If you don't have the Adobe Acrobat reader, you may download it here. 
Copyright © 1993, 1994 Appalachian Search and Rescue Conference--
Center for Emergency Medicine of Western Pennsylvania,
Wilderness Emergency Medical Services Institute.
May be freely copied for use by WEMSI/ASRC/NCRC personnel.
Comments and suggestions to:
Dr. Conover, 36 Robinhood Road, Pittsburgh, PA 15220-3014
Medical oversight is a major goal of the Wilderness Emergency
Medicine Curriculum Development Project, as first stated in our
Prospectus of 1987. WEMSI now provides wilderness medical
oversight for the Appalachian Search and Rescue Conference and
the National Cave Rescue Commission, and has been approached by
many other groups, including the Western Maryland Grotto Cave
Rescue Team, and Search, Rescue and Recovery Services, and the
Pennsylvania Search and Rescue Council to consider providing some
form of centralized medical oversight for them. This desire is
based on the work we have already done in establishing the
Wilderness EMT Curriculum, and is to them a logical extension of
it. Several factors argue for the efficiency and higher quality
afforded by centralized medical oversight: 1)
Medically-complicated wilderness rescues are infrequent. 2) The
number of Wilderness EMS agencies is small but growing. 3) The
total number of Wilderness ALS providers and Wilderness Command
Physicians is also small. 4) Many Wilderness ALS personnel work
for more than one Wilderness EMS agency.
As a Pennsylvania-based provider of centralized medical
oversight, WEMSI is coordinating with Pennsylvania EMS, the
Pennsylvania Emergency Health Services Council (PEHSC), the
Atlantic EMS Council, the Maryland Institute for Emergency
Medical Services Systems (MIEMSS), and agencies in other states
to regulate and improve wilderness EMS. PEHSC has in the past
considered the need for better organization for Wilderness EMS,
and has now established a Wilderness EMT Subcommittee to make
formal recommendations to PEHSC and thence to the state
legislature.
To fulfill these functions, WEMSI must carefully craft a system
well-suited for the unique characteristics of Wilderness EMS.
The road to better care for Wilderness EMS patients leads
inevitably to better physician medical oversight. The road is
strewn with many obstacles, and picking a way through them is
delicate work. Those wishing to review the technical aspects of
medical oversight should review the new second edition of the
National Association of EMS Physicians EMS Medical Directors'
Handbook, now called Prehospital Systems and Medical Oversight,
and particularly the chapter on Wilderness EMS. A summary of our
present understanding of the legal aspects is available on-line
(from kconover+@pitt.edu) and is being reviewd and updated by
lawyers expert in this area.
Please review the Policy Manual and get your comments to Jack,
Gene or me. We plan to institute this Policy Manual on April 1,
based on comments received prior to March 1. Medical Advisory
Board Members: I will forward an interim version to you on or
about March 1 for final revision and approval, and April 1 we
will publish the official version. Suggestions for improving the
Policy Manual will be accepted at any time.
Comments to:
Keith Conover, M.D., Medical Director
[kconover+@pitt.edu; 412-561-3413 (H)]
36 Robin Hood Road Pittsburgh, PA 15220-3014
or
Jack T. Grandey, EMT-P, Operations Director
[grandeye@jeflin.tju.edu; 1-215-232-8105 (H) 1-215-533-2094 (W)]
862 N. Beechwood St. Philadelphia, PA 19130
or
Gene L. Harrison, EMT, Communications Officer
[harrison@mitre.org; 1-703-777-6111 (H), 1-703-883-6142 (W)]
P.O. Box 1584 Leesburg, VA 22075
C O N T E N T S
I. WEMSI Medical Control Policy 2
II. WEMSI Accreditation Policy 4
III. WEMSI Medical Communication Policy 6
Appendix A: Medical Communication Background 9
Appendix B: Definitions 11
I. WEMSI Medical Control Policy
Purpose:
WEMSI provides medical care to patients in the specialized
prehospital situations of wilderness, backcountry, and other
delayed and prolonged transport contexts such as catastrophic
disasters (referred to jointly as "the wilderness context"
throughout the Operations Policy Manual). The specific purpose of
this policy is to establish criteria under which individuals may
provide medical care under auspices of the Wilderness EMS
Institute.
Scope:
1. This policy applies to all individuals, including Field
Providers* who are authorized to provide direct patient care, and
Wilderness Command Physicians who direct such care, under
auspices of the Wilderness EMS Institute.**
* Term definitions are provided at the end.
** This edition of the WEMSI Policy Manual does not address
operations outside of WEMSI's home state of Pennsylvania. For
states that are members of the Atlantic EMS Council (PA, NJ, DE,
MD, DC, VA, WV) this may be addressed by a new mutual aid and
reciprocity agreement that is in the planning stages. Once such
an agreement is completed, this Manual will address such
questions.
2. Individuals shall only provide or direct patient care when
accredited in accordance with the WEMSI Accreditation Policy.
3. This policy shall apply to all WEMSI personnel unless
overruled by specific and relevant state or federal law.
Medical Control:
1. When faced with a patient care situation in the wilderness
context, WEMSI-accredited Field Providers shall attempt to
establish Medical Communication with, and obtain patient-specific
medical control from, a WEMSI-accredited Wilderness Command
Physician. If the delay in making such an attempt will adversely
affect the patient, Field Providers may start acting on the basis
of the WEMSI Protocols and Standing Orders. WEMSI Field
Providers may accept patient- specific medical direction from a
WEMSI Wilderness Command Physician only when there is Medical
Communication between the Field Providers and the Wilderness
Command Physician.
2. As used in this policy, Medical Communication is a specific
and circumscribed term defined in the WEMSI Medical Communication
Policy.
3. If unable to establish or maintain Medical Communication,
WEMSI Field Providers shall use the WEMSI Protocols and WEMSI
Standing Orders to guide their patient care; if the Protocols or
Standing Orders do not address the problem at hand, Field
Providers shall provide patient care in accordance with their
training, their best judgment, and the patient's best interests,
and shall continue attempting to establish Medical Communication.
4. WEMSI personnel are not authorized to act under remote or
direct medical control of physicians who are not WEMSI-accredited
Wilderness Command Physicians.
5. When in the wilderness context, WEMSI Field Providers shall
turn patient care over to a licensed but non-WEMSI physician at
the patient's side, if and only if said physician (a) identifies
self by name and by state license number in writing, and (b)
signs a statement accepting all responsibility for the patient's
care on a continuing basis
6. Once a patient is out of the wilderness context, WEMSI Field
Providers are authorized to transfer patient care responsibility
to (1) the physician directing a "street" EMS agency's (ground,
air or water) ambulance crew, (2) a licensed physician in a
health care facility, or (3) directly to a WEMS Wilderness
Command Physician. A WEMSI Field Provider should continue to
attend the patient and provide advice to the "street" EMS
agency's physician and ambulance crew, except (1) when safety
concerns dictate otherwise (e.g., aircraft payload limitations),
or (2) the WEMSI Field Provider, preferably in consultation with
a WEMSI Wilderness Command Physician, believes that the patient
is stable, and that the WEMSI Field Provider's special training
is unlikely to be needed during transportation to a health care
facility.
Documentation:
All patient care by WEMSI Field Providers shall be documented
using WEMSI Patient Record forms and Pennsylvania EMS report
forms, and submitted to WEMSI for Quality Improvement review.
II. WEMSI Accreditation Policy
1. All individuals seeking accreditation as WEMSI Field Providers
or Wilderness Command Physicians shall submit evidence that they
have obtained and are maintaining certification or licensure in
their home states as EMS providers or physicians.
2. Those seeking accreditation to provide advanced wilderness
medical care in the field shall submit evidence that they have
obtained and are maintaining accreditation to provide Advanced
Life Support (ALS) Emergency Medical Services care in their home
states.
3. Those seeking to provide basic or advanced wilderness medical
care in the field shall submit evidence that they have
successfully completed a Wilderness EMT course that meets the
educational objectives of the WEMSI Wilderness EMT Curriculum,
including all required clinical training, or equivalent training.
The WEMSI Education Officer shall establish procedures for
determining equivalence.
4. Those seeking WEMSI accreditation at any level shall complete
an interview and oral examination, based on guidelines provided
by the Personnel Evaluation Officer, appropriate to their level
of care.
a. For Field Provider applicants, this interview and oral
examination shall be provided by an accredited WEMSI Wilderness
Command Physician selected by WEMSI, and the ALS Coordinator or
the ALS Coordinator's designate.
b. For Wilderness Command Physician applicants, this interview
and oral examination shall be provided by an accredited WEMSI
Wilderness Command Physician selected by WEMSI, and the Medical
Command Officer or the Medical Command Officer's designate.
c. Those conducting the shall provide a written summary of the
interview and oral examination and a formal recommendation to
approve or not approve to the WEMSI Medical Director.
5. The WEMSI Medical Director shall be the final arbiter of all
accreditation decisions. WEMSI accreditation is not a property
right, it is permission to use the WEMSI Medical Director's and
Wilderness Command Physicians' medical licenses, and may be
denied or withdrawn without due process of law.
4. Those seeking WEMSI accreditation as Field Providers must
complete an application for accreditation established by the
WEMSI Operations Director, including, but not limited to, the
following information:
a. Current certification or license (copies of relevant
certificates required).
b. Present affiliation, which must with a recognized ALS or BLS
EMS service, with a medical practice, or with a hospital.
c. Endorsement of affiliate EMS service's medical director, the
medical practice's lead physician, or the hospital service
supervisor.
d. Completion of a WEMSI Wilderness EMT Course, or equivalent
as determined by the WEMSI Education Officer.
e. A letter of endorsement from a WEMSI-accredited Wilderness
Command Physician.
5. Those seeking WEMSI accreditation as Wilderness Command
Physicians must complete an application for accreditation
established by the WEMSI Operations Director, including but not
limited to:
a. Current medical license(s), including a Pennsylvania license
and main practice state license, if not in Pennsylvania.
b. Current and valid DEA Controlled Substances Registration
Certificate.
c. Specialty board certification(s), or evidence of board
eligibility.
d. Evidence of malpractice insurance and claims history.
III. WEMSI Medical Communication Policy
Purpose:
This policy lays out the communication parameters required for
adequate patient-specific medical direction ("on-line command,"
"direct medical control") in the wilderness context, where
technical difficulties may make "direct" voice contact difficult
or impossible. Such Medical Communication must provide accurate,
bi-directional voice or text data transfer.
Scope:
This policy applies to all patient-specific messages by WEMSI-
accredited Wilderness Command Physicians and WEMSI-accredited
Field Providers. This includes messages between WEMSI-accredited
Wilderness Command Physicians and WEMSI-accredited Field
Providers. It also applies to WEMSI-accredited Wilderness
Command Physicians if requested to provide patient-specific
medical direction or advice to field providers who are not
accredited by WEMSI.
Policy:
1. Medical Communication: Voice
a. Medical Communication exists when a Wilderness Command
Physician and Field Provider can speak directly to one another:
real-time bi-directional voice communication. Examples are as
follows:
when the Wilderness Command Physician and Field Provider are in
direct proximity (e.g., the Wilderness Command Physician is
looking over the medic's shoulder); or
when the Wilderness Command Physician and Field Provider are
close but not in direct physical proximity, and can still speak
to one another by voice (e.g., shouting down a cave passage); or
when the Wilderness Command Physician and Field Provider are
not in proximity, but may speak with one another via technical
means that enable accurate real-time bi-directional voice
communications (e.g., radio, telephone, field phone, or
combinations of these three).
b. Digital voice retransmission equipment, sometimes used as a
single-frequency alternative to automatic repeater stations, is
considered the same as other forms of electronic voice
communication for the purposes of this policy.
c. This does not require a full-duplex communications mode; an
alternate unidirectional communications mode, such as the
standard radio communications mode where one cannot listen while
pressing the push-to-talk button, is acceptable.
d. All medical voice communication shall be in standard American
English. Standard medical terms, abbreviations, and acronyms are
acceptable provided they are understood by both parties.
e. Should voice communications quality be marginal (due to such
factors as poor communications equipment or channel quality),
personnel shall use the ASTM Standard Practice for Phonetics.
2. Medical Communication: Data
a. Medical Communication exists when a Wilderness Command
Physician and Field Provider can exchange data messages or
digital information with one another that include text data.
Though some unidirectional or bi-directional non-text information
may be transmitted, the data must include bi- directional voice
or text data to be Medical Communication. EKG or other telemetry
by itself would not constitute Medical Communication as it does
not include bi-directional voice or text data. However,
communication need not be real-time if the medical mission can
still be performed successfully. Potential examples of data
Medical Communication are as follows:
hand-written or typed notes;
facsimile;
imagery, electronic or otherwise;
voice recordings;
machine transmissions such as teletype or TTD;
wireless data transmissions using international Morse code, or
CCITT alphabets 5 (Baudot) or 7 (ASCII) (e.g., HF radio, VLF cave
radio, VHF/UHF packet data systems)
b. Medical data communication that uses written or recorded
language shall be in standard American English. Standard medical
abbreviations are acceptable provided they are known to both
parties.
c. Should recorded voice or data communications quality be
marginal (due to such factors as poor communications equipment or
channel quality), personnel shall use the ASTM Standard Practice
for Phonetics.
3. Medical Communication: Relay
To be Medical Communication, a relay or series of relays must:
transmit all messages word-for-word;
read back the message word-for-word from the recipient to the
originator;
have an acknowledgment from the originator to the recipient
that the message was returned intact; and
have a written or typed log of the message at the originator,
and at the recipient. Logs may be kept at intermediate relay
stations but are not required.
Policy Manual Approvals:
___________________________________________________________ WEMSI
Medical Director Date
___________________________________________________________ WEMSI
Operations Director Date
___________________________________________________________ WEMSI
Communications Officer Date
Appendix A: Medical Communication Background
Medical care is best delivered with a qualified physician at the
patient's side. An alternative level of care is having field
providers providing care based on standing orders. Intermediate
between the two is having a physician direct care through two-way
communication with field providers in the field: not as good as
having a physician present, but better than field providers
directed only by standing orders.
Traditional EMS requires immediate, bi-directional, real-time
voice communication for field providers to act on the direction
of a remote physician. This requires sophisticated
communications equipment. It also requires sophisticated system
design. In the wilderness and in the backcountry, sophisticated
communications infrastructures are seldom available.
Nonetheless, wilderness and backcountry patients deserve the
benefit of physician control of their care when possible.
Despite technical limitations of the wilderness/backcountry
context, physicians can and should, with adaptations, provide
medical control to field providers. For WEMSI, instead of
"direct" communication for on-line medical control, we use the
term "Medical Communication" to signify the situations when field
providers in the field may accept and act on orders from a remote
physician.
This policy outlines and defines how patient-specific medical
control can be accomplished through Medical Communication.
Accurate, Immediate, and Bi-directional Communication for Urban
EMS
Patient-specific medical control ("on-line command") generally
requires "direct" communication between the physician and the
out-of hospital providers in the field. The legal definition of
this "direct" communication varies from publication to
publication and from state to state. Used in its precise
meaning, "direct" communication only occurs when the physician
and field provider are standing near one another. However,
communications equipment such as two-way radios, telephone, and
cellular phones provide communications that are so similar to
direct communication as to substitute for it.
"Direct medical control" for traditional urban EMS supports
information interchange that has three important characteristics.
First, it is without intermediaries that might introduce
significant errors: it is accurate. Second, it allows real-time
(instant) interactive exchanges: it is immediate. Third, it
allows both physician and medic to initiate communications and
send and receive information: it is bi-directional. The two-way
nature of medical communication is essential to the proper
functioning of patient-specific medical control. Some aspects of
medical communication, such as EKG telemetry, may be
unidirectional. The usual radio or telephone connection between
hospital ED physician and urban medic is accurate, immediate, and
bi-directional.
While such communications are the ideal, they may not always be
available in the backcountry. However, other forms of
communication may be adequate to legitimately support
patient-specific medical control.
Modification for the Wilderness/Backcountry Context
In the wilderness/backcountry context, immediate communications
are not always possible. An extreme example is during the
initial stages of a cave rescue. In such a case, written notes
between the physician at the surface and the medic underground
convey all medical (and other) information.
Wilderness rescue operations often last for hours or days.
Therefore, a delay of minutes (or even hours) will not invalidate
the value of a link between physician and field providers.
Provided that information is passed accurately both ways, even
written messages can be a valid method of medical control.
Personnel in the field must have written standing orders to
follow in the gaps between such communications. However, written
standing orders do not negate the value of a physician's patient-
specific medical control.
The two critical requirements for Medical Communication are that
it is accurate and that it is bi- directional. Delays should be
minimized but Medical Communication need not be immediate.
Traditional EMS, which emphasizes the real-time nature of direct
medical control, does not permit relaying of messages. There is
good reason for this. The classic game of "gossip" illustrates
the problem: a message is started at one corner of a classroom
and whispered from one student to another. When the message
arrives at the far corner of the classroom, it is unrecognizable.
In wilderness search and rescue, however, relays are common.
Backpackable automatic repeaters are sometimes used, but not
always available or in the right location. A rescuer at the top
of a mountain uses a handheld radio to relay messages from people
on one side to those on the other side. Because of the problems
of relaying accurate messages, reliable relay protocols have
evolved. They involve composing a written message at one end,
transmitting it word-for-word through the relay, then reading it
back to the originator word-for-word for confirmation. This
protocol has provided reliable error-free communication for
military and search and rescue operations for many years.
Appendix B: Definitions
Accurate: as used in this manual, allowing verbal or text
information to be communicated without errors in meaning.
Bi-directional: as used in this manual, allowing both physician
and medic to initiate communications and send and receive
information.
Field Provider: as used in this manual, includes both basic
level (e.g., first aid, First Responder, EMT-Basic, with
wilderness training) and advanced level (e.g., Nurses,
Paramedics, Physician's Assistants, Nurse Practitioners), but
not physicians, who are independently licensed to practice
medicine.
Wilderness Context: as used in this manual, the specialized
prehospital situations of wilderness, backcountry, and other
delayed and prolonged transport contexts such as catastrophic
disasters, in which EMS delivery is complicated by one or more of
the following four factors:
remoteness as far as logistics and access;
a significant delay in the delivery of care to the patient;
an environment that is stressful to both patients and rescuers;
or
lack of equipment and supplies.
Wilderness Command Physician: as used in this manual, licensed
physicians who have training in remotely directing care for sick
or injured persons; who have training in doing so for the
specialized prehospital situations of wilderness, delayed, or
prolonged transport contexts (the WEMSI Wilderness Command
Physician class); and who have been accredited by the Wilderness
EMS Institute to remotely direct other wilderness medical
treatment by WEMSI Field Providers.
Wilderness EMT: as used in this manual, individuals trained as
Emergency Medical Technicians who care for sick or injured
persons in the specialized prehospital situations of wilderness,
delayed, or prolonged transport contexts. Wilderness EMTs are
trained in accordance with U.S. D.O.T. HS 900-075 Training
Curriculum for Emergency Medical Technicians and ASTM F1287-90
Standard Practice for the Training of the Emergency Medical
Technician (Basic), or the subsequent D.O.T. EMT-Basic Training
Program.
Wilderness First Responder: as used in this manual, first
responders who may care for sick or injured persons in the
wilderness contexts, including catastrophic disasters.
Wilderness First Responders are trained as First Responders in
accordance with ASTM F1287-90 Standard Guide for Performance of
First Responders Who Provide Medical Care and ASTM F1453-92
Standard Guide for the Training and Evaluation of First
Responders Who Provide Medical Care. They have additional
training in applying their training in the wilderness context.
Wilderness Medic: as used in this manual, a Wilderness EMT who
has completed training to the standards of the Wilderness EMT
Curriculum of the Wilderness EMS Institute, who is an active EMT-
Paramedic or equivalent, who has achieved a high level of
competence in providing wilderness medical care, and who has been
accredited by the Wilderness EMS Institute to administer
medications and other wilderness medical treatment.
-0-
We are also providing this information in Adobe Acrobat format.
All our pdf files are in Acrobat 3.0, and if you have problems reading them with version 1.0 or 2.0, please follow the above link to upgrade to the latest version (free).
 |
Designed by a member of  |
 |
| Maintenance Data:
opp.html Date Last Revised: April 10, 2001 |
