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September/October 2004
ISSN-1059-6518
The Agony of the
Teeth
Volume 15, Number 5
Managing Backcountry
Dental Emergencies
By Frank Hubbell, DO
IT’S EARLY FALL OVER NORTHERN MICHIGAN; a beautiful time of year to go
paddling. The leaves are changing, the air is turning crisp, early morning fog
envelops the ponds and rivers, and the smell of wood smoke accents the air.
After several days of paddling you find yourself and several friends well into the
boundary waters of northern Michigan. That evening the crew whips up their famous pot of chili; hot, spicy, and a lot of it. While enjoying another mouthful, you bite
down on what is supposed to be a pinto bean, but instead it turns out to be a small stone
that made its way into the pot. Suddenly you feel the sharp crunch of a tooth breaking
and the intense pain of an exposed nerve. Your stare down at the chunk of tooth in your
hand as your jaw starts to throb. You’re miles from the nearest road, it’s dark, and none
of your friends are dentists. Okay, now what?
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Agony of the Teeth .... Cover
Tales of the Tapeworm ...... 5
Wilderness Medicine Newsletter
1
INSIDE
Reducing a Dislocated Patella ...... 6
Calendar ......... Back Cover
ANATOMY:
A tooth consists of the root, neck, and crown. The visible
part of the tooth, the crown, consists of a yellowish soft dentin covered by harder enamel. At the gum line is the neck and
elbow the gum line is the root of the tooth, anchored into the
tooth socket by periodontal ligaments. In the center of the
tooth and roots, is the pulp cavity that contains the blood
vessels and nerves.
Dental problems are commonly encountered on expeditions and in the extended care setting. They can range from
a simple nuisance, with a little pain or discomfort while eating, to a true dental emergency that, if not managed properly, can destroy the tooth or put an individual’s health at
risk.
ORAL TRAUMA
There are three types of traumatic tooth injuries:
Fracture
Luxation
Avulsion
DENTAL PROBLEMS:
DENTAL EMERGENCIES
These injuries are not dangerous to the person’s
overall health, but they do need to be managed
emergently for the health of the tooth:
fractured teeth
luxation
avulsion
oral Infections
First and foremost, when an individual has suffered
enough trauma to their face to cause a tooth to break off or
become avulsed, they deserve to be closely examined. Before you do anything else, take the time to get a complete
history, including mechanism of injury (MOI), and do a thorough hands-on-examination of their face, jaw, temporomandibular joint, and cervical spine. Also, test the integrity of the
facial structure and the airway by placing a gloved finger inside their mouth and pushing on the hard palate between the
upper teeth to make sure that they do not have a significant
facial fracture (Le Fort fracture).
These conditions can be VERY hazardous to the
individual’s health and can be very painful:
dental caries
abscessed tooth
Subacute Bacterial Endocarditis (SBE)
TOOTH FRACTURE
A tooth fracture can be classified as a root fracture, a
crown fracture, or a chipped tooth. A root fracture is when
the tooth is broken off with ½ the root still in the socket and
½ of the tooth broken free. A crown fracture describes when
the tooth is broken off at the base of the crown or the gum
line. A chipped tooth occurs when part of the crown, but not
the whole crown, is “chipped” off.
Any of these fractures are usually cosmetic and can be
easily repaired later. If the fracture exposes the pulp, and
thus the nerves, there can be significant pain. Pain can be
controlled by reducing exposure of the tooth to temperature
changes, air, saliva, and the tongue.
Treatment:
Three steps: control bleeding, save fragments, and cover
any exposed nerves.
Nuisance Problems—While not affecting the
individual’s health, these can be quite painful and
bothersome:
lost fillings, displaced crowns, cracked teeth
aphthous ulcers
cold sores
2
Bleeding can appear significant, but it is not life-threatening, and can be easily controlled with direct pressure. Direct
pressure to the tooth or socket can be achieved by gently
biting down on a piece of folded gauze.
Any tooth fragment is worth saving and sending out with
the patient. When handling tooth fragments or dislodged teeth,
try to handle them by the enamel avoiding the pulp or the root,
as touching the pulp will most likely destroy it, and handling the
root may harm the ligaments. The tooth or tooth fragments
need to be kept moist. The most effective way to do this is to
wrap the tooth in gauze moistened with the patient’s own saliva and then placed in a plastic wrap to maintain the moisture.
It has often been recommended that the tooth be placed in the
patient’s mouth, like a wad of chewing tobacco, “between cheek
and gum,” but my concern is the obvious risk of their swallowing or aspirating the tooth into their airway.
If the fracture is painful, the exposed nerve needs to be
sealed off from the air, temperature changes, saliva, and even
their tongue which can be achieved by covering the exposed
tooth with soft candle wax, using a commercial product called
Cavit, or with “super glue,”* cyanoacrylate. Clove oil, eugenol,
can be applied directly to the exposed pulp and will alleviate
the pain for several hours.
(*Superglue, cyanoacrylate, has not been FDA approved
for this application.)
person bite down on the tooth will also help to reseat it.
While possible to do this, it probably is not reality: it can
be difficult to figure out which way to reinsert the tooth and
the procedure would be very painful. The other problem is
that once the tooth is back in its socket, it will remain loose
and can easily become dislodged. After reinserting the tooth,
a dentist would splint the tooth with a tooth bridge.
If you are unable to reseat the tooth in its socket, treat it
like any tooth fragment: Wrap it in gauze moistened with the
patient’s own saliva and place it in plastic wrap to keep it
moist. Be sure to transport it out with the patient.
With any traumatic tooth injury, pain control and the risk
of infection may be concerns. Over-the-counter, non-steroidal anti-inflammatory drugs (NSAID’s), such as Advil, Ibuprofen,
Motrin, Aleve, or aspirin will help. Tylenol can be taken alone
or with an NSAID for more pain control. Also, 1-2 drops of
clove oil on the exposed nerve root can be used to help mitigate the pain. If this is not enough to reasonably control the
pain, the patient may need a mild narcotic such as Tylenol
with codeine (Tylenol #3) or hydrocodone (Lortab or Vicodin).
If evacuation is going to take several days, serious consideration should be given to antibiotic prophylaxis, especially
with avulsed teeth. For prevention of oral infections, the best
antibiotic is penicillin VK 500mg given by mouth 3 times per
day. If they are penicillin-allergic, then erythromycin 500mg
by mouth 2 times per day is also effective.
LUXATION
A luxation occurs when the tooth is shifted out of normal
anatomical position but otherwise left intact. How the tooth is
treated depends upon in what direction the tooth was displaced.
There are 3 types of tooth luxation:
Extrusion:
If the tooth appears longer than the surrounding teeth, it
is “extruded.” Proper management involves repositioning the
tooth. Grasp the tooth with a gloved hand and firmly push it
back into proper anatomical position.
Laterally displaced:
If the tooth appears to be pushed ahead of or behind the
normal tooth row, it is “laterally displaced.” Like the extruded
tooth, proper management is to reposition the tooth to normal anatomical position.
Intruded:
If the tooth appears shorter than the surrounding teeth, it
is “intruded.” This injury should not be field managed. Simplyleaveitasfound;DO NOT MOVE THE TOOTH.
ORAL INFECTIONS
Dental caries or pulpitis
Abscessed tooth
Osteomyelitis
Subacute Bacterial Endocarditis (SBE)
Each of these dental problems is the natural progression
of the preceding condition. In other words dental caries or
pulpitis can progress to an abscessed tooth which can deteriorate to an infection of the jaw, osteomyelitis, or an infection of the heart valves, Subacute Bacterial Endocarditis (SBE):
Dental caries or cavities occur from simple neglect of the
teeth. For too long, the teeth have not been properly tended
to. There has not been enough brushing or flossing on a regular
basis to prevent the build-up of plaque and bacteria on the
teeth. Chemicals produced by the bacteria break down the
enamel and allow the bacteria to move into the tooth. Eventually, the bacteria reach the pulp cavity where pressure and
infection will affect the nerve root causing pain, ultimately an
abscessed tooth, and tooth destruction.
Bad teeth, bad gums, and dental caries all will affect the
individual’s overall health status. In fact, bad teeth can even
cause a potentially life-threatening infection of the heart. When
a tooth is infected, the bacteria that is growing inside the
tooth has direct access to the circulation in the root of the
tooth. That circulation drains into the alveolar circulation in
the jaw and finally to the heart.
So, a simple untreated cavity will eventually cause an
infection of the pulp, pulpitis, that can worsen to become an
abscessed tooth. If nothing is done about the abscess, it can
either expand into the skeletal structure of the jaw bone causing an infection, osteomyelitis, or get into the circulation and
infect one of the valves of the heart leading to a life-threatening infection called Subacute Bacterial Endocarditis.
AVULSION
Avulsion occurs when the entire tooth has been removed
from its socket. The best results occur when the tooth can be
replaced within 30 minutes if possible. After two hours of being out of the socket, the chances of the tooth surviving are
minimal.
When a tooth has been avulsed, gently pick up the tooth
by the crown and examine it closely. The trick is to figure out
which way it should go back into the socket. Both the shape of
the tooth and the root configuration will help to direct proper
placement. To clear it of any debris or blood clots, the socket
may need to be gently rinsed with warm water. Once irrigated
clear, the tooth can be reinserted into the socket. Give it a
good push, and it will seat and snap back into place. In addition, placing a gauze pad between the teeth and having the
3
Signs and Symptoms:
Simple dental caries or cavities do not hurt; they are usually found on dental exam. The decayed area of the crown or
enamel can be seen as a different color, or they are discovered on dental x-ray screening.
If the decay expands into the pulp of the tooth, the resulting pulpitis causes intermittent pain, usually associated with
the pressure of chewing or temperature change. As the infection progresses, an abscess forms inside the tooth. The
pressure of the abscess precipitates a constant toothache and
throbbing pain. If the infection spreads out from the pulp into
surrounding soft tissue or bone, the area around the tooth
and jaw will swell and become warm and tender to the touch.
At the same time the infection can spread into the adjacent
lymph nodes causing pain and swelling of the nodes. If the
infection spreads to the valves in the heart, causing SBE, the
damage to the valves will result in a heart murmur, as well as
systemic signs and symptoms of sepsis: fever, chills, fatigue,
weakness, tachycardia, and hypotension, eventually even septic shock and death.
Treatment:
The goal of emergent treatment is to control the pain,
treat the infection, and evacuate.
Initially the pain can be controlled with any NSAID with
acetaminophen (Tylenol). Because they have different mechanism of action, NSAID’s and acetaminophen can be used together for more effective pain control.
If the simple dental caries or pulpitis evolves into a dental
abscess, stronger narcotic pain relievers may be needed, such
as Tylenol with codeine (Tylenol #3), or hydrocodone (Lortab
or Vicodin).
If a dental abscess is suspected because of the constant
pain, the severity of the pain, or erythema and swelling of the
gums around the tooth, antibiotic therapy is appropriate. The
drug of choice is penicillin VK 500mg by mouth 3 times per
day. If they are penicillin allergic, erythromycin 500mg by
mouth 2 times per day if also very effective.
A warm, moist heat pack applied to the painful area of
the face or jaw will also bring relief; several drops of clove oil
may applied to the cavity area and may help. Unless there is
an obvious cavity or swelling from an abscess, it may be impossible to tell which tooth is the culprit.
oil. The treatment is to cover the exposed pulp. As mentioned
above, this can be accomplished with softened candle wax,
super glue, or, even better, Cavit, a commercially available
product that can be used as a temporary filling. Avoid stimuli
that will cause pain, such as drinking hot or cold fluids or
chewing on that area. Pain can usually be controlled with an
NSAID or Tylenol. Occasionally, a mild narcotic such as Tylenol
with codeine is necessary.
Evacuate for dental follow-up.
APHTHOUS ULCERS (CANKER SORES)
We have all had them at one time or another. The exact
cause is unknown, but it is thought to be an autoimmune
process resulting in breakdown of the oral mucosa with secondary infection in the exposed tissue.
Rarely, if ever, are these serious, but they can be a real
nuisance and painful. There is no quick cure. Warm salt
water gargles several times per day or other oral cleansing
rinses may help. Pain is intermittent and usually associated
with eating or drinking.
COLD SORES (ORAL HERPES)
Another common nuisance are cold sores. Typically
caused by a virus, oral herpes, it is estimated that 80% of
people harbor this virus. Protecting the lips from harm, chapping, and sunburn will help to minimize the risk of an outbreak. If this is a problem for you, be sure to carry the appropriate treatment, such as acyclovir ointment (Zostrix) or
other medications that work well for you.
PREVENTION
Before any major trip or expedition it is well worth the
money and effort to see your dentist and make sure that your
teeth are in good repair. If you are going to be participating
in an activity that can cause tooth injury, such as mountain
biking, then again it is worth talking with your dentist about
having a mouth guard made. Most people would not go climbing, skiing, or mountain biking without a helmet. For some
sports it is equally important to your teeth to protect them
with a guard. Using lip balms with sun block will decrease
injury and the risk of recurrent cold sores. If you know that
you are prone to oral herpes, bring a supply of the oral meds
or ointments that you use for a recurrence.
If you are planning to go on a trip or expedition that is
going to take you away from immediate medical care, an
important consideration is to add some dental supplies to your
first aid kit. Hard to believe I know but this is one of the few
places where duct tape is of little or no help. There just aren’t
many uses for it with dental emergencies.
NUISANCE PROBLEMS
lost fillings, dislodged crowns, cracked teeth
aphthous ulcers
cold sores
FILLINGS, CROWNS, and CRACKED TEETH
Teeth are hard, tough, and designed to last. But, various
restorations that have been used to repair broken teeth or
cavities can loosen with time and can come off, or the tooth
can crack and a piece can fracture off. This tends to happen
at the most inopportune time and typically occurs while chewing, which increases the risk of losing or swallowing the dislodged part. Any one of these problems can expose the pulp
and the nerves, resulting in pain. Although these problems
are not serious and can be easily repaired later; in the meantime it may be necessary to deal with the pain.
If, for any reason, the pulp and the nerves of the tooth
have become exposed, the pain can be alleviated with clove
CONTENTS OF A BASIC EMERGENCY DENTAL KIT
Candle wax: The wax can be softened and used to cover
exposed pulp or act as a temporary filling.
Clove oil (eugenol): An herbal remedy, a small bottle
can bought from herbal remedies’ stores or web sites.
Super glue (cyanoacrylate): This is not FDA-approved
for dental repairs, but it will glue a crown back in place or can
be used to cover exposed pulp.
4
Cavit: This is a commercially
available product from 3M. It is a
temporary filling material that your
dentist can order for you.
A plastic dental mirror can
be very handy for seeing around
the corners in the mouth.
Other supplies that would be
handy that you most likely have
with you:
Toothbrush
Dental floss
Gauze or cotton balls
Cotton-tipped swabs
NSAID such as aspirin or
ibuprofen
Tylenol
Many of these supplies are also available
in a convenient manufactured kits:
Dental Emergency Kit, produced by
Atwater Carey, easily found on the web.
Dental Repair Kit, produced by Adventure Medical Kits, easily found on the web.
For expeditions consider also carrying
antibiotics for dental abscess or other oral
infection:
Penicillin VK 500mg, 1 po qid x 10 days.
Erythromycin 500mg po bid x 10 days.
Shown actual size (4 tubes to a box)
Frank Hubbell is the co-founder of Stonehearth Open
Learning Opportunities and the Saco River Medical Group,
both in Conway, NH, and is the medical editor for this
newsletter.
REFERENCES
Douglass, AB, Douglass, JM, Common Dental Emergencies, American Family Physician, Vol. 66, No 3, Feb 1, 2003.
Herrmann, HJ, Chapter 23, Dental and Facial Emergencies, Fourth Edition of Wilderness Medicine, 2001.
Roberts, WO, Field Care of Injured Teeth, The Physician and Sportmedicine, Vol 28, No. 1, Jan 2000.
Tales of the Tapeworm
By Dr. E.C. Oli
STARI
Southern Tick-Associated Rash Ilness (Borellia lonestari)
Well, guess what? There is a new kid on
the block. Another tick-borne illness called
STARI has been added to our list.
Tick-borne illnesses are diseases that are spread by ticks, Lonestar Tick
(commonly referred to as “little
Amblyomma americanum
cesspools”), which spread the
microbes in their saliva. When
a tick bites, before it begins to feed, it injects
its saliva, an anticoagulant, into its victim
which allows the tick to have a blood meal.
STARI is a spirochete, Borrelia lonestari,
that is very similar to the Lyme Disease spirochete, Borrelia burgdorferi, and it
causes similar symptoms and a simiactual size
lar rash.
Following a tick bite by the
Lonestar tick, Amblyomma americanum,
STARI may present as an erythematous rash
with central clearing, known as erythema
migrans similar to Lyme Disease. This tick is found
in the Southeast and south-central states.
Like the deer tick, Ixodes, that spreads Lyme Disease,
the Lonestar tick is also a very small brownish tick but with a
Tick-borne Diseases of
North America:
white spot, or “star” in the center of its back.
Anyone who develops a suspicious
rash and has been exposed to ticks
or has had a tick bite should see
their primary care provider for appropriate testing and treatment. The
Center for Disease Control (CDC) recommends that anyone with a tick bite from a deer
tick, Lonestar tick, or other suspicious tick
should take a single dose of doxycycline
200mg once as prophylaxis against these illnesses.
Prevention always makes more sense
than treatment. To prevent any tick-borne
illness, you need to avoid tick bites.
This is accomplished by wearing protective clothing, using an
insect repellant or insecticide,
such as permethrin, and doing a tick
check every three hours to look for the nasty
little critters. Remember that they like to hide in
dark, moist places.
Tales of the Tapeworm is a regular column on infectious disease by Dr. E.C. Oli
(Frank Hubbell, DO)
Lyme Disease—Borrelia burgdorferi
Cat Scratch Fever—Bartonella hensaelae
Rocky Mountain Spotted Fever—Richettsia richettsii
Human Monocytic Ehrlichiosis—Ehrlichia richettsii
Human Granulocytic Ehrlichiosis—Ehrlichia chaffeensis
Colorado Tick Fever—RNA coltivirus
5
Babesiosis—Babesia microti
Tularemia—Francisella tularensis
Tick-borne Relapsing Fever—Borrelia sp.
Tick Paralysis—neurotoxin
Q Fever—Coxiella burnetti
Southern Tick-Associated Rash Illness (STARI)—Borrelia lonestari
You’re in Good Hands
Practical Treatments for Backcountry Medical Emergencies
By Frank Hubbell, DO
(with help from friendly, gloved Raccoons)
A RELATIVELY COMMON SPORTS INJURY, a dislocated patella typically occurs when a force is applied to the
medial side of the patella forcing it laterally out of the
femoral groove in which it rides. The groove, produced by the femoral condyles of the patella,
is held in place inferiorly by the patella
tendon and supported on the sides by
the medial and lateral patella femoral ligaments.
The patella almost always dislocates laterally. When this occurs,
the patient will be in significant pain
with their knee flexed and the patella displaced laterally. As with most
dislocations, the longer the patella remains out of joint, the more swelling there will be in and around the joint. This
swelling makes it harder to reduce. So, the sooner the joint can be reduced back into normal
anatomical position, the better.
Treatment:
Push the patella back into position
while slowly straightening the leg
Examine closely:
Palpate the patella for fractures.
Gently check the stability of the knee.
With one hand grasp the ankle. Place the other hand on
the knee with the fingers in the popliteal space and the thumb
against the lateral aspect of the patella.
As you push against the patella with your thumb, slowly straighten
out the leg with the hand that is on the ankle. As the leg extends,
the patella will reduce back into normal anatomical position.
Once reduced, wrap the knee with a 6” ace wrap for gentle
compression, to minimize swelling, and splint the leg straight.
Because of the risk that the medial patella ligament has been
partially torn and there may also be other ligamentous damage,
the knee has to be splinted. Once the knee is wrapped and splinted,
the patient may try to walk with the leg stiff and straight. If the only injury
was a dislocated patella and ligamentous sprain, walking should be pain free.
Please note: in the event that the patella does not reduce, splint the leg in the
position found and transport the patient in a litter.
6
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Heart Attack in the Backcountry
Level of Consciousness: Part 2
Level of Consciousness: Part 1
When Jack Frost Bites: a personal story
The Performance Triad: hydration, fuel, pacing
Musculoskeletal Injuries Part 3
Lightning: Beauty & Beast
Field Weather Forecasting
Behavior Meds in the Backcountry
Problems with the Pump
Staying Well in a World of Disease
The World of Infectious Disease
Managing Backcountry Fatality
History of Wild. Med. schools
Drugs in the Backcountry
Wilderness Rescue in Winter
Diabetes in the Wilderness
Poison Ivy, Oak, Sumac
Don’t Blame Montezuma
Have You Ever Wondered Why?
Got the Travel Bug?
Stonefish, Sea Snakes, and...
Leadership in Prevention...
Sunscreen Controversy
Unraveling Abdominal Pain
Lions &Tigers & Bears
Breathing Hard in Backcountry
Oh, My Aching Feet
Children in the Mountains
Critical Incidents
Anaphylaxis
Tendinitis
Gender Specific Emergencies
GPS (Global Positioning)
ISMM Discussion Case
The Charcoal Vest
ALS in the Backcountry
Avalanche Awareness
Human Rights
Water Disinfection
Women’s Health Issues
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2004 WILDERNESS MEDICINE NEWSLETTER, INC., ISSN 1059-6518. All rights
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12/05/04
12/05/04
01/09/05
01/09/05
01/09/05
01/16/05
01/23/05
02/06/05
02/13/05
02/16/05
02/20/05
03/13/05
03/13/05
03/13/05
03/20/05
03/27/05
10/29/04
11/21/04
11/24/04
12/15/04
12/18/04
01/07/05
01/14/05
01/13/05
01/14/05
01/13/05
03/10/05
01/16/05
01/16/05
01/16/05
05/04/05
02/16/05
02/19/05
03/20/05
03/26/05
05/22/05
12/22/04
10/17/04
11/21/04
12/05/04
01/07/05
01/16/05
01/16/05
02/20/05
02/25/05
12/14/04
02/06/05
02/11/05
COURSE
WFA
WFA
WFA
WFA
WFA
WFA
WFA
WFA
WFA
WFA
WFA
WFA
WFA
WFA
WFA + CPR
WFA + CPR
WFA
WINTER MEDICINE
WFA
WINTER MEDICINE
WFA + CPR
WFA + CPR
WFA
WFA
WFA
WFA
WFA
WFA
WFR
WFR
WFR
WFR
WFR
WFR
WFR
WFR
WFR
WFR
WFR
WFR
WFR
WFR
WFR
WFR
WFR INTENSIVE
WFR
WFR
WFR
WFR
WFR REVIEW
WFR REVIEW
WFR REVIEW
WFR REVIEW
WFR REVIEW
WFR REVIEW
WFR REVIEW + CPR
WILD
WILD DAY
WILD DAY
WILD DAY
LOCATION
AMC - BOSTON H/B @ SOLO, NH
AMC-WORCESTER, MA
GREEN MOUNTAIN COLLEGE, VT
YALE OUTDOORS, CT
AMC - BOSTON, MA
BSA, GILMANTON IRON WORKS, NH
MONMOUTH COUNTY PARKS, NJ
PACK, PADDLE & SKI, NY
ST. MICHAEL’S COLLEGE, VT
AMC - BERKSHIRES, MA
HULBERT OUTDOOR CENTER, VT
UNHOC, NH
MIT, MA
UNIVERSITY OF MICHIGAN, MI
GARRETT COLLEGE, MD
MOHICAN OUTDOOR CTR., NJ
AMC-PINKHAM, NH
COLLEGE OF DUPAGE, IL
COLUMBUS OUTDOOR PURSUITS, OH
AMC-PINKHAM, NH
BSA - TROOP #355, CT
SUNY-ONEONTA, NY
UNIVERSITY OF MAINE, MAINEBOUND, ME
AMC-GORHAM, NH
PACK, PADDLE & SKI, NY
SOLO, NH
UNIVERSITY OF MISSISSIPPI, MS
SHAVER’S CREEK, PA
AMC-PINKHAM, NH
WILDERNESS ADVENTURES@EAGLE LANDING, VA
GREEN MOUNTAIN COLLEGE, VT
UNIVERSITY OF MISSOURI, MO
GARRETT COLLEGE, MD
GEORGE MASON UNIVERSITY, VA
NEW CANAAN NATURE CENTER, CT
UNIVERSITY OF VERMONT, VT
NANTAHALA OUTDOOR CENTER, NC
SOLO, NH
SUNY-POTSDAM, NY
GARRETT COLLEGE, MD
AMC-PINKHAM, NH
SOLO SOUTHEAST, NC - CULLOWHEE
HIOBS - NEWRY, ME
SOLO SOUTHEAST, NC - CULLOWHEE
UNIVERSITY OF MAINE@ORONO, MAINE BOUND, ME
HIOBS, ME
WILDERNESS ADVENTURES@EAGLE LANDING, VA
NANTAHALA OUTDOOR CENTER, NC
SOLO, NH
SOLO, NH
SOLO, NH
CONTACT
978-283-7326
978-562-4494
802-287-8389
203-675-8925
508-655-6509
978-590-4073
732-842-4000x4296
585-346-5597
802-654-2614
413-562-6792
802-333-3405
847-533-7582
zjm@mit.edu
734-764-9577
301-387-3325
802-333-3405
617-523-0655x317
802-333-3405
603-466-2727
802-333-3405
630-942-2787
802-333-3405
614-890-6269
603-466-2727
860-666-3447
734-764-9577
607-436-3455
207-581-1794
603-466-2727
585-346-5597
603-447-6711
802-333-3405
662-915-6737
814-863-2000
603-466-2727
800-782-0779 OR 540-864-6792
802-287-8389
573-884-1764
734-764-9577
301-387-3330
703-993-9832
203-966-9577x15
802-656-3489
800-232-7238x355
603-447-6711
315-267-3130
301-387-3330
603-466-2727
828-293-5384
888-824-2302x400
802-333-3405
828-293-5384
207-581-1756
888-824-2302x400
800-782-0779 OR 540-864-6792
800-232-7238x355
802-333-3405
603-447-6711
603-447-6711
603-447-6711
KEY: AWFA: Advanced Wilderness First Aid • WEMT: Wilderness Emergency Medical Technician • EMT/RTP: Refresher Training Program • WFR: Wilderness First Responder
8

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Transcription

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