This is the fourth in a series of drafts of subsections of a formal state Wilderness EMS plan for Pennsylvania. This is a project of the Wilderness EMT Subcommittee, EMT and Paramedic Advisory Committee, Pennsylvania Emergency Health Services Council. Input is also coming from the Legislative and Medical Advisory Committees of PEHSC.

We are looking for commentary from outside PEHSC. Please review and reply with your comments to wilderness-emergency-medicine@list.pitt.edu. If you have questions that don't need to go to all list recipients you may contact Keith Conover, M.D. (kconover+@pitt.edu), Subcommittee Chair.

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The fourth part of the plan, as per a vote at a Subcommittee meeting in March 1995:

"4. Centralized Program: developing a cost-effective and inexpensive program to address the above concepts at the state level, and to address the other systems component needs of wilderness/backcountry patients:

"+ manpower

"+ training

"+ communications

"+ transportation (in the case of Wilderness EMS, evacuation to a vehicle)

"+ facilities

"+ critical care units

"+ public safety agencies

"+ consumer participation

"+ access to care

"+ coordinated patient recordkeeping

"+ public information and education

"+ review and evaluation

"+ disaster plan

"+ mutual aid

"[list taken from Mustalish AC, Post C. Chapter 1: History. In: Kuehl AE, ed. National Association of EMS Physicians' Prehospital Systems and Medical Oversight, 2E. St. Louis: Mosby, 1994.]"

I think we'll need to take this one or two sub-sections at a time. For this fourth message thread, let's address manpower and training.

Our goal is to provide for high-quality care for wilderness and backcountry patients throughout Pennsylvania. To do this, we need to have personnel with the appropriate training and need to get them to the patients. As my own thinking about Wilderness EMS in Pennsylvania has matured, I've come to think that we need a four-tier system of training and personnel.

First Tier: Wilderness First Aid

We need _wilderness-oriented_ first aid training for the outdoor public.

The Wilderness Medical Society and the National Safety Council have joined together to establish a national standard wilderness first aid program, complete with textbook, instructor's manuals, videos, 35 mm slide set, and cards and patches. Alton Thygerson, the editor of several excellent first aid textbooks, is one of the primary people working on this project. It should be out in the next year or so.

I think that this program will provide uniform high-quality wilderness first aid training throughout Pennsylvania, and we should recognize the role of this training in our wilderness EMS plan, and encourage its use in educational institutions and by outdoor groups.

Second Tier: Wilderness First Responder

Those responsible for public safety in the backcountry -- state and national park and forest rangers, river guides, and college outing club trip leaders -- need more than wilderness first aid training. The Wilderness Medical Society and ASTM are currently standardizing Wilderness First Responder training nationwide, and I expect that within the next two years the Wilderness Medical Society will begin accrediting institutions that offer Wilderness First Responder training.

This move is prompted in large part by recent lawsuits which have made the member organizations of the Outdoor Recreation Coalition of America recognize the need for standardized Wilderness First Responder training and certification. They addressed the problem of WFR training in a sewries of risk management meetings, and then out of this the Association of Wilderness Medicine Educators was formed with the major WFR training providers as members. When the WMS decided to set up its PETSAC Committee (Prehospital Emergency Training, Standards and Certification Committee), the Association of Wilderness Medicine Educators quickly dissolved. WMS's PETSAC is also now talking about, in addition to WFR and WEMT Curricula, a procedure for accrediting programs that provide this training.

I think Pennsylvania should officially recognize the ASTM Wilderness First Responder standards as soon as they come out (the next few months). This can be in the form of some sort of official nod in the regulations, such as a definition or a recommendation, but without any enforcement mandate. Since the courts are now looking at the emergency care training standard for outdoor trip guides in several court cases, and this will undoubtedly be appealed, I don't think Pennsylvania needs to worry overmuch about setting this standard; the courts will do it for us. However, placing a definition in whatever regulations eventuate from this will help the public by pointing to the national standards.

Third Tier: Wilderness EMT-Basic Module

There are a basic core of "extended skills" that are useful for EMTs in the backcountry, and which require minimal training. These skills are identified in the document that the nonurban (now rural) committee of the National Association of EMS Physicians put together a couple of years ago and published in Prehospital and Disaster Medicine. These skills are: 1) rationally applying CPR guidelines in the backcountry (i.e., stopping when clearly useless); 2) reducing selected dislocations even with intact distal neurovascular status; 3) "clearing" the cervical spine based on examination rather than solely going on the basis of mechanism of injury; and 4) irrigating wounds and removing impaled objects. These are available from NAEMSP in a collected form (call 1-800-228-3677 or 578-3222 in the Pittsburgh area to get a copy). ®MDNM¯ Here are the citations:

1. Rural Affairs Committee NAEMSP. Clinical guidelines for

delayed/prolonged transport. I. Cardiorespiratory arrest.

Ed. Goth P Garnett G. Prehosp Disast Med 1991;6(3):335-40.

2. Rural Affairs Committee NAEMSP. Clinical guidelines for

delayed or prolonged transport. II. Dislocations. Prehosp

Disast Med 1993;8(1):77-80.

3. Rural Affairs Committee NAEMSP. Clinical guidelines for

delayed or prolonged transport. III. Spine injury. Prehosp

Disast Med 1993;8(4):369-71.

4. Rural Affairs Committee NAEMSP. Clinical guidelines for

delayed or prolonged transport. IV. Wounds. Prehosp Disast

Med 1993;8(3):253-5.

These principles are also reflected in the Practice Guidelines of the Wilderness Medical Society.

As these are accepted national guidelines that require minimal training, the WEMT Subcommittee should recommend that PEHSC's Medical Advisory Committee should review these Guidelines and other relevant literature, and develop a set of similar clinical guidelines to incorporate into local EMS protocols for delayed transport situations.

All Wilderness EMT and related programs around the U.S. teach the skills necessary to give care according to the above Guidelines. We should do as Maryland is now doing: develop an official state WEMT module, similar to BTLS, that is a continuing education module for EMT-Basics and EMT-Paramedics. Then, we can offer reciprocity for those trained in equivalent WEMT courses. We should also give local medical directors the option of providing local continuing education as a means to implement the clinical guidelines approved by PEHSC's Medical Advisory Committee.

All EMS agencies and search and rescue teams would be able then to provide service at this Wilderness EMT-Basic level. Search and rescue teams that do not run an ambulance would have to be recognized as "Special Response" EMS agencies, and we would need to provide for their certification and inspection in the EMS regulations.

Fourth Tier: Wilderness Medic

Some Pennsylvania search and rescue teams already have the capability to offer very sophisticated medical care in the backcountry. Department of Health legal counsel Kenneth Brody said that this could not be accomplished as part of the EMS system. He based this on his interpretation of the existing EMS legislation, which he says cannot be extended from "street" EMS delivered via ambulance to routine backcountry medical care. He said that EMTs and paramedics who find themselves in the backcountry are still within their scope of practice in exceptional cases, but that routine backcountry emergency medical care cannot be part of the EMS system without new legislation.

The Wilderness EMS Institute is already providing medical oversight for some search and rescue teams through the generic delegated practice provisions of the Pennsylvania Medical Practice Act. These search and rescue EMTs and EMT-Paramedics, when in the backcountry, function as "wilderness medics" rather than as EMS personnel. They can follow their medical directors' on-line or standing orders. This means that the physicians do not have the liability protection of the PA EMS laws (not a major consideration), but they also have the freedom to order drugs and procedures beyond those permitted to EMT-Basics and EMT-Paramedics. Since long wilderness rescues may require great flexibility in medication selection (e.g., having wilderness medics give patients anticonvulsants or antihypertensives during a long evacuation), the consensus at a recent Medical Advisory Committee was that it would be best to leave this as is, and simple recognize the existence of this system in whatever regulations we eventually create.

Wilderness Medics would then be available, via their search and rescue teams, to respond to lengthy or difficult rescues, supplementing the capabilities of local EMS agency Wilderness EMTs. At present, the Wilderness EMT Institute is the only organization that provides this kind of service, but there is no bar to another organization offering similar services.

Please, let us know what you think. Thanks.

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Again, please reply with your comments to wilderness-emergency-medicine@list.pitt.edu. Thank you.