Being an outdoor enthusiast inevitably lends itself to plenty of moments when sh*t hits the fan. We’ve consulted a panel of four of the region’s wilderness medicine experts with 12 real-life scenarios so you can prepare for the worst and hope for the best on your next adventure.


are wilderness medicine ninjas well versed in the ways of Mother Nature’s capriciousness. They are climbers, paddlers, surfers, outdoor enthusiasts of every type who know firsthand what can go wrong when you’re recreating outside.

David Fifer
Owner, Red River Adventure Medical, LLC | Coordinator, Red River Gorge Special Treatment, Access, and Rescue Team | Lecturer, Emergency Medical Care, Eastern Kentucky University

Originally from Roanoke, Va., Fifer has served in the emergency medical services field for 15 years. His love of climbing landed him in eastern Kentucky, where he now serves wilderness rescue needs in the Red River Gorge and Natural Bridge State Park.

Karsten Delap
Owner and Head of Alpine Programs | Fox Mountain Guides
Wilderness EMT | AMGA Certified Rock and Alpine Guide Instructor |High Angle, Technical, and Wilderness Rescue, National Park Service | Volunteer, Brevard Rescue Team and Henderson County Rescue Squad

When Delap’s not guiding clients on climbs, he’s rescuing climbers from some of the very places he guides. Delap’s resume is chock full of high-altitude summits of some of the most revered mountains in the world, but his most important work is often done right here in the Blue Ridge near his western North Carolina home.

Mairi Padgett
Administrative Director, Landmark Learning | Instructor, National Outdoor Leadership School Wilderness Medicine

In 1996, Mairi and her husband Justin founded Landmark Learning out of their apartment. Now, 21 years later, the Padgetts oversee the nation’s leading institution for education and training in the outdoor community, the first outdoor school in the country to receive a national education accreditation.

Seth Collings Hawkins
Assistant Professor of Emergency Medicine, Wake Forest University | Medical Director, Burke County EMS & Burke County Communications | Medical Director, North Carolina State Parks |Chief, Appalachian Mountain Rescue Team

For over 20 years, Hawkins has made out-of-hospital, in-field medical care his specialty. He’s founded numerous organizations, including the Appalachian Center for Wilderness Medicine and the Carolina Wilderness EMS Externship, and is the lead author for the upcoming climbing medicine and wilderness first aid handbook Vertical Aid (available April 2017).

Scenario 1, Excessive Bleeding

The Scene: It’s a quiet afternoon near Kentucky’s Red River Gorge, or so it seems. David Fifer and a teammate pull their response vehicle into the parking lot of a local business, owned by other team members, just to check in. Minutes later, a vehicle grinds to a halt outside. From behind the driver’s seat, out stumbles a man completely covered in blood.

“It looked like something out of The Walking Dead,” Fifer remembers. “He was stumbling toward us and had an avulsion from the knee down to the ankle. It was just a massive slab of skin hanging off.”

The gentleman confessed to having gone on a “spiritual journey” in the gorge, a saga that entailed fasting for multiple days and bushwhacking with a machete. Somehow, the man had managed to, in effect, filet the lower half of his leg, which was still bleeding uncontrollably. To his credit, the man had attempted to fashion a tourniquet by shredding his pants into long strips of fabric, but the material was too delicate and the strips were hardly wide enough to make a difference. Recognizing this, the man painfully found his way back to his vehicle and started driving. Coming upon Fifer’s idle response vehicle was just a stroke of good luck.

“He was about to lose consciousness,” Fifer says of the patient. “The big mistake he made was that the material he was using was just too thin. He had probably already lost so much blood in the first place that he wasn’t really able to focus.”

With two other team members, the crew was able to stem the bleeding through direct pressure and without the use of a commercial tourniquet.

What not to do:

Bushwhack with a machete, solo, while fasting

Underestimate blood loss—“You can lose a lot of blood over time from even a small wound, and it can be really hard to estimate blood loss since blood can get soaked into soil or leaves or clothing,” says Fifer. “The wound site itself can be deceptive. It’s hard to go wrong about being aggressive with bleeding in the first place. When it comes to controlling bleeding, go big or go home out of the gate. You can’t replace blood if you lose it in the field—the only way to replace blood is through a transfusion.”

What to do:

Fashion a tourniquet, early. “Although direct pressure to the wound will control the bleeding in most cases,” says Fifer, “it makes sense to go straight to a tourniquet for any wounds to arms or legs that are bleeding significantly.” Tourniquets can be removed later if deemed too aggressive, but blood can’t be replaced, especially when you’re in the backcountry.

To create a makeshift tourniquet, use materials that are “fairly robust,” such as tubular webbing or nylon rain shells. The fabric should be at least two to three inches wide. “You don’t want something that is going to stretch or tear easily,” Fifer adds, but the material should still be thin enough to twist tightly.

Situate the tourniquet above the wound but not near a joint or too close to the injury site. “Think high and tight.” Find something to act as the windlass, or twisting mechanism, such as a carabiner, tie a square knot over the mechanism, and twist until the hemorrhaging stops and the pulse farthest from the injury is gone. Secure the windlass device so it doesn’t untwist. A tourniquet can stay on safely for at least two hours.

Keep patient warm.

• Inspect tourniquet often for loosening.

Scenario 2, Hypothermia

The Scene: Fifer and a friend are hiking in the Shenandoah National Park to Marys Rock. The backpacking trip itself isn’t necessarily trying, physically at least, but it’s early March and the nights are still cold. The two arrive at camp, set up their tent, and settle in for the night, at which point, Fifer starts to shiver.

“I was not wearing appropriate layers at all,” he says. “My companion was reporting that I was really lethargic, not clear in my thoughts, slurring my speech,” all of which, he says, are signs suggesting mild hypothermia, if not moderate.

His friend acted quickly, insulating Fifer with extra layers inside his sleeping bag and fixing up a hot bowl of ramen to get his metabolism working again.

What not to do:

Suck it up—“Some people get in this mindset where they say, ‘It’s cold, so I should be cold,’ but if you layer effectively, that should keep you from experiencing that cold.”

Strip down and cozy up in an attempt to transfer body heat. Though there is some research that suggests this approach can be effective, it should be used as a last resort, as it increases the risk of another individual succumbing to hypothermia. “If you’re running low on options, you’re low on calorie-dense food, having trouble starting a fire, don’t have a way to heat liquids, and can bundle up with your companion in a way that won’t make you hypothermic, why not?” says Fifer. “But I’d probably need to not have options A thru D before trying some body heat transference.”

What to do:

Shed any wet layers from the patient and add dry ones.

• Prevent moisture from reaching the patient.

• Add a heat source, like heat packs or a warm water bottle inside the sleeping bag, to increase patient’s heat production.

If patient is able to chew and swallow safely, make high-calorie food to spur metabolism. Warm liquids can make a patient feel comforted, “which is not for nothing. Psychological first aid is real,” says Fifer.

Create a hypo wrap by insulating the patient and wrapping them in a cocoon using an outer moisture barrier, like a rain fly.

If patient is severely hypothermic (think cold to the touch, pale, altered mental status, stopped shivering), handle the patient as gently as possible because aggressive motion can cause them to go into cardiac arrest.

Scenario 3, Snakebite

The Scene: Fifer is scrambling up a hill to set up a rappel, using his hands to stay balanced. Too late to do any good, he notices a copperhead right beside his hand. Surprisingly it doesn’t strike.

“Copperheads in particular are actually pretty docile. For the most part, they’re not looking to tangle,” he says, “unless you really make that snake feel threatened.”

That’s not to say that climbers and hikers in the gorge aren’t getting bit by snakes. In fact, a friend of Fifer’s recently spent a couple of weeks in the hospital after being bitten by a copperhead. But even then, he says, about 30 percent of all snakebites from the Crotalus genus (copperheads and rattlesnakes) are “dry bites,” where no envenomation occurs. For the remaining 70 percent of bites that do contain venom, the mortality rates are relatively low, about a dozen or less per year, and typically occur in people who either have certain underlying health conditions or are very old or very young. That’s not to say that snakebites in the backcountry should be taken lightly.

“Puncture wounds, by definition, are pretty deep and they really do lend themselves to infection,” says Fifer. “Moreover, Crotalus envenomations can cause serious tissue damage if not treated.”

What not to do:

Use a tourniquet. Snakebites won’t produce that much blood, and you don’t want to concentrate the venom in one area.

Panic. Snakebites can be treated successfully, even if you are in the backcountry.

What to do:

Wash the wound if you can with drinkable water. Puncture wounds are ideal breeding grounds for infection.

Splint and dress the bite as if it were a strain or break, using the “rule of thumb,” for dressings. “You want to be able to slip your thumb underneath the dressing, not too tight,” Fifer says.

Monitor the dressing frequently, as bite site will likely swell. Remove shoes, socks, jewelry, anything near the bite site that could constrict the blood flow in the event of excessive swelling.

Evacuate the victim and get to the hospital immediately for antivenin.