Dr. Patrick Fink interviews Dr. Nick Daniel and Dr. Gavin Clark about an in-hospital case of exertional heat stroke in a mid-20s runner who collapsed just before the finish of an October New England half marathon in 45°F weather. EMS treated presumed SVT with adenosine, but in the ED the patient was hypotensive, profoundly diaphoretic, and altered; an oral temperature was normal while a rectal core temperature was 105.5°F, highlighting that peripheral temps can’t rule out heat stroke. 

We discuss rapid “cool first” management using ice packs, misting, and fans to reach 102°F within ~30 minutes, compare cooling methods (cold-water immersion, tarp-assisted oscillation, Quantico method, frozen sheets), review labs showing lactate 9 and AKI, explain sepsis-like physiology via gut hypoperfusion, and note possible risk contribution from recent COVID and acute Lyme IgM positivity. 

Links:
Ep. 33 - Heat Illness Fundamentals

Ep. 27 - Thermoregulation: The Physics and Physiology of Body Temperature Regulation

Clark G, Kocen S, Daniel N. Icy Hot: A Case of Unexpected Heat Illness. Wilderness Environ Med. 2026 Jun 16:10806032261458332. doi: 10.1177/10806032261458332. Epub ahead of print. PMID: 42300334.

Eifling KP, Gaudio FG, Dumke C, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Heat Illness: 2024 Update. Wilderness & Environmental Medicine. 2024;35(1_suppl):112S-127S. doi:10.1177/10806032241227924

Chapters:

00:00 Show Intro and Guests
02:43 Meet the Doctors
03:48 Race Day Collapse Setup
04:47 Finish Line Differential
06:48 EMS Report and History
08:55 Core Temp Surprise
11:25 Field Temp Takeaways
13:38 Rapid Cooling in ED
15:36 Cooling Rates and Goals
16:28 Immersion and Alternatives
18:17 Tarp and Body Bag Hacks
19:32 Quantico and Frozen Sheets
21:10 Field Cooling Methods
21:48 Lab Workup Red Flags
23:23 Lactate Nine Explained
24:21 Heatstroke Sepsis Pathway
26:40 Hidden Factors COVID Ticks
29:09 Fever Versus Hyperthermia
31:27 Prehospital Takeaways
35:00 Race Day Kit Checklist
36:35 Cool First Transport Later
37:29 Outcome And Wrap Up
39:46 Podcast Closing Notes

As always, thanks for listening to Wilderness Medicine Updates, hosted by Patrick Fink MD FAWM.

Connect with us by email at [email protected].

You can pay us a compliment and share the show with a new listener on any popular platform here.

Forty to seventy-five percent of tourniquets placed in the field are never actually needed. In Ukraine, tourniquets left on too long during delayed evacuations have cost people limbs that the original wound never would have.

This fast push covers the new May 2026 TCCC Guidelines update and two CoTCCC training briefs on tourniquets, built around lessons from prolonged evacuations in the Russo-Ukrainian war. Topics: telling truly life-threatening bleeding from bleeding that just looks bad, the case of an 11.5-hour tourniquet that cost an arm, reassessment moving from a medic-only skill to something every responder needs, the six options at reassessment (remove, convert, reposition, tighten, add a second, leave alone), how to convert a tourniquet, and what changes once one's been on past six hours.

Takeaway: applying a tourniquet is the easy part. Knowing what to do with it for the next several hours is what actually saves the limb.

References:

Committee on Tactical Combat Casualty Care. TCCC Guidelines, 01 May 2026. https://deployedmedicine.com/tccc Full guidelines PDF: https://learning-media.allogy.com/api/v1/pdf/18ccfdfc-a076-47e9-8a34-376efdd81b43/contents

Butler F, Holcomb J, Dorlac W. TCCC Quick-Look: What Kind of Bleeding Requires a Tourniquet? 19 May 2026. https://www.aast.org/static/dadfd895-d295-4a5d-9f45f8d92940991c/TCCC-260521-TCCC-Quick-Look-Who-Needs-a-Tourniquet.pdf

Koch EJ, Andersen M, Barbee GA, et al. Standardizing Tourniquet Reassessment and Conversion Across TCCC Tiers: TCCC Guidelines Proposed Change 25-2. J Spec Oper Med. 2026;26(1):M4V1-O3Y7. This is the peer-reviewed paper behind the Tourniquet Reassessment Quick-Look. https://jsomonline.org/product/standardizing-tourniquet-reassessment-and-conversion-across-tccc-tiers-tccc-guidelines-proposed-change-25-2/ PubMed: https://pubmed.ncbi.nlm.nih.gov/41818038/

As always, thanks for listening to Wilderness Medicine Updates, hosted by Patrick Fink MD FAWM.

Connect with us by email at [email protected].

You can pay us a compliment and share the show with a new listener on any popular platform here.

Dr. Patrick Fink reviews the spectrum of heat illness using 2024 Wilderness Medical Society guidelines, covering recognition, physiology, field treatment, and key mimics. He distinguishes heat edema, heat cramps (salt-depletion vs exercise-associated), heat syncope and exercise-associated collapse, and defines heat exhaustion by preserved mental status versus heat stroke by altered mental status in a heat context, warning not to wait for a temperature threshold. He explains heat stroke pathophysiology as direct thermal injury plus a sepsis-like inflammatory cascade from gut hypoperfusion and barrier failure, emphasizing “heat × time” and a 30-minute cooling window. Core management is “cool first, transport second,” with cold water immersion as gold standard and improvised “tarp taco” alternatives; stop cooling around 38.3–38.8°C, avoid antipyretics and dantrolene, and use fluids only as support. He highlights exercise-associated hyponatremia as a dangerous mimic requiring hypertonic saline, and discusses disposition, including possible field release after full recovery within two hours for healthy exertional cases.

Links

Episode 27: Thermoregulation: The Physics and Physiology of Body Temperature Regulation

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Heat Illness: 2024 Update

Chapters

00:00 Heatstroke Trail Scenario
01:02 Episode Roadmap
03:34 Thermoregulation Basics
06:43 Mild Heat Illness
11:21 Heat Exhaustion Line
13:32 Heat Stroke Recognition
17:18 Why Heatstroke Kills
22:37 Cool First Transport Second
24:51 Cold Water Immersion
27:31 Improvised Field Cooling
28:28 Myths Meds and Fluids
33:56 Hyponatremia Mimic
36:57 Disposition and Transport
39:38 Gear and Preparation
41:05 Key Takeaways Wrap Up

As always, thanks for listening to Wilderness Medicine Updates, hosted by Patrick Fink MD FAWM.

Connect with us by email at [email protected].

You can pay us a compliment and share the show with a new listener on any popular platform here.

That EpiPen in your kit expired eighteen months ago. Anaphylaxis is happening. Do you use it?

This episode digs into a 2025 systematic review from the American Red Cross Scientific Advisory Council that asked a question most of us have quietly wondered about: do expired resuscitation medications still work? We walk through the evidence on the four drugs that matter most in the field — albuterol, aspirin, epinephrine, and naloxone — and what the science actually says when in-date meds aren't an option.

In this episode:

• Why the expiration date is a manufacturer's guarantee, not a tombstone — and what it actually measures
• The honest limitation behind all 17 studies: this is bench chemistry, not human outcomes
• Albuterol holding 98% potency 20–30 years out, and why the inhaler's valve is the real weak link
• The aspirin asterisk: solid for years, but down to under 12% active drug at 28–40 years
• Epinephrine that's gone a little brown — discolored doesn't mean toxic, it means weaker
• The nornaloxone question, and why decades-old naloxone still isn't dangerous
• Sterility, storage, and the dashboard-baked-pen problem the studies couldn't answer
• Where the ethics land: doing something with a probably-weakened drug vs. doing nothing

The takeaway: Carry in-date meds. Rotate your stock. Store them cool and dark. But throw out the binary — in a real emergency with no alternative, that expired pen very likely still has most of its fight left.

The mountain doesn't check expiration dates. Neither does anaphylaxis.

Reference: Charlton N, Berry DC, Kannan V, Yee R, Carlson JN, Orkin AM. "The use of expired resuscitation medications for life-threatening first aid conditions: a systematic search and narrative review." Resuscitation Plus. 2025;26:101110. Open access (CC BY).

As always, thanks for listening to Wilderness Medicine Updates, hosted by Patrick Fink MD FAWM.

Connect with us by email at [email protected].

You can pay us a compliment and share the show with a new listener on any popular platform here.

Prehospital Airway Fundamentals for BLS: Positioning, Pocket Mask, NPA/OPA, BVM, and LMA

Dr. Patrick Fink presents a BLS-focused airway fundamentals episode for prehospital and wilderness/SAR responders, emphasizing an ingrained, stepwise approach to stave off respiratory badness. 

Links:

Airway Fundamentals Video

Intersurgical iGel LMA

Chapters:
00:00 Airway Basics Overview
01:52 Questions And Upcoming Episodes
04:04 Scenario Mountain Biker
05:33 Airway Positioning Jaw Thrust
09:42 Pocket Mask Ventilations
13:24 Nasal Airway NPA
17:53 Oral Airway OPA
22:22 Putting It All Together
24:26 Oxygen And Bag Valve Mask
29:03 PEEP Valve Tips
30:29 Laryngeal Mask Airway
35:52 Full Airway Algorithm Walkthrough
38:39 What I Carry In My Kit
39:39 Practice And Mental Rehearsal
42:17 Wrap Up And Support The Show

As always, thanks for listening to Wilderness Medicine Updates, hosted by Patrick Fink MD FAWM.

Connect with us by email at [email protected].

You can pay us a compliment and share the show with a new listener on any popular platform here.

In this episode, Dr. Patrick Fink reviews accidental hypothermia for wilderness providers, building on Ep. 27 Thermoregulation, explaining physiologic changes as core temperature falls  and why accurate core temperatures are difficult to obtain in the field. 

We learn the modified Swiss staging system (0–4) based on signs and symptoms and outlines field management: 

- 0 cold stress (shelter, dry/insulate, warm calories; avoid alcohol), 

- 1 mild hypothermia (ataxia/fine motor impairment; passive plus active external rewarming with a hypothermia wrap and heat near axilla/groin; frequent reassessment), 

- 2 moderate hypothermia (confusion/lethargy; active external rewarming, evaluate hypoglycemia, gentle handling and no exertion to avoid afterdrop, cardiac monitoring, expedite evacuation), 

- 3 severe hypothermia (unresponsive with vital signs; airway/ventilation support, extremely gentle transport)

- 4 hypothermic cardiac arrest (60-second pulse check, CPR, limited shocks under 30°C, withhold epinephrine/amiodarone under 30°C, consider intermittent CPR per protocol, and note potassium’s role in termination decisions). 

We also briefly contrasts slow non-extracorporeal warming with ECMO/cardiopulmonary bypass, previewing a future episode on advanced care and the HOPE score

Links

Episode 27: Thermoregulation

WMS 2019 Accidental Hypothermia Guideline

AHA Hypothermia Guidelines

European Resuscitation Council Hypothermia Algorithm

Chapters:

00:00 Welcome and Overview
00:48 Hypothermia Basics
01:12 Cooling Physiology
04:06 Severe Effects and Arrhythmias
06:38 Field Temp Challenges
07:41 Swiss Staging Intro
08:35 Stage 0 Cold Stress
11:40 Stage 1 Mild Hypothermia
16:04 Stage 2 Moderate Hypothermia
20:44 Afterdrop and Handling
22:54 Stage 3 Severe Hypothermia
27:00 Stage 4 Cardiac Arrest
27:57 CPR Shocks and Drugs
37:01 Advanced Rewarming ECMO
43:26 Key Takeaways Summary
46:57 Wrap Up and Support

As always, thanks for listening to Wilderness Medicine Updates, hosted by Patrick Fink MD FAWM.

Connect with us by email at [email protected].

You can pay us a compliment and share the show with a new listener on any popular platform here.

Reevaluating Spinal Motion Restriction: Evidence Update

In this episode of Wilderness Medicine Updates, host Dr. Patrick Fink delves into the evolving guidelines and practices concerning spinal motion restriction. Drawing from historical dogma and modern research, Patrick explores the inefficacies and potential harms of traditional spinal immobilization tools like rigid spine boards and cervical collars. Instead, he advocates for more flexible, evidence-based approaches such as using well-padded surfaces and coaching patients to minimize their own motion. Key points from a comprehensive literature review by the National Association of EMS Physicians and other authoritative bodies are discussed, highlighting the shift from immobilization to motion restriction and its practical implications. Listeners are urged to stay updated with current evidence and consult medical directors before altering their practices.

Links

Ep. 14 - Spinal Immobilization Guidelines Update

2018 ACEP/NAEMSP Sminal Motion Restriction Position Statement

Prehospital Trauma Compendium: Prehospital Management of Spinal Cord Injuries - A NAEMSP Comprehensive Review and Analysis of the Literature

Chapters

00:00 Introduction to Wilderness Medicine Updates

00:42 Historical Perspective on Spinal Immobilization

01:44 Transition to Spinal Motion Restriction

03:30 Review of Recent Literature

05:40 Key Findings on Spinal Motion and Neurological Outcomes

09:30 Effectiveness of Backboards and Cervical Collars

12:10 Potential Harms of Immobilization Tools

16:38 Practical Recommendations and Future Directions

21:48 Conclusion and Final Thoughts

As always, thanks for listening to Wilderness Medicine Updates, hosted by Patrick Fink MD FAWM.

Connect with us by email at [email protected].

You can pay us a compliment and share the show with a new listener on any popular platform here.

Wilderness Orthopedics: Managing Trauma in Remote Environments with Dr. Chris Healy

In this episode of Wilderness Medicine Updates, host Dr. Patrick Fink tackles orthopedic injuries in the wilderness with Dr. Chris Healy, an orthopedic surgeon and outdoor enthusiast. They explore the management of long bone fractures, traction for femur, pelvic binders, and the nuances of treating injuries in limited-resource environments. The episode covers strategies for handling common injuries like shoulder dislocations, tibia fractures, knee injuries, and how to prioritize care. They also emphasize the importance of timely evacuation and when and how to safely attempt reductions in the field.

Links:

Donate to the Tina Biddle Memorial Scholarship

Sulcus sign / Squaring of the shoulder

Chapters:

00:00 Introduction and Episode Overview
01:36 Tribute to Tina Biddle
04:09 Meet Dr. Chris Healy
05:11 Ski Patrol Background and Pre-Hospital Care
08:12 Approaching Orthopedic Injuries in the Field
17:50 Managing Tibia and Fibula Fractures
21:40 Understanding Compartment Syndrome
27:50 Femur Fractures and Traction Splinting
36:57 Pelvic Fractures: Identification and Management
38:41 Understanding Pelvic Fractures and Binders
39:53 The Role of Pelvic Binders in Pre-Hospital Care
41:11 Challenges with Pelvic Binders in the Field
43:15 Proper Placement of Pelvic Binders
46:36 Field Management of Shoulder Dislocations
50:43 Techniques for Reducing Shoulder Dislocations
54:17 Managing Upper Extremity Injuries
57:51 Handling Knee Injuries in the Field
01:00:37 Patella vs. Knee Dislocations
01:08:06 Evacuation Priorities for Knee Dislocations
01:10:53 Common Issues in Pre-Hospital Orthopedic Care
01:15:36 Final Thoughts and Listener Engagement

As always, thanks for listening to Wilderness Medicine Updates, hosted by Patrick Fink MD FAWM.

Connect with us by email at [email protected].

You can pay us a compliment and share the show with a new listener on any popular platform here.

Understanding Stress Injuries in First Line Responders with Laura McGladrey

This episode of Wilderness Medicine Updates, hosted by Patrick Fink, features a conversation with Laura McGladrey, founder of the Responder Alliance. They discuss the critical issue of stress injuries among first line responders, including professional ski patrollers, healthcare workers, and rescue team members. Through personal stories and expert insights, Laura explains the concept of stress injuries, how they develop, and the importance of early detection and mitigation. The episode highlights the need for both individual and organizational strategies to support resilience and manage stress. Listeners are introduced to practical tools, cultural shifts, and personal anecdotes to help maintain a long, healthy, and fulfilling career in high-stress environments.

Links

Responder Alliance Home Page
Access all that the organization has to offer.

Responder Alliance: Resource Hub
Easy access to critical tools and offerings.

The Stress Continuum
See the visual continuum that we discuss on the show.

Scholarships: Responder Alliance Foundation
Apply for aid for an individual or team training.

Make a Donation to Responder Alliance Foundation!
Join me in making a tax-deductible donation to support the valuable work of the Responder Alliance and bring this work to those who need it, regardless of cost.

Chapters
00:00 Introduction and Guest Welcome
02:11 Laura's Background and Work
06:00 Understanding Stress Injuries
10:02 Responder Alliance Mission and Challenges
20:55 Critical Incident Stress Management
30:49 Empowering First Responders
32:13 Daily Investments in Resilience
37:26 Recognizing and Managing Stress
38:14 Organizational Support for Stress Management
39:45 Building Resilient Teams
46:12 Learning from Resilient Leaders
52:42 Resources for Stress Mitigation
57:54 Conclusion and Final Thoughts

As always, thanks for listening to Wilderness Medicine Updates, hosted by Patrick Fink MD FAWM.

Connect with us by email at [email protected].

You can pay us a compliment and share the show with a new listener on any popular platform here.

In this episode of Wilderness Medicine Updates, host Patrick Fink delves into the topic of thermoregulation, explaining how our bodies regulate temperature in response to environmental changes. Listeners will learn about methods of heat exchange (conduction, convection, radiation, and evaporation), how to measure core temperature, and the body's physiological responses—such as shivering, sweating, and blood flow control. 

The episode also touches on the effects of age, metabolic stressors, and pregnancy on thermoregulation, as well as the importance of understanding these principles in the context of treating conditions like hypothermia and heat-related illnesses.

00:00 Introduction and Episode Overview
01:29 Importance of Thermoregulation
03:12 Human Thermoregulation Mechanisms
04:20 Measuring Core Temperature
07:55 Heat Exchange Methods
14:52 Behavioral and Physiological Responses
24:48 Sex and Age Differences in Thermoregulation
27:14 Conclusion and Next Steps

As always, thanks for listening to Wilderness Medicine Updates, hosted by Patrick Fink MD FAWM.

Connect with us by email at [email protected].

You can pay us a compliment and share the show with a new listener on any popular platform here.