This is the fifth 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 private questions that you want to keep from going out to list recipients, you may contact Keith Conover, M.D. (kconover+@pitt.edu), Subcommittee Chair (but we generally prefer comments to the list.)

-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-

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.]"

The fourth message thread dealt with the first couple of above bulleted items: manpower and training. For this fifth message thread, let's address communications and transportation.

Communications

==============

Gene Harrison, WEMSI's Communications Officer, has a great variety of plans for possible experimental systems to facilitate wilderness EMS communications: near-vertical incidence HF radio links, satellite links, and the like. However, these are really gravy for Pennsylvania, as EMS agencies already have VHF and UHF radio communications links into most of Pennsylvania's nooks and crannies (mountains, valleys, ravines and canyons). And most of these VHF and UHF systems can link into the telephone system, so they can, for instance, connect a provider at the scene to a command physician at a local facility, and connect this physician and his prehospital personnel in turn to a Wilderness Command Physician with specialized expertise. And, with the increased penetration of the cellular telephone system even in rural areas, direct calls via cell-phone are becoming more and more common.

And what about those few areas that don't have reliable cellular telephone or VHF/UHF radio connections? For a most extreme example, underground in caves? Well, the National Cave Rescue Commission has field telephones scattered around the region, and NCRC-trained cave rescue personnel can patch these field phones to a VHF or UHF radio, or into the the telephone system. So the technical aspects of wilderness EMS communications, at least in Pennsylvania, are already fairly good and likely to improve if some of Gene's projects work out.

But what about those situations where there won't be communications? For instance, during the initial phases of a cave rescue? I propose a two-pronged approach to this. First prong: standing orders. EMS systems with Wilderness EMTs should be able to have standing orders for the most basic and important skills (discussed in the Part 4 thread: discontinuing CPR, "clearing" the cervical spine, reducing dislocations, and managing soft-tissue wounds. To encourage this, EMS regulations should specifically include these skills in the scope of practice for EMTs with extended training: either having completed a state-recognized Wilderness EMT course, or those who have had specific training by their medical director.

The second prong: allow "unconventional" on-line medical direction. In its "non-EMS wilderness emergency medical system," the Wilderness EMS Institute has already addressed this problem. I think that Pennsylvania should steal (or adapt slightly) this directly from WEMSI's Operations Manual, and I'll paste it in the relevant sections right here:

[begin quote]

I. WEMSI Medical Control Policy

[snip]

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.

[snip]

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.

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.

[end quote from WEMSI Operations Manual]

Transportation

==============

Well, to begin with, transportation via ground ambulance or helicopter is _not_ wilderness EMS and thus outside the scope of what we need to address. But what the search and rescue teams call "evacuation" -- that is, bringing the patient to the ambulance or helicopter -- now THAT is realistically a concern of wilderness EMS. What if, en route to the ambulance with a patient with minor injuries, you injure or kill the patient or a rescuer? (It's happened many times; ask me for stories over beer and pizza some time.) Or, what if the evacuation takes so long the patient expires en route? (Less common but does happen.) Or, what is even worse, what if you don't understand how to look for a lost person, and the person dies in the interim? (DON'T ask me for these stories over beer and pizza, because I tend to start screaming and frothing at the mouth.)

However important good search and evacuation are to the patient's well-being, they're primarily nonmedical aspects of wilderness EMS. And I think we (the EMS community) should lean on the state Search and Rescue system to provide those things, but not get involved in the details in any EMS regulations.

Let's simply require that each EMS agency in a rural or suburban area have in place plans for (1) lost person searches and (2) backcountry evacuations, either through EMS agency personnel who are trained to Pennsylvania Search and Rescue Council standards, through a mutual aid agreement with a search and rescue team, or through a formal policy to call the Pennsylvania Emergency Management Agency or the Pennsylvania Search and Rescue Council in the event of such an occurrence. (Hmmm, sounds controversial. Good.)

Please, let us know what you think. Thanks.

-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-

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