I am frequently asked to write articles for magazines, chapters for textbooks, and commentaries for journals. Almost always, these are published, but sometimes a publishing project will fall through. Such is the case with a book entitled "Prehospital Care - Pearls and Pitfalls," edited by two longstanding emergency physician friends. Since their book is not going to be published, they have given me permission to use my contribution as I see fit in other venues, so please allow me to make the readers of this blog the beneficiaries. With a big thanks to my co-author, Dr. Laurie Kates, here goes:

WILDERNESS EMERGENCY MEDICAL SERVICES

1. What is wilderness medicine?

According to the Wilderness Medical Society (WMS): “Wilderness medicine focuses on medical problems and treatment in remote areas. It includes aspects of physiology, clinical medicine, preventive medicine, and public health.” For the purpose of emergency medical services (EMS) personnel, there are four qualities that define wilderness medicine:

• An austere environment
• Prolonged time to definitive care requiring modifications to traditional pre-hospital protocols
• Integration of rescue and medical skills
• Environmental threats

2. What is the difference between wilderness EMS and urban EMS?

Rapid response, stabilization and transfer to an advanced care facility comprise the focus of traditional urban EMS training systems. The physical remoteness, environmental exposure, challenging geography and often extended periods of time required for a rescue and stabilization require special training and define wilderness EMS. Traditionally, urban EMS is reactive and protocol driven, whereas wilderness EMS requires improvisation, innovation and extended protocols. In urban EMS, patient extrication is typically the responsibility of Fire Department personnel,who hand off patients to EMS providers, who begin providing medical care. In wilderness EMS, patient extrication is often technically difficult and time-intensive, requiring simultaneous administration of medical care by providers skilled in both medical and rescue skills.

3. How are wilderness emergency medical technicians (WEMTs) different from regular EMTs?

The Department of Transportation (DOT) is responsible for creating EMT curricula. The National Registry of Emergency Medical Technicians was inaugurated in 1970 to serve as a national certifying body for EMTs. Standardized tests are used to certify and recertify EMTs at the state level or into the National Registry of EMTs. There is no national standard or formal certification exam for WEMT designation. The WEMT curriculum is based on the DOT EMT curriculum and establishes an approach to emergency care in wilderness settings and is based on the recommendations of the Wilderness Medical Society, the Wilderness EMS Institute (WEMSI), the National Association of Search and Rescue (NASAR), the National Ski Patrol, the National Outdoor Leadership School (NOLS) and several other groups. Typically, a WEMT course includes 45-100 hours of classroom didactic time, 10 hours of emergency department time, and an additional 48 to 80 hours of clinical training as opposed to non-wilderness EMT courses, which require approximately 120 hours of classroom and ambulance ride-along time. WEMT courses include a minimum of 22 hours of training on medical conditions related to environmental conditions. In contrast, the typical EMT course includes only 3-10 hours addressing environmental emergencies. Other unique aspects of the WEMT curriculum include added training on extended patient care, rescue techniques, special equipment, and in providing care for injuries unique to the remote outdoors.

4. What procedures can be performed by WEMTs?

The procedures performed by a WEMT are determined by both the state protocols under which a WEMT practices, as well as his or her level of training. As there is no national standard for WEMT training, different states and health care systems have a variety of policies regarding what health care providers may and may not do given their levels of training. It is the responsibility of all health care providers to know the standard of care for their level of training, what procedures may be performed, and the protocols and policies of their system. Key elements in WEMT training include technical skills and authority, depending on the system in which they are working, to perform the following:

•Airway management, including endotracheal intubation.
•Needle thoracostomy for tension pneumothoraces
•Shock management, including intravenous therapy
•Use of military antishock trousers (MAST), although this is experiencing decreased use and popularity.
•Oxygen administration.
•Medication administration, including epinephrine for allergic reactions; antibiotics for certain circumstances; acetazolamide, nifedipine, and furosemide for altitude sickness; and pain medications for injuries.
•Field rewarming techniques.
•Field reduction and splinting of fractures and dislocations.

5. What employment opportunities and experiences are available for WEMTs?

Wilderness EMT skills are useful for anyone who spends a substantial amount of time in wilderness areas, but can also open new opportunities for employment. Some possibilities include:

• National and state park ranger, such as the ParkMedic program in Yosemite National Park
• Adventure travel
• Search and rescue
• Forest Service worker
• Disaster medicine/relief work
• Work in rural/wilderness areas
• Military

6. Are standards for wilderness (e.g., mountain, water) rescue teams different around the world?

Wilderness rescue teams vary tremendously around the world. In the United States, most teams are volunteer, with a wide range of qualifications and skills from first aid to paramedic, and are under the jurisdication of national parks, state parks, or county sheriffs. In Canada, mountain rescue teams are coordinated by the military. In Europe, most teams are staffed with full-time physicians and paramedics. In many of the most remote areas of the world, there is no organized system of wilderness emergency care, so travelers and expeditions are required to be self-sufficient.

7. What questions must be answered when assembling a team for a rescue?

Wilderness rescue requires coordinated and thorough preparation with consideration to the following:

ENVIRONMENT/GEOGRAPHY

•What time of day is it and will it be? (Are you prepared for a night rescue?)
•What are the anticipated weather (environmental) conditions, and are you prepared for them?
•Is a helicopter, boat, or other specialized rescue vehicle(s) needed or available?
•Is the weather acceptable for air rescue?

VICTIMS

•How long ago did the accident occur?
•What is the number of victims?
•What are their injuries?
•How many people are in the victim’s party?
•How well prepared are they?
•Does anyone in the party have medical experience or training?

RESCUE PERSONNEL

•Do you have a location, or is this a search and rescue?
•Is a “hasty” team (a smaller, less equipped team sent ahead to provide initial care or to search and rescue while the main team prepares and follows) needed? If so, has it been deployed yet?
•Are all team members prepared?

ARE THE RESCUERS AT SIGNIFICANT RISK?

•Are all team members trained for this type of rescue?
•Who is on the medical team?
•Who is on the evacuation team? Is the number of team members adequate? (For instance, 16 to 20 litter carriers are typically necessary for a ground evacuation of 1 to 3 miles over level terrain).
•Is the team equipment organized and divided up adequately?
•How urgent is the situation?
•Will multiple agencies be involved?
•Are communications coordinated between the different agencies?

8. Who is responsible for search and rescue?

•Search and rescue (SAR) is the responsibility of national and state parks, sheriffs, state conservation offices, or other government agencies, depending on the location and jurisdiction. National and state parks do not have a “duty to rescue.” In addition, there is sometimes significant controversy about when rescue missions should be attempted and who should pay for them. The prevailing opinion is that a call for help cannot ethically be dismissed.

•As mentioned in question 4, most rescues are done by volunteer groups.
•90% of mountain rescues are done by foot.
•95% of rescues are performed without physicians present.
•Only Yosemite and Grand Teton National Parks use helicopters extensively.
•Only Denali National Park uses fixed-wing aircraft extensively and helicopters occasionally.
•Only Yosemite, Grand Teton, and Mount Rainier National Parks have rangers specifically trained in technical rescues, advanced medical care, and helicopter operations.
•Many backcountry and climbing areas are outside parks. Rescues in these areas are by local fire and rescue departments, with or without the benefit of special training or technical skills.

9. What special knowledge is needed for searches and rescues (e.g., mountain, high angle, cave, ocean)?

•Understanding equipment (ropes, slings, carabiners, harnesses, helmets, litters, litter harnesses, haul systems, personal flotation devices, throw rings and bags, and litter patient packaging equipment) used in SAR operations, including their maintenance and care.
•Basic radio communication and signaling.
•Basic helicopter and fixed wing operation and procedures.
•Understanding search and rescue procedures.
•Knowledge of the Incident Command System and its use in SAR.
•Basic rope handling and knot tying skills.
•Advanced skills as needed for specific circumstances, including water SAR, white-water rescue, avalanche SAR, technical or vertical (rock) techniques, or cave training.
•Interpersonal skills and the ability to deal with field death and inform family and friends of deaths.

10. What are some examples of scenarios likely to require “extended” rescue and emergency care?

Mountain, wilderness, rural, white-water, air-sea, cave, and avalanche rescue, as well as expedition and disaster medicine and most search and rescue missions. The terms “extended rescue” and “extended emergency care” refer to medical care and rescue efforts beyond the first, or “golden,” hour.

11. What government agencies are responsible for search and rescue?

Federal SAR activities are either under the supervision of the United States Air Force (for inland regions), Aerospace Rescue and Recovery Service (responsible for federal aircraft incidents) or the United States Coast Guard (supervises coastal regions and all maritime and ocean searches). At the state level, there is significant variety in SAR supervision, because it is often under the jurisdiction of law enforcement agencies. All states have legislation that provides support to local governments during emergencies. During a nationally declared disaster, the Federal Emergency Management Agency (FEMA) assumes responsibility for SAR activities. The Department of Health and Human Services runs the National Disaster Management System (NDMS), which develops Disaster Medical Assistance Teams (DMAT) that can be rapidly deployed to nationally declared disaster areas.

12. What are the four phases of SAR?

•Locate.
•Access.
•Stabilize.
•Transport.

13. How many SAR missions occur each year in the United States?

Specific numbers are not reported. It is estimated that more than 100,000 SAR missions occur annually.

14. What are factors that may cause someone to need to be rescued (and therefore, to require the services of a WEMT)?

Any one, or a combination, of the following, may produce a situation that results in the need to be rescued, stabilized, and treated.

•Improper clothing or footgear.
•Fatigue.
•Dehydration.
•Hypo- or hyperthermia.
•Overextension of abilities.
•Lack of physical conditioning.
•Inadequate food.
•Inadequate planning.
•Inadequate leadership.
•Itinerary confusion.
•Inadequate recognition of environmental, physical, or mental factors.
•Inadequate preparation for weather conditions.
•Lack of navigational proficiency (getting lost).
•“Invincible” mind-set.
•Bad luck resulting in injury, illness, or exposure to an adverse environmental condition or event.

15. Is an EMS provider on a trip liable for care rendered during that trip?

The question is, “Is the provider acting as a designated health care provider, or is the provider merely a person on the trip who happens to be an EMS provider?” If the provider is the latter, then he or she is not duty bound to assist others in need. If he chooses to help, he is not invariably protected from liability by a Good Samaritan Law. While a Good Samaritan Law provides protection for medical personnel assisting within the scope of their skills, voluntarily, at an emergency scene, it is important to note that the provider is held to the full capabilities commensurate with his training. If an EMS provider is acting as the trip medical support, then he is liable to provide care at the accepted standard of care. In addition, because EMTs and almost all EMS providers act under a physician’s license, the doctor under whom the EMT is working is also liable for his or her actions.

16. What are some unique ethical dilemmas associated with wilderness EMS?

•How much risk will you accept for yourself and your team when planning SAR (e.g., going out in a snowstorm looking for a child) and treating victims in the wilderness?
•If a rescuer becomes injured, who will you treat first? The original victim or the rescuer?
•If a limited amount of supplies is available, who gets treated?
•How will the care affect others in the group (e.g., leaving scuba divers in the water in order to deliver a diver with decompression sickness to a hyperbaric chamber)?
•In a remote and prolonged care situation, how do the relationships of people in the group affect their choices for care and decisions regarding the group?

More so than in urban situations, a serious emergency in a wilderness area stresses many unique aspects of relationships and decision-making capabilities. From a survivalist point of view, it is necessary to take care of rescuers and teammates before caring for victims. Many potential circumstances can influence this decision. So, one must think about potential circumstances in advance and plan appropriate ways to incorporate a productive reaction to insure the survival and optimal outcome for rescuers, the team, and patients.

17. Where can I get more information about wilderness medicine and wilderness EMS?

WILDERNESS MEDICINE ORGANIZATIONS

•The Wilderness Medical Society, P.O. Box 2463, Indianapolis, IN 46206; (317) 631-1745
•The International Society of Mountain Medicine
•The International Society of Travel Medicine
•The Divers Alert Network

SEARCH AND RESCUE ORGANIZATIONS

•The Mountain Rescue Association
•The National Association for Search and Rescue
•The National Ski Patrol
WILDERNESS EMT TRAINING PROGRAMS

•The Wilderness Emergency Medical Services Institute
•The National Outdoor Leadership School, Wilderness Medicine Institute

There are many companies and colleges that offer WEMT courses. Check in your region for programs near you.

Pearls and Pitfalls

1. Wilderness EMT (WEMT) designation requires specialized training in rescue techniques, use of special equipment, and extended patient care in remote areas.
2. WEMT’s must work very closely with all search and rescue (SAR) personnel to ensure the safety of the patient and all team members.
3. The four phases of SAR are locate, access, stabilize and transport.
4. A unique ethical dilemma for the WEMT is how much personal risk is acceptable to accomplish the rescue.

BIBLIOGRAPHY

1. Auerbach PS (editor). Wilderness Medicine, 5th ed. Philadelphia, Mosby Elsevier, 2007.
1. Cooper DC, LaValla PH, Stoffel RC: Search and rescue. In Auerbach PS (ed): Wilderness Medicine, 5th ed. Philadelphia, Mosby Elsevier 2007, p. 708.
2. Langer CS: Medical liability and wilderness emergencies. In Auerbach PS (ed): Wilderness Medicine5th ed. Philadelphia, Mosby Elsevier 2007, p 2163.
3. Hubbell FR: Wilderness emergency medical and response systems. In Auerbach PS (ed): Wilderness Medicine 5th ed. Philadelphia, Mosby Elsevier 2007, p 694.
4. Iserson KV: Ethics of wilderness medicine. In Auerbach PS (ed): Wilderness Medicine 5th ed. Philadelphia, Mosby Elsevier 2007, p 2170.
5. Johnson, L. An introduction to mountain search and rescue. Emerg Med Clin N Am 22 (2004): p. 511
6. Klainer PH: Prehospital emergency medical services. In Harwood-Nuss AL, Linden CH, Luten RC, et al (eds): The Clinical Practice of Emergency Medicine, 2nd ed. Philadelphia, Lippincott-Raven, 1996, p. 1517
7. Russell, M.F. Wilderness emergency medical services systems. Emerg Med Clin N Am 22 (2004): p. 561
8. Sholl, JM and E.P. Curcio. An Introduction to wilderness medicine. Emerg Med Clin N Am 22 (2004): p. 265

photo courtesy National Outdoor Leadership School (NOLS)