Day 1 Recap CAWM 2025 Conference

CAWM 2025 – Recap of Day 1

Annual Conference of the Canadian Association of Wilderness Medicine (CAWM), Canmore, Alberta

Marc Gosselin MD, Medical Director SIRIUSMEDx

Every fall, the Canadian Association of Wilderness Medicine (CAWM) brings together Canadian and international experts to discuss advances in wilderness and austere-environment medicine. This annual meeting is a privileged moment to exchange on the clinical, logistical, and human challenges we face in extreme environments.

I attend every year, and this time we’re in Canmore, Alberta. I’m here with Julie Kennedy, Director of Training at SIRIUSMEDx, and I’m taking the time to write this summary to digest everything I heard and to share the highlights with you. Nothing replaces showing up—on-site or online—but I hope these notes fuel your thinking and add to your knowledge base.Here is a summary of the day's conferences:

• Dr Gordon Giesbrecht: for his deeply practical, life-saving approach to evacuating a submerged vehicle, offering simple, immediately applicable strategies that save lives.
• Dr. Alex Poole: for his immense contribution to improving frostbite care in Canada, which continues to transform our practices and inspire front-line clinicians.
• Dr Neal Pollock: for his unique ability to popularize complex physiological subjects, making them not only understandable, but applicable in the field.
• Dr. Steve Roy: for his art of elevating strategic thinking while remaining clear, precise and focused on actions applicable by first-aiders and trainers.
• Dr Laura Beatty: finally, for her accessible, impeccably prepared and documented presentations, which convey solid knowledge with exemplary pedagogy.

1. Cold, Coordinated, and in Command: Relational Coordination, Dynamic Teams, and Logistics in Extreme Environments

Melissa Bouwsema & Tegan Fletcher

This talk highlighted the difference between an “ad hoc” group and a truly coordinated team in extreme settings. In remote contexts, success depends not just on clinical skill but on the team’s ability to coordinate rapidly, anticipate failure, and communicate clearly.

The speakers showed how preparation, team culture, and dynamic leadership can turn chaos into an effective response. They emphasized explicit routines, shared cognitive anchors, and ongoing recognition of everyone’s efforts.

• Key Takeaways for SIRIUSMEDx instructors & simulations
• • 5-step briefing to standardize in training for rescue/medical ops:
    • Intros: who's who.
    • What we know: factual summary of the situation.
    • cWhat we expect (Plan A + B/C): clarify immediate objectives and alternatives.
    • Roles: explicit distribution of tasks.
    • Concerns/Suggestions: open the floor to everyone before starting.
• Dnamic Leadership
• • The lead circulates according to the phase: safety → extrication → airways → logistics.
  • 👉 Training to pass the baton to the most competent, rather than keeping a fixed hierarchy.
• Culture & confidence = technical gestures
• • Praise good deeds.
• • Explicitly invite each opinion.
• • Correct without humiliating. 👉 These micro-actions influence cohesion as much as medical gestures.
• Ad hoc ≠ improvised

​ With an unknown team.

• • Standardize procedures, priorities and criteria.
  • Over-communicate objectives and constraints.
  • Pay attention to non-verbal cues (calm, posture, tone).
• Forecasting failure
• • Estimate  O₂ for In&out + safety margin.
• • Minute-by-minute planning in a tight weather window.​
• • Evaluate accumulated delays.
• Reconfiguring the environment
• • Equipment always placed in the same place.
• • Color-coded/labeled infusions.
• • Appropriate lighting and unobstructed access. 
    👉 The "90% invisible" that makes work flow smoothly.​
• Cognitive anchor

​ Always come back to the question:

​ ​ 👉 « What are we trying to achieve? »

​ → Separate the need-to-have from the nice-to-have.

• Key attributes to assess in simulation
• • • Humility
• • • TénaciTenacityté
• • • Creativity
• • • Liability

​ 👉 Include these human criteria in the evaluation grids, not just technical gestures.

2. Wildland Fire and Public Health

Dr Brian Drury

Dr Brian Drury gave an enlightening presentation on the growing impact of forest fires on public health, a particularly topical subject with their increasing frequency and intensity across Canada and the USA. He addressed not only the immediate risks of fires (trauma, burns, smoke poisoning), but also the long-term consequences of exposure to smoke and fine particles (asthma, chronic respiratory disease, cardiovascular effects).  ​

He pointed out that smoke from fires does not respect borders: remote communities, sometimes hundreds of kilometers from the source of the fires, suffer dangerous levels of pollution. In remote areas, these impacts are compounded by the lack of medical resources, the difficulty of evacuation and the heightened vulnerability of indigenous populations and exposed workers.​

Brian insisted on the need to reinforce public health and medical preparedness in isolated regions: warning systems, adapted respiratory protection equipment, protocols for mass evacuations and coordinated interventions between fire, health and civil security services.

Key Takeaways

• 🔥 Forest fires are now a major public health issue, going far beyond fire management.
• 😷 Smoke is the main risk to the population: even at a distance, it seriously affects respiratory and cardiovascular health.
• 🏞️ In isolated environments, preparedness must include evacuation plans, mobile medical resources and effective communication between responders.

3 keywords :

Smoke - Health - Preparation ✅​

3. Physiology and Pathophysiology of Immersion

Dr. Neal Pollock

Dr. Pollock presented the main mechanisms behind syncopation, pulmonary trauma and respiratory distress in freediving and technical diving. His aim: to dismantle preconceived ideas, remind us of what really kills divers, and suggest simple rules for education, triage and care in isolated environments.

Presentation summary

Apnea & hyperventilation

• L’hypervHyperventilation ("workout breathing", even if we change the word) lowers CO₂.entilation (« workout breathing », même si on change le mot) abaisse le CO₂.
• This delays the "urge to breathe" but removes the safety alarm → sudden syncope, with no warning signs, especially on ascent when ambient pressure drops rapidly. 
   👉 Example: a freediver who feels "fine" up to 5 m from the surface can pass out without any signal.

Lung packing & empty-lung dives 

• "Inflating" or "emptying" your lungs voluntarily is sometimes used for training (simulating a greater depth).
• But this weakens lung tissue: microbleeds visible in the larynx from 10-20 m; possible barotrauma. 
  👉 Can only be used under expert supervision, not for amateur training.​

Pulmonary squeeze (barotrauma associated with deep apnea)

• The greater the maximum depth reached, the more episodes of coughing, bleeding and dyspnea the freediver has had.
• Lesions visible on imaging take several weeks to heal, not 1-2 days as many believe. 
  👉 Example: a diver who resumes too soon after an episode can trigger a fatal pulmonary rupture.​

Golden rules of freediving safety

• Never hyperventilate.
• Once you stop descending, you don't come back down (to avoid breaks and syncopations).
• Always train under surface supervision.​

Technical diving / rebreather

• Rebreathers control O₂ and CO₂, but require a delicate balance:
  • Too much O₂ = neurological toxicity.
  • Not enough = risk of hypoxia.
  • CO₂ poorly eliminated = drunkenness and a quick accident. 👉 Incorrect adjustment or technical failure is often fatal.

Immersion pulmonary edema (OPI / SIPE)

• Symptoms: cough, dyspnea, bloody sputum, crackles → within minutes underwater.
• Aggravating factors: prolonged immersion, cold water, too-tight wetsuit, excess hydration, violent exertion, respiratory resistance (e.g. narrow snorkel, rebreather). 
  👉 Example: triathlete coughing up blood and gasping for breath after a few minutes swimming in cold water = suspect OPI.​

OPI/SIPE support

• Get out of the water, rest, O₂.
• If available: CPAP or positive pressure ventilation, beta-agonists, sometimes diuretics.
• Investigate cardiovascular factors whenever possible (often a predisposing factor).​
• Resumption: only in hot water + after correction of risk factors.

Hypothermia & Cold

• Real danger: incapacitating cold (frozen hands, inability to handle equipment).
• Deep systemic hypothermia is rare with a wetsuit, even when flooded (e.g. 43 min dive in Antarctica with pierced wetsuit = loss of only 0.3°C).

High-risk consumer equipment​

• Poorly designed full-face masks ("bubble helmets") → CO₂ reinhalation, panic, death. 
  👉 Clear message: train, equip properly, avoid gadgets.​

Key Takeaways (for SIRIUSMEDx instructors)

✅ Anti-hyperventilation: teach that even "deep relaxing breathing" before apnea = hyperventilation → silent syncope, especially on ascent.

✅ Pulmonary squeeze = prolonged rest: after hemoptysis or respiratory signs, plan weeks of rest, not 24-48 h.

✅ OPI/SIPE: think early, treat simply (out + O₂ + CPAP if possible), and target factors (cold, tight suit, overexertion, fluid overload).

3 key words

Hyperventilation - Squeeze - OPI/SIPE

4. I’ve Got That Sinking Feeling: What Most People Don’t Know About Surviving a Vehicle Submersion

Dr. Gordon Giesbrecht

Dr. Giesbrecht has dismantled, with evidence and videos, the persistent myths about cars falling overboard, and delivered a simple protocol that can be operationalized in 60 seconds. 
Central message: you have ~1 useful minute (float phase 30-120 s) to get out through a window, not a door, and certainly not while waiting for help.​

Presentation summary 

• Chronology of a flood
  1. Floating (≈ 30-120 s): water has not yet reached all windows → open a window (electric = still works ~30 s).
  2. Sinking: water overruns windows, external pressure > internal pressure → windows/doors can't be opened.
  3. Submerged: the car is full of water, pressures equalized → door openable... but you're probably already in hypoxia.
• Myths corrected
  • "Let the passenger compartment fill up, then open the door" ❌: too late.
  • "Any object (belt buckle, headrest) will break a window" ❌: often untrue; laminated side windows increasingly common (≈ 1/3 of vehicles) → unbreakable with consumer tools.
  • "Electric windows no longer work in water" ❌: yes, at first (≈ 30 s), this is your exit window.
  • "We can survive in the air bubble" ❌ most vehicles sink without an operable bubble.
• Why not open a door? Opening a door creates a massive influx of water, accelerating the flow, slamming the door (finger/arm trap), and condemning other passengers.
• Children: evacuation order Older → younger. The older one can be independent (get out, hold on to the vehicle), while you help the younger one.
• Tools for glass breakage
  • Only if the glass is not laminated.
  • Location: visible and reachable (e.g. hanging from the rear-view mirror), not in the glove box/key holder (inaccessible under stress).
  • Point of impact: front corner near the hinges, not the center (the door absorbs the impact).
• Driving in high water / flooded pavement 12-18 in (30-45 cm) of water is enough to float a car and carry it away with the current → do not engage.
• Why rescue makes no difference Vehicle submersion mortality rate very high; no service can reach you in ≤ 1 min. → Autorescue = only chance.

Teaching field protocol (SWOC mnemonic)

• Seatbelts: all unbuckled immediately (adult driver first).
• Windows - Windows: immediately open a side window (electric if possible).
• Out - Get out through the window (do not touch the phone).
• Children first - Enfants d'abord: from the biggest to the smallest.

Instructor reminder: exit through window, never through door. If breakage necessary and tempered glass: strike at front corner near hinges. If laminated glass: unbreakable → only realistic option = open early (electric/manual) during float phase.

Application examples (simulation)

• 60 second scenario: vehicle in lake - minute 0-0:15: seat belts off; 0:15-0:30: open driver's window; 0:30-0:45: largest child exits; 0:45-1:00: youngest + adult exit. Debrief: what cost unnecessary seconds (phone, tools, door attempts)?
• By-stander: shout "Belts-Windows-Hinders-Children!"; if close to shore, push/pull the vehicle into shallow water (difference between 2.5 m and 1 m of water = survival).

 3 key words

SWOC - Fenêtre - 60 secondes

Key takeaways

• Your only window (of time and exit): the side window in the first minute.​
• Never open a door; don't call until you're outside.
• Teach and automate SWOC in short, realistic and repeated simulations.
  

5. Providing care on K2 or Everest​

Dr. Christian Dean

A fascinating comparison between two extreme environments: Everest, with its logistical access, clinics and helicopters, versus K2, more exposed, isolated and under military constraint. Geopolitical and cultural contexts have a direct impact on expedition medicine.

Key Takeaways for instructors :

• Every terrain has its own constraints: logistics, politics, culture, weather. Plans must be contextualized.
• Medical expeditions are not limited to clinical procedures: understanding the local system is just as vital as the drugs.
• K2 illustrates prolonged crisis medicine, where rapid evacuation is not possible.

6. Advanced Problem-Solving and Improvisation

Dr Steve Roy

Summary

Dr. Steve Roy explored strategies for deciding and improvising when information is partial, resources limited and time scarce - the day-to-day business of medicine in remote areas. He distinguished between ambiguity (we don't know what's going on) and uncertainty (we don't know what's going to happen), and showed how to develop adaptive expertise: going beyond the repetition of protocols to apply physiological principles and transform them into creative solutions.

Practical applications for Wilderness First Aid

• Ambiguity: no point in differentiating between two diagnoses if the course of action is identical → e.g. abdominal pain = rest + monitoring + evacuation, regardless of whether it's appendicitis or biliary colic.
• Robust decisions: provide a kit/plan that covers several scenarios, even if unlikely (hemorrhage, allergic reaction, loss of consciousness).
• Recoverable vs. irreversible failure: a homemade splint that comes undone = tolerable; uncontrolled bleeding = non-negotiable.
• Improvisation intelligente :
  • Substitution: strap + stick = turnstile.
  • Subtraction: no need for cervical collar if no added value → simplify.
  • Reframing: instead of "find an IV route no matter what", think "how else can we infuse?" → oral liquids, rectal route, positioning.​
• Prepare for failure: time stages (T0, T+5...), anticipate weather conditions, assess cumulative time loss.

3 key words

Robustness – Adaptation – Improvisation

Key Takeaways

• Train stakeholders to tolerate uncertainty and act despite ambiguity.
• Teaching the logic of care rather than just protocols.
• Promoting adaptive expertise: safe, simple and robust solutions, even off the beaten track.

7. Pre-Hospital Frostbite Care with Iloprost: Minimizing Warm Ischemia Time

Dr. Alex Poole

Dr. Poole presented the new Canadian practice of administering Iloprost in the field to treat severe frostbite, as recently tested in the Yukon. The aim is to reduce the period of warm ischemia (after rewarming, but before treatment), which drastically reduces the chances of tissue salvage.

Key message

The severity of frostbite is not only due to the cold, but above all to the damage caused by rewarming. Every hour lost after rewarming a frozen limb reduces the chances of saving tissue.

The aim is to act quickly and efficiently, even in remote areas.

Explanation in the Context of Wilderness First Aid

1. Two phases of frostbite
   • Freezing: little damage, tissue potentially recoverable.
   • Warming: onset of ischemia-reperfusion syndrome (thrombosis, vasoconstriction → progressive tissue destruction).
   👉 Educational message: Frostbite isn't "over" when it warms up. That's when it all begins and tissue can be saved or lost.
2. Iloprost as a key treatment
   • Drug that acts as a targeted vasodilator.
   • Reduces clot formation.
   • Protects tissues in pain.
   👉 Practical application in remote areas :
   • Can be administered from the control tent, in a helicopter, or at the nursing station.
   • Infusion kept warm (e.g. in a sleeping bag during transport).
   • Generally well tolerated, limited side effects.
3. The concept of 'warm ischemia time'.​
   • Every hour that passes after reheating without treatment = loss of chances.
   • Studies: up to 28% reduction in tissue saved per hour of delay.
   👉 Educational message: in isolated areas, don't wait for "the hospital" → start treating as soon as possible in the field.

Case studies presented (to be transposed into teaching exercises)

• Athlete with grayish toes at checkpoint → rewarming in warm water basin, iloprost infusion started in heated tent before evacuation → full recovery.
• Other athlete with more delay → iloprost started 4 h after warm-up → partial recovery only.

Educational applications for medicine in remote areas

• Teach people to recognize early signs: gray, numb, hard fingers/toes = severe frostbite.
• Simulate warming up in the field: warm water 37-39°C, pain monitoring.
• Insist on rapid decision-making: don't let the patient leave, priority evacuation.
• Training in IV protocols: how to start an infusion in a tent, a refuge or a remote post.
• Systematic debriefing: highlight the role of logistics (having iloprost available and stocked), team cohesion and discipline in the face of cold.

Takeaways 

✅ Warm up quickly, but well (controlled hot water).

✅ Start iloprost as soon as possible after warming up - even in the field.

✅ Every hour counts: reducing warm ischemia time.

✅ Having a clear, repeated protocol: teams act faster and save more tissue.

3 key words to remember

Rewarm, treat, salvage.

8. Don’t Touch That! Toxic and Venomous Creatures in the Canadian Wilderness

Dr. Lorri Beatty

A fun and informative talk on venomous animals in Canada: rattlesnakes, black widow spiders, lion's mane, Portuguese man-of-war, sea urchins and stinging caterpillars. Emphasis was placed on recognition, gestures to avoid (tourniquet, suction, vinegar, ice), and the importance of working with poison control centers.

1) Serpents (rattlesnakes) – Crotales de l’Ouest, des Prairies, Massasauga

Canadian context: present in interior BC, Alberta/Saskatchewan (Prairie), southern Ontario (Massasauga). Antivenin stored in "cache" centers (e.g. Oliver BC, Medicine Hat/Lethbridge AB, Parry Sound ON).

Recognize (without approaching)

• Body with camouflage pattern, triangular head, bell (not always visible/heard).
• NB: Several snakes imitate the pattern → never handle.

In the field - DO

1. Immobilize + elevate bitten limb (avoid self-displacement).
2. Remove rings/watches/tight shoes (edema).
3. Splint loose in comfort position.
4. Mark the edge of the erythema/edema with a felt-tip pen + measure the perimeter at the same point every 15-30 min (two small lines with the marker to rest the tape at the same point).
5. IV/IM analgesia (opioids if severe pain). IV fluids: sparingly.
6. Photo of snake if possible without getting too close.
7. Call Poison Control Centre (give nearest site with antivenom + decision aid).
8. Assisted evacuation (avoid walking/exertion, which accelerates diffusion).

In the field - DONT'S ​

• ❌ Tourniquet (aggravates lesions).
• ❌ Suction/incision, electrocution, alcohol, ice (local ischemia).
• ❌ "Lymphatic" compression bandage (useful in Australian-type neurotoxins, not in Canada → more necrosis).
• ❌ NSAIDs (theoretical increase in bleeding risk).

At the hospital (to contextualize your transmissions)

• Close monitoring + repeated check-ups (CBC, PT/INR, fibrinogen, creatin, CPK).
• Indications for antivenom (to be discussed with poison control): rapid progression of edema/pain, thrombocytopenia or low fibrinogen, systemic manifestations.
• Antivenins in Canada: Anavip® (long half-life, fewer rebounds) vs CroFab® (short half-life → redoses/prolonged biology). Risk of anaphylaxis + serum sickness (patient information).
• Fasciotomy very rare (discussed after maximum doses of antivenom and persistent pressures >25 mmHg).

Concrete example (exercise)

"Dry trail in valley, patient bitten ankle, edema rising to calf in 30 min" → splinting, elevation, marking/measuring 15 min, opioid, no NSAID, poison call, evacuation without walking.

2) Spiders - Black widow (West & Ontario)

• Picture: crampy abdominal/back pain, muscle spasms, sweating, hypertension/tachycardia, N/V. Recluse necrosis is not Canadian.
• Land: firewood, sheds, stacks of planks.

FIELD – TO DO 

• Wash with water, analgesics (up to opioids if necessary), benzodiazepines if spasms, call poison control, evacuation if widespread pain/ATCD at risk (pregnancy, elderly, comorbidities).

Antivenin: provides relief in 30-60 min, but risk of anaphylaxis/serum sickness. Reserve for severe forms (refractory pain, cardiovascular complication, obstetrical threat).

3) Cnidaria & "marine stings" - Lion's Mane jellyfish, Physalia (Man-of-War), purple sea urchins (Pacific)

Mechanism: nematocysts "shoot" micro-harpoons → toxins, mainly cyto/hemotoxic.

Fiels - Simple Protocol (3D)

1. Decontaminate: gently remove tentacles (forceps/gloves/spoon). Rinse thoroughly with SEAWATER (⚠️ no fresh water before deactivation)..
2. Deactivate nematocysts:
   • East coast: no vinegar (may aggravate). Rinse with sea water.
   • West coast: vinegar sometimes OK, but if in doubt → stay seawater.
   • Liquid topical lidocaine may help (if available) to deactivate + analgesia.
3. Denature toxin: hot water 42-45°C (shower/bath) 20-30 min (or until lasting relief).

Sea urchin: remove spines (forceps), hot water idem, tetanus up to date, watch for superinfection.

4) Urticating caterpillars (Hickory Tussock)

• Tableau : dermite prurigineuse type "orties".
• Field- DO: remove bristles, wash, mild local cold (compress), antihistamine, topical hydrocortisone if available. Monitor rare systemic reaction.

Training elements (WFA/WFR/WEMT)

• Snakebite" algorithm displayed in the intervention bag.
• Edema marking/measurement workshop (tape + Sharpie, 15-minute repeat).
• Poison call" role-play: know what to pass on (time, site, progress, systemic signs, photo).
• Drill "3D jellyfish" with false tentacles and set up a controlled hot bath.
• Check-list kit: tweezers, permanent marker, tape measure, analgesics, topical lidocaine (beach), compresses, seawater rinse solution (bottle filled on site).

DON'T FORGET (quick reminders)

• Don't chase the snake/spider → photo from a safe distance.
• No tourniquet, no ice, no incision/suction, no electroshock.
• Immobilize + elevate > everything else.
• Poison control center = ally no. 1 (antivenom routing, dosage, follow-up).
• Antivenin useful but not harmless → decision guided by local progression and hematological abnormalities.​

3 key words

Immobilize – Assess – Call

Key operational takeaways

• Snakes: immobilize/elevate, mark & measure every 15-30 min, analgesics, no NSAIDs, call poison control + evacuate.
• Black widow: pain/spasm → opioids + benzo, monitor BP/FC; antivenom only if severe form.​
• Jellyfish/physalia/sea urchins: seawater (rinse), no fresh water at first, heat 42-45°C 20-30 min, remove spines/tentacles carefully.
• Teaching: standardize the "snake" algo, the 3D jellyfish sheet, and the marking/measuring exercise to anchor the right gestures.

Conclusion

At the end of this conference, what stands out most is the richness and complementarity of the presentations: each offered practical tools, new perspectives and messages that can be directly transposed to our reality in isolated regions.​