness First Aid.” As one can imagine, given the myriad options available for receiving a certification entitled “Wilderness First Aid,” consistency in outcomes and competencies is difficult to summarize.

Individuals who enroll in WFA courses do so for myriad reasons. Everyone from the weekend warrior exploring the topic for the first time, to the Boy Scout headed off to Philmont for a summer of work, to the seasoned wilderness trip leader using the course to recertify their WFR for the tenth time, may be enrolled in a WFA course. Indeed, challenging the idea that this is not a WEMS credential, some SAR teams and wilderness response services utilize WFA or WFR as a minimum medical standard, especially those that do not purport to specifically deliver medical care as part of their rescue work (see Chapters 30 and 31 for further discussion of this).

Given the time constraints of providing such a broad curriculum in a short period of time, a WFA tends to focus heavily on prevention, and recognizing key and obvious signs and symptoms. Little time is available for anatomy and physiology, and only basic treatment of some injuries and illnesses can be covered. Though limited in scope, the WFA course is often an excellent introduction to WM, which opens students’ eyes to the complexities of providing effective patient care in a wilderness setting.

The WAFA (also referred to as Advanced Wilderness First Aid [AWFA])^* course usually occupies an in-between space in the list of WEMS offerings. Most schools place this credential level between WFA and WFR, as it may meet the needs of either camp or trip leaders likely to operate within reach of EMS response, or recreationists seeking more training than a WFA who do not have the time for a full WFR. Given that there have been no consensus documents generated for WAFA training, individual companies self-define the intent of their courses and SOP for graduates. These descriptions vary rather significantly. The Wilderness Medicine Training Center (WMTC) suggests that their WAFA course is
“designed for the recreational public who wish to learn more about lightning injuries, wilderness toxins, and treating spine injured patients… and for day and weekend trip leaders in college or university outdoor programs.”²¹ Contrast this description with the following from WMA: “[WAFA] is comprehensive medical training designed for remote professionals or wilderness leaders who venture into remote and challenging environments… We prepare students for emergency situations that involve prolonged patient care, severe environments, and improvised equipment.”²²

Though companies describe their courses differently, some consistencies can be drawn regarding their offerings. WAFA or AWFA courses are longer than WFA courses, but generally shorter than WFRs. They are offered in four- and five-day formats, with some companies offering a hybrid self-directed/on-site format (see Box. 2.7). With more training hours than a WFA, several additional topics can be explored. Depending on the provider, there may be more in-depth anatomy and physiology, leadership skills, long-term patient care, greater injury/illness assessment tools, exploration of evacuation options, or further resources for treatment provided. More time is available for scenarios as well, providing the WAFA student increased simulated patient care experience, and deepening their understanding of the material.

While WFA, AWFA, and WFR are the most common courses offered within this level of WM care, one company focused on a subset of the outdoor guide and recreational population. In response to research that identified a gap in education for overuse injuries in rock climbing within the most common courses described above,²⁶ Vertical Medicine Resources developed a unique curriculum with a focus on climbing injuries. Specifically, Climbing First Aid and Climber First Aid (two different courses with different curricula and length) cover common injuries and illnesses identified in evidenced-based literature to tailor a course to meet the needs of the growing climbing community. These courses range from 1 to 2 days, are centered on the most common traumatic and chronic injuries, and are configured to student’s interest and needs based upon a pre-course survey.

In this discussion, it is critical to mention the new nationally recognized EMS certification Emergency Medical Responder (EMR), which is replacing the EMS certification level of First Responder. For decades, the WFR course and certification shared part of its name with the nationally recognized certification of First Responder. Indeed, the WFR course as initially conceived in the late 1970s and early 1980s by industry leaders like Frank Hubbell (SOLO) and Peter Goth (WMA) was intended to be the wilderness analogue for the new front country EMS First Responder certification—a certification intended for fire, police, and lay public who would arrive first at a scene and had very little, if any, equipment (Figure 1.1). First Responder was standardized and regulated beginning in the mid-1990s by the U.S. Department of Transportation (DOT), which also regulates the terms Emergency Medical Technician (EMT) and paramedic.²⁷ Though WFR and front country First Responder curricula and certification shared part of their name, they did not necessarily completely overlap, and over the years grew even more divergent. This was in general for good reason, as the FR curriculum (like much of EMS in the 1970s) was originally conceived around motor vehicle accident response, and later expanded to include basic techniques in urban injury stabilization. In the mid-2000s, the National Highway Transportation Safety Administration (NHTSA), a division of the DOT, and state providers began developing an expanded curriculum for the EMR certification, meant to replace First Responder, and add skills to the SOP. The NHTSA now estimates that EMR training may take approximately 48 to 60 hours to achieve competency, though places no requirements on contact time.²⁸ As the EMR standard has been rolled out at the state and national level, WEMS providers are taking advantage of the opportunity to provide their graduates with certifications that can be recognized in both the backcountry and the front country. Several WEMS schools are now offering opportunities to add or combine an EMR certification to a WFR. At least one WEMS provider has branded their WFR course as a WEMR.²⁹ The growing distinction between WFR and WEMR more clearly than ever delineates a difference between WM and WEMS. WEMR certification continues the theme of creating hybrid EMS and WM certifications using standards and terminology familiar to EMS regulators, with additional wilderness modular components, similar to the original early 1980s concept of WFR. Increasingly this should become a standard requisite basic certification for WEMS teams, even though WEMR is not in name a certification recognized by the NHTSA. In Chapters 24, 25, 30, and elsewhere in this book, we also endorse WEMR (or the equivalent for truly niche specialties such as lifeguarding or ski patrols) as the minimum acceptable EMS certification for a wilderness rescue team that positions itself as formal medical care providers in addition to a search or technical rescue team. Alternately, WFR is now completely divorced from any EMS certification, and is free to grow as a true WM certification without the need to match regulatory and EMS standards.

The addition of WEMR to the WEMS education offerings is a great service not only to students, but also to anyone who finds themselves in the care of a trained wilderness medical provider. The more wilderness and traditional EMS can overlap, work together, and share training modalities, the better patient care and transfer of care (as discussed in Chapter 6) will be across the board. On the other hand, there is significant clarity brought to regulatory questions, certification intent and purpose, and the difference between WEMS and WM at foundational certification levels by having separate WFR and WEMR certifications.

WFR certification is the level at which WM training expands significantly upon the idea of “first aid” and becomes what many consider a “professional” certification. Many wilderness trip-leading organizations require WFR certification for their trip leaders.^30,31 Given the ubiquity of the model, the weight it carries in the industry, and the number of hours spent teaching this course type over the last 30+ years, it is no surprise that WFR not only has a very large number of training providers, but has also seen significant investment in defining its scope.^5,7,14 The growth of the field over the last several decades has allowed a more evidence-based evaluation of likely wilderness medical injuries and illnesses as incident data are gathered by trip-leading organizations. Consistency in topic content has been in part driven by a more analytical perspective on medical situations providers may encounter. Figure 2.1 provides an example of the kind of data large wilderness trip-leading organizations can contribute to the conversation.

WFR educators are reasonably consistent in their descriptions of what the course entails. For example, Desert Mountain Medicine describes WFR as “the standard level of training expected for professional guides, outdoor educators, and search and rescue personnel.”³² Wilderness Medicine Outfitters states their WFR course is “great for the self-sufficient active back country person who hikes an hour from town or days in the wilderness. This is the required training for the professional guide in most all categories.”³³ NOLS Wilderness Medicine characterizes their WFR course as “recommended for anyone who works or recreates in the outdoors or in other austere environments.”34 A more formal SOP document from the WMEC has grown from this general agreement regarding what constitutes a WFR.⁵ Though nonbinding, the SOP document developed by numerous wilderness medical training providers suggests that a WFR course provide a minimum of 70 hours of training, and cover a specific list of topics (Box 2.3).

As an increasing number of organizations and professions adopt WFR as the standard training model for their staff and more educational options, especially online options, have become available, new providers have entered the market and delivery methods have diversified. Some WFR courses are run over eight or more straight days, some courses take a day or more break in the middle to allow students to relax or return home, still others have adopted the distance learning model (see Box 2.7), allowing students to complete some amount of curriculum on their own, before completing the remainder of the course on-site (generally no less than 5 days.) WFR is also presented as a semester-long class at various colleges, with curriculum delivered several hours at a time, including field sessions (Box 2.4).