Backcountry Decision Making

Due to the absence of simple black and white answers to very important questions, backcountry emergencies poise unique challenges. Rescuer needs, patient needs, and group needs are of absolute priority at every step of the process, as is gathering and sorting information for proper decision making.

As an outdoor leader with responsibility for friends, family, clients, students or even as an independent traveler with some medical knowledge, others look to me for guidance and order during a potentially chaotic situation. I have learned that this role requires an efficient system for gathering information, formulating a plan that addresses the needs of those involved, and delegating responsibility to others. While each event or situation will be unique, I have been taught throughout my backcountry medical training a system used for decision making in the backcountry that can be essentially universal.

In the medical field, we have five steps to decision making.
1. Scene Survey

• Scene Safety
• Number of patients- Is everyone accounted for? 

2. Patient Assessment

• Primary Survey
• Triage if there are multiple patients -Sort by injury/ patient priority
• Secondary Survey

3. Patient Needs

• Injury Severity
• Injury Management 
• Ambulatory Status

4. Situational Variables

• Group status: nutrition, hydration, rest, number
• Location: distance, terrain, time of day, and season
• Weather: worsening/ clearing, wind precipitation
• Resources available: splint/ litter materials, personnel, camping gear, communications, gear, first aid kits, etc. 

5. Developing a plan

• Should you stay or should you go?
• How/ when will you go?
• Do you require assistance?

These same points and sub points if you will can be used outside an emergency medical scenario. 

The three biggest things to remember; aside from keeping in mind the nasty little heuristics that easily impair ones judgement, are Developing a plan, prevention, and details. 

In the backcountry developing a plan is important for patient assessment, it is also critical when managing the scene and evacuation. It is just as important in the front country making so-called "simple" decisions such as when, where, and how to begin a large project for a class. Backcountry situations usually require a more comprehensive evaluation of the resources available, the personnel available, the patient's condition, the number of patients, the location and environmental conditions, and the condition of the remainder of the group. Considering each component of a good backcountry emergency plan is essential to ensuring proper patient care and group safety. However, it need not be overwhelming and can, in fact, be relatively straightforward. A plan is a guideline to keep everybody safe. It works almost the same way I use sticky notes and lists in my daily life. I use it as a guideline to follow so I don't become distracted and/ or become consumed in something that is not in need of immediate attention. If the plan needs to change, change it, but only for a good reason. Developing contingency plans is especially helpful in the ever-changing backcountry environment. 

Formulating a strategy for possible evacuation before entering the backcountry is the best way to mitigate many of the complications that are bound to arise during an emergency situation. This includes forethought on communications (eg. radio. spot phone, evacuation points) terrain hazards and evacuation routes, skills among your group and the other possible resources available to you. Careful planning takes time. Recognize this and your stress will immediately be reduced greatly. STOP and THINK. The operational principle in developing an effective plan is prioritization; taking the extra few minutes to organize your thoughts and consider the options will allow you to prioritize well. 

One thing to remember when you are busy developing plans, laying out prevention tools and remembering the details is to keep in mind of your own judgement. Our own heuristics and our judgement call in a situation can lead to complete failure in a medical call or completing a class project. John S. Hammond, Ralph L. Keeney, and Howard Raiffa refer to these heuristics as "traps" in their article, "The hidden Traps in Decision Making."

Many of the "traps" listed throughout this article are ultimately the same as the heuristics I learned in my medical training in backcountry medicine. The Heuristics such as familiarity, availability, frequency, hero, zero- sum, self- serving, gender, and affect are just a few mentioned throughout my medical training. Within the article of "The Hidden Traps in Decision Making," Hammond, Keeney and Raiffa have mentioned traps such as the status-quo, sunk- cost, confirming- evidence, framing,  estimating and forecasting, overconfidence, prudence.... All of these listed so far play into the ones I have been previously familiar with. 

We have all heard a story a skier or possibly a group of skiers out in mid february trying to make the first turns through the bowl after a long spell of now snow and now blessed with a heavy dump. But it's sunny out. The bowl isn't part of a resort. Its too early for an avalanche crew to hit it. And sure enough, the individuals who have been skiing this very bowl for years and years end up on the front page of the paper. Many, many decision making traps play into a tragic, yet common day such as this. Familiarity, availability, frequency, status- quo, hero, over- confidence and many more play into a day gone south.

To wrap all of this together, when we are out making decisions, we need to keep in mind our scene survey, patient assessment, patient needs, situational variables, and developing a plan. By following these five steps and taking preventative steps in the first place as well as remembering the tiny details, we can try our best to dodge those tricky traps and carry out our decisions in the best way possible.