Lesson Overview
Learning objectives
- Sort an evacuation into emergent, urgent, or non-urgent
- Package a patient for transport so they stay immobilized and warm
- Build a safe improvised litter and run a team carry
- Use your emergency communication device, and give rescuers the patient information they need
- When no device gets through, send two messengers with a written note, and keep someone with the patient
- Prepare a landing zone and stay safe around a helicopter
Getting the patient out
Out here your transport options are limited, and you work with what you've got. Your calls on urgency, method, and timing decide whether the patient gets to a hospital in time, whether complications set in on the way, and how it ends. Deciding how this patient gets out (walking, on a litter, or in a helicopter) is the medicine. Some patients need a helicopter now. Others can walk out slowly with a little support.
Evacuation Decision Framework
Core principle: urgency × feasibility
Every evacuation decision weighs two things: how urgent the patient's problem is, and what it'll really take to get them out. A life-threatening condition means an emergent evacuation, however hard the terrain. A stable patient with a minor injury might walk out, or wait for the weather to improve.
Evacuation urgency categories
| Category | Timeline | Examples | Notes |
|---|---|---|---|
| Emergent | Now. Minutes count. | A life threat now or likely soon: uncontrolled or suspected internal bleeding, shock, altered mental status (AMS) that your fix doesn't fully and quickly reverse, anaphylaxis (even after epi, because it can rebound), heat stroke, severe hypothermia, chest pain, stroke, breathing trouble that isn't resolving, spine injury with deficits (numbness, tingling, weakness) | Fastest possible evacuation. Call for rescue immediately, helicopter if available. |
| Urgent | Within hours, not minutes | Open fractures, closed long-bone fractures, an ankle fracture they can't bear weight on, dislocations, a spine mechanism with an unreliable exam but no deficits, a wound infection that's spreading. Snakebite: evacuate now, and treat it as emergent if symptoms are building. | Needs a hospital. Move steadily, and don't take big risks to go faster. |
| Non-urgent | Walk out, or finish the day with a plan | An ankle sprain they can walk on, minor wounds, mild GI illness, fatigue | Teach the patient the red flags that would change this decision. |
Decision factors
Patient condition & trend
Is the patient stable, improving, or getting worse? Judge them by where they're heading. A patient who's getting worse moves up a tier, however they look right now. Declining consciousness or worsening internal bleeding is emergent.
Terrain & distance
How far is it to a hospital, and how long will the trip take? Narrow passes, elevation changes, and water crossings all add time and work.
Resources available
How many trained people do you have? What gear? Any way to call out? If you're short on people or gear, you may have to move the patient to an agreed meeting point where rescuers take over, rather than all the way to the nearest hospital.
Environment & weather
What's the forecast? How much daylight is left? Is cold, a storm, or darkness coming? Weather and daylight can force a faster evacuation, even over a short distance.
Keep reassessing
The category can change. Reassess every 15 minutes in a stable patient and every 5 minutes in an unstable one. A non-urgent patient who develops breathing trouble or altered mental status is now emergent. Write each assessment down so you can see the trend.
There's no observation unit out here. You can't admit anyone overnight or order blood work. If you aren't sure an evacuation is needed, evacuate. Standing down a rescue that's already reached the trailhead is a lot easier than calling for one after dark in a storm.
Preparing a Patient for Transport
Documentation: SOAP note for handoff
Have a SOAP note (Subjective, Objective, Assessment, Plan) finished before EMS reaches the trailhead or the helicopter lands. Put in the chief complaint, how it happened, vital signs, what you did, how the patient responded, and how stable you think they are. EMS gets the whole picture on paper, and nothing gets lost at handoff.
Hypothermia prevention during transport
A patient who can't move gets cold fast, and shock, pain, and exposure speed it up. Insulate aggressively, even in moderate weather.
Ground insulation
Put 3-4 layers of insulation between the patient and the ground: sleeping pads, sleeping bags, packs, vegetation. Do not let them lie directly on cold ground or snow.
Vapor barrier
Wrap the patient in plastic sheeting or garbage bags. The plastic traps warm air, stops evaporative heat loss, and keeps the wind off.
Head coverage
Heat loss tracks exposed surface area, and the head is roughly 10% of the body's surface, not the 30-40% of the old myth. Cover it anyway. It has good blood flow, it's often left bare, and it's one of the easiest places to insulate. A wool hat, a balaclava, or something improvised makes a real dent in overall heat loss.
External heat sources
Put bottles of warm (not boiling) water or heat packs on the chest, in the armpits, and along the back. Wrap them first. Never put them directly on skin, because they can burn.
Insulating shell
Wrap the patient in sleeping bags, then add spare clothing or blankets on top.
Securing the patient in the litter
Once they're in the litter, strap them in so they can't fall or shift.
Padding & positioning
- Pad every bony prominence: back of the head (occiput), sacrum, heels, elbows
- Position for the injury (see the table below)
Strapping
- Chest strap: above the nipple line, so they can breathe
- Waist/hip strap: holds the pelvis
- Thigh straps: stop them sliding
- Arms: padded, and secured at the sides or across the chest
- Head: rolled sleeping pads on both sides keep it from rolling side to side
Recheck the ABCs after packaging, every time. Before anyone lifts, confirm the airway is open, breathing is adequate, and circulation is present.
Transport positions
| Condition | Recommended Position |
|---|---|
| Unconscious, no mechanism for spine injury | Recovery position (on their side, head tilted back to keep the airway open). When in doubt, treat it as a spine injury. |
| Spinal precautions | Flat on the back (supine) with the spine neutral, padded on both sides and strapped into the litter so the spine can't shift. If they vomit, logroll them as a unit onto their side (Lesson 7). |
| Respiratory distress | Propped up (semi-recumbent), head raised about 45°, which makes breathing easier |
| Shock | Flat on the back (supine). Raise the feet 6–12 in only if there's no trauma and it doesn't hurt. Insulate above and below, with heat sources at the trunk. |
| Nausea/vomiting risk | Recovery position or partly on their side, so they don't inhale vomit |
| General comfort (no specific concern) | Position of comfort, whatever the patient prefers |
Medication monitoring
Write down every medication given: drug name, dose, time, route (swallowed, chewed, inhaled, auto-injector), and how the patient responded. EMS needs it, and it keeps the next person from giving a second dose by mistake.
Vital sign monitoring during transport
Recheck vitals every 5 minutes in an unstable patient and every 15 minutes in a stable one. Record each set so the trend shows. Any change in mental status, breathing, heart rate, or perfusion means you check more often and ask whether the evacuation needs to move up a tier.
Improvised Litter Construction
When you need an improvised litter
You need one when there's no helicopter, the trailhead is a long way off, or the patient can't walk even with help, and nobody brought a commercial stretcher.
A sagging litter is uncomfortable for the patient and exhausting to carry. Build it stiff enough to hold them up.
Improvised litter methods
| Method | Materials | Pros | Cons |
|---|---|---|---|
| Jacket + poles | 2-3 jackets, 2 sturdy poles (branches, ski poles, ice axes) | Easy, uses common gear, good for moderate distances | Less rigid; struggles with bigger patients |
| Tarp/poncho litter | Tarp or poncho, 2 rigid poles | Very strong, large surface area, good for rough terrain | Needs a tarp; can be heavy |
| Two-backpack litter | 2 large packs, poles lashed through the pack frames or straps | Sturdy, good padding from the pack frames, materials usually on hand | Heavier than the other options |
| Blanket/sleeping bag roll | Sleeping bag or blanket, poles run through the sides | Excellent insulation, quick to build, light | Less rigid; not great over long distances |
Running the carry team
Team size
- Ideal: 6 carriers (2 at the head, 2 at the middle/waist, 2 at the feet), which spreads the weight and keeps the lift even
- Minimum: 4 carriers (2 at each end, on opposite sides)
Commands
One leader at the head calls the commands: "Prepare to lift," "Lift," "Step," "Halt." When everyone lifts and steps on the same word, nobody gets hurt by a move they weren't ready for.
Rotation
Rotate carriers every 10-15 minutes, before they wear out. Tired carriers stumble, and a stumble can drop the litter.
Pace and communication
- Go slow and steady. You can't move fast on uneven ground, and trying just gets people falling.
- Call out obstacles ahead of time: "Rock on right," "Step down," "Creek crossing ahead"
- Give one person a single job during the carry: watching the patient's comfort and stability
Narrow trail technique
On single-file trail, carriers can stagger their feet (one foot on each side of the trail, alternating) to get the litter through narrow sections. It's harder than it sounds and takes practice.
One-rescuer carries (short distances only)
One person can move a patient a short distance with the right technique. Solo carries are only for patients with no suspected spine injury, and only when immediate danger forces the move. You can't watch the airway of an unconscious patient draped over your shoulders, so these are a last resort:
- Fireman's carry: for a larger patient, draped across your shoulders. If they're unconscious, you can't see their airway up there. Get clear of the danger, put them down, and check it.
- Cradle carry: for a small patient or a short distance. You hold them across your chest and arms.
- Walking assist: for an alert patient who can walk. Their arm around your neck, your arm around their waist.
Helicopter considerations
If a helicopter's likely, ask the crew how they want the litter oriented. Which end goes in first depends on the aircraft, and the crew decides. Build your litter so it can load either way.
Emergency Communication in the Wilderness
Communication devices compared
Cell phone
Pros: Everyone has one. Cons: Coverage gaps, battery drain. Tips: Hold the phone high, try 911 even with no bars (it may reach any tower), and try a text when calls fail.
Satellite communicator (Garmin InReach, SPOT)
Pros: Two-way messaging anywhere, GPS tracking. Cons: Needs a subscription; SOS response is slower than a voice call.
PLB (personal locator beacon)
Pros: Free monitoring through COSPAS-SARSAT, no subscription, watched worldwide by rescue authorities. Cons: One-way only (nobody can talk back), and hard to cancel once it's activated.
Satellite phone
Pros: Voice calls from anywhere. Cons: Expensive, less portable, slower to connect.
MIST report: what rescuers need
When you get through to emergency services, give a MIST report, then the logistics:
- M = Mechanism of injury: How did it happen? A fall, avalanche, lightning, animal attack?
- I = Injuries found: The chief complaint and the injuries you've found. "Open femur fracture, ankle swelling, intact neurovascular."
- S = Signs and symptoms: Vital signs, mental status, pain level, relevant history (diabetic, allergies, medications).
- T = Treatment given so far: Medications, splinting, wound care, anything given by mouth. "Bandaged wound, splinted ankle, gave aspirin."
- Plus: exact GPS coordinates, if you have them
- Plus: number of patients and number of rescuers on scene
- Plus: resources available (litter, communication device, medical equipment)
- Plus: weather conditions and forecast
- Plus: ETA to the trailhead, if you're self-evacuating
When nothing gets through: sending messengers
Exhaust your communication options before you spend people. Try the phone from high ground, try a text, try the satellite device. Walking people out splits the group, puts the messengers at risk, and leaves fewer hands with the patient. Send people only when every device has failed or you don't have one.
- Send two, never one alone. A lone messenger who rolls an ankle or takes a wrong turn becomes a second patient nobody knows about. Two can look after each other and still get the word out.
- Send a written note. A tired, scared messenger forgets details, and a spoken message changes every time it's repeated. The note carries four things:
- Location: GPS coordinates if you have them, plus a description of the spot and the route in
- Patient: age, sex, what happened, and the injuries or illness you've found
- Status: the latest vitals with the time you took them, and whether the patient is stable or getting worse
- Needs: what you're asking for (helicopter, carry team, gear) and what you already have on scene
- Don't leave the patient alone if you can avoid it. Someone stays to keep them warm, watch the airway, and recheck vitals. A patient left alone can't tell anyone they're getting worse.
Hope is not an evacuation plan. Until someone outside the group knows you need help, nobody's coming, so call, signal, or send.
Helicopter landing zone preparation
Minimum clear area
100 × 100 feet (30 × 30 meters) of fairly flat ground, clear of debris, branches, and loose material that could get sucked into the rotors or blown into faces.
Marking the LZ
- Mark it with an X that's visible from the air, in bright colors (surveyor tape, sleeping bags, packs)
- Take off hats and secure loose items that rotor downwash will blow around
- Keep all bystanders back 200+ feet from the LZ
Signaling
- Arms raised in a Y: "Yes, land here"
- One arm down, one arm up (an L shape): "No, do not land"
Staying safe around the aircraft
- Never approach a helicopter from the rear. A spinning tail rotor is nearly invisible, and it kills. Approach only from the front or side, within the crew's line of sight, and only after they signal you in. Stay low and secure loose items.
- The signaler stands at the edge of the LZ with their back to the wind. The aircraft lands into the wind, facing the signaler.
- No fires or smoke downwind of the LZ
- When it's time to load the patient, do exactly what the crew tells you. They run the loading.
Device testing & false activations
Before every trip, check the battery and make sure the device works. Learn which button is SOS and which sends an ordinary message at home, not by pressing it on the trail. A false activation launches an expensive rescue and can bring serious legal trouble. Never trigger an emergency device as a test in the field.
If you're not sure you need an evacuation, alert rescuers early anyway. Give them your location and situation, and let them tell you whether a formal rescue is needed. Standing down a rescue that's reached the trailhead is easy. Launching one after dark in a storm isn't.
Scenario-Based Learning
Setting: A climber falls 15 feet in a slot canyon and has an obvious open femur fracture. You're 8 miles from the trailhead. It's 3 PM, with 4 hours of daylight left. You have a satellite communicator, a first aid kit, two sleeping pads, and 2 uninjured partners besides yourself.
Think it through:
- What's the evacuation urgency?
- What do you do in the next 10 minutes?
- Do you self-evacuate or call for rescue?
- Urgency: urgent, at minimum. An open fracture means contaminated bone, a risk of major bleeding and of shock, and a lot of pain. It can't wait. If the bleeding won't stay controlled or shock sets in, it's emergent.
- Spine: 15 feet is more than about 10, so this is a high-energy mechanism. Take spine precautions: keep them still and ask the spine questions (Lesson 7). A broken femur hurts enough to hide neck or back pain, so their spine exam isn't reliable. Stay conservative and move them as one unit.
- Next 10 minutes:
- Bleeding first. If it's life-threatening (spurting, steadily pooling, or soaking through dressings), put a tourniquet on the thigh right away, high and tight near the groin, and write down the time. Don't try pressure first on a bleed like that. Never place a tourniquet below the wound. If the bleeding isn't life-threatening, control it with direct pressure and a pressure dressing.
- Do not reduce (realign) the fracture. Support it in the position you found it.
- Gently irrigate the exposed bone and wound with clean water, and cover it with a loose sterile dressing.
- Splint the femur with the sleeping pads, clothing, or an improvised splint. Immobilize from hip to ankle.
- Check CSM (Circulation, Sensation, Motion) below the fracture: pulses, capillary refill, color, feeling, and whether they can wiggle their toes. If the foot is pulseless or numb, the limb itself is at risk. Say so in your SOS message, because every hour now counts.
- No food. Small sips of water are fine if they're fully alert, stable, and swallowing normally, because the wait could be hours. If they get drowsy, confused, or shocky, nothing by mouth.
- Evacuation decision: Don't try to carry a litter 8 miles with 3 rescuers. The terrain is brutal, the patient is badly hurt, and a carry like that is likely to hurt them further on the way out. Activate the satellite communicator now: "Open femur fracture, 8 miles from trailhead, 1 patient, 3 rescuers, urgent evacuation needed. GPS: [coordinates]. Patient immobilized, bleeding controlled, needs helicopter or SAR with additional personnel."
- While you wait for rescue:
- Check vitals every 5 minutes. Shock is a major risk.
- Prevent hypothermia with ground insulation, a vapor barrier, and head coverage.
- Manage pain without medication: good splinting, padding, and gentle handling. Don't give NSAIDs when significant bleeding is a concern. Local wound care only, no suturing.
- Keep them as warm and comfortable as you can
- Write the SOAP note: mechanism, vital signs, treatments given, how the patient responded
- When the helicopter arrives: Clear the LZ, mark it with an X, and follow the crew's loading instructions.
Setting: Day 5 of a 7-day river trip. A 58-year-old in the group develops crushing chest pain that spreads to the left arm, and they're sweating (diaphoresis). There's no satellite communicator, but you have a PLB. The nearest takeout is 2 days away by river.
Think it through:
- What's your field assessment and treatment?
- How do you call for help?
- How do you package them?
- Field assessment: OPQRST for the chest pain: Onset 30 minutes ago, Provocation none, Quality crushing, Radiation to the left arm, Severity 8/10, Time ongoing. Also present: sweating (diaphoresis), anxiety, possible shortness of breath. SAMPLE: history of high blood pressure, takes aspirin and lisinopril, last ate 2 hours ago. Vitals: BP, HR, and RR all elevated.
- This looks like the heart. Treat it as acute coronary syndrome (ACS) until a hospital evaluates them. Chest pain makes this an emergent evacuation.
- Field treatment:
- Aspirin 325 mg, chewed, if there are no contraindications (no allergy, no history of GI bleeding)
- Position of comfort. Most cardiac patients prefer sitting up slightly.
- No food. Small sips of water are fine while they're alert and stable, since rescue could be hours away.
- Watch the vital signs closely
- Calling for help: Activate the PLB now. Don't wait to see if the symptoms improve. The signal goes out through COSPAS-SARSAT satellites, rescue authorities worldwide are notified within minutes, and your location goes with it automatically. But a PLB is one-way, so rescuers can't message you back. The rescue coordination center will call the beacon's registered emergency contacts for trip details, which only helps if you registered the beacon and left a trip plan with someone at home.
- Packaging for evacuation:
- Semi-recumbent (head raised about 45°) for comfort
- Warm insulation
- Check ABCs and vitals every 5 minutes. A cardiac patient can go downhill fast.
- Be ready for a helicopter extraction if that's how rescue arrives
- Do not paddle out. Exertion makes the heart work harder and need more oxygen. Wait for rescue.
- Keep reassessing. Any change in mental status, new breathing trouble, loss of consciousness, or cardiac arrest changes your priorities on the spot, and you step up care to match.
Knowledge Check
10 questions. Pick an answer to get immediate feedback. Answer order is shuffled each attempt, and your best score is saved on this device.
Lesson Summary
Key takeaways: evacuation & transport
- The patient's trend, the terrain, your resources, and the environment set the evacuation urgency.
- Three tiers. Emergent: a life threat now or soon, so call for rescue and get the fastest evac you can. Urgent: a hospital within hours, so move steadily without big risks. Non-urgent: they can walk out or finish the day with a plan.
- Keeping a patient warm in transport means ground insulation, a vapor barrier, head coverage, and external heat sources.
- You can build a rigid improvised litter from jackets, tarps, backpacks, or sleeping bags.
- Carry teams need 4-6 rescuers, rotating every 10-15 minutes to prevent fatigue.
- Satellite communicators and PLBs reach past cell coverage. Test yours before every trip.
- A MIST report gives rescuers what they need. Add GPS coordinates and logistics.
- Exhaust communication before you spend people. If you must send for help, send two, never one alone, with a written note: location, patient, status, needs. Don't leave the patient alone.
- A helicopter landing zone needs to be 100×100 feet, clear, and marked. Never approach from the rear. Come in from the front or side, and only after the crew signals.
- Alert rescue early, not late. It's easier to stand down than to launch in darkness or a storm.
Glossary of terms
- Emergent Evacuation
- A life threat now or likely soon, including a patient who's getting worse. Fastest possible evacuation; call for rescue, helicopter if available.
- Urgent Evacuation
- The patient needs a hospital within hours, not minutes (an open fracture, for example). Move steadily and don't take big risks.
- Non-Urgent Evacuation
- The patient can walk out or finish the day with a plan, and knows the red flags that would change it.
- Patient Packaging
- Getting a patient ready for transport: padding, strapping, insulation, and positioning.
- MIST Report
- A short, standard way to hand rescuers the patient's story: Mechanism, Injuries, Signs/symptoms, Treatment.
- PLB (Personal Locator Beacon)
- A one-way emergency beacon monitored worldwide by COSPAS-SARSAT. No subscription, and no way for rescuers to talk back.
- Satellite Communicator
- A two-way messaging device that works anywhere. It needs a subscription, and it lets you message back and forth with rescue coordinators.
- Landing Zone (LZ)
- A clear area set aside for a helicopter evacuation. At least 100×100 feet, marked with an X.
- Search and Rescue (SAR)
- An organized rescue, with more people and gear, run with the emergency authorities.
- Improvised Litter
- An emergency stretcher built from whatever's available (jackets, tarps, packs, branches) to carry a patient.
- SOAP Note
- A documentation format: Subjective (history), Objective (vitals and findings), Assessment (diagnosis), Plan (treatment).
- Hypothermia Prevention
- How you keep a patient warm during transport: ground insulation, vapor barrier, head coverage, external heat.
- Litter
- A stretcher or carrying device for a patient who's immobilized or can't walk.
Wilderness Medicine: Beyond First Aid (7th ed.) - William Forgey
COSPAS-SARSAT: cospas-sarsat.int (PLB information)
Wilderness Medical Society Guidelines: wms.org
Leave No Trace Principles: lnt.org
Exhaust your communication options before you spend people. A satellite message is cheaper than a six-person carry. And make the evacuation call as carefully as you made the treatment calls, because how this patient gets out is part of the medicine.