Wilderness Emergency Medical Services Institute

An Open Letter to the Pennsylvania SAR and EMS Communities

from
Keith Conover, M.D., FACEP
www.pitt.edu/~kconover
412-561-3413 (H)

Member, Board of Directors, Pennsylvania Search and Rescue Council;
Member, Medical Advisory Committee, Pennsylvania Emergency Health Services Council;
Medical Director, Wilderness Emergency Medical Services Institute;
Medical Director for Pennsylvania, Appalachian Search and Rescue Conference;
Medical Advisor, Eastern Region, National Cave Rescue Commission

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Several recent events have convinced many that now is the time to rethink wilderness / backcountry rescue in Pennsylvania.

• Searches:
  There were several Wilderness EMTs and wilderness rescue-trained people at the search base during several recent searches in southwest Pennsylvania. But when the find was made, this rescue/medical capacity didn’t make it to the patient.
• SAR Forms:
  The Pennsylvania Search and Rescue Council is now revising the state SAR forms packet. These are the standard for search operations in Pennsylvania, and includes a medical/evacuation plan.
• Pennsylvania EMS changes:
  Pennsylvania EMS has a new director, Margaret Trimble. Many changes are coming to the Pennsylvania EMS system; EMS has been "moved up" a level in the state bureaucracy. And after many years, there is hope of having an organized wilderness EMS capacity within the Pennsylvania EMS system. At present, Wilderness EMS has to be outside the EMS system. See below, and the postings at www.wemsi.org , for more about the legal and legislative aspects of wilderness EMS in Pennsylvania.
• Rescues:
  At a recent meeting of the Pennsylvania Emergency Health Services Council Medical Advisory Committee, I was chatting with Dr. Doug Kupas of Geisenger Medical Center. Doug has a strong interest in wilderness as well as "street" EMS and has been the medical director for Wilderness EMT classes in north-central PA. Geisenger’s helicopter service responds several times a year to rescues in Rickett’s Glen State Park. Doug said that the rescue management is usually fragmented between several different agencies, with varying experience levels and wilderness rescue training. Seldom are Wilderness EMTs taking care of the patients, even though the rescues often take several hours.
• WEMSI:
  The Wilderness EMS Institute continues its attempts to improve backcountry medical care in Pennsylvania and around the globe. WEMSI WEMT and Wilderness Command Physician classes are offered in Pennsylvania on a regular basis. WEMSI also works to develop model Wilderness EMS systems in the U.S. and other countries.

Well, who knows how these are all going to come together, or what the results will be? But the synchronicity is undeniable. Wilderness rescue and wilderness EMS in Pennsylvania need to improve, and the resources and determination are coming together. What can we do? What should we do?

A first step (because it’s easiest): improve rescue and Wilderness EMS when a search finds someone. DCNR (Department of Conservation and Natural Resources) Rangers and PSARC (Pennsylvania Search and Rescue Council) teams work together pretty closely, and do the bulk of the searches in Pennsylvania. Together, we can make some changes for the better right now. Let’s first agree on what needs to happen to make rescues and backcountry medical care work out right. And then we can make it happen during every search. The easiest way to make it happen is to (1) put the protocol on the Medical/Evacuation Plan form in the new PSARC SAR Forms Packet, and then (2) tell all search managers to use the Forms Packet.

Here are some specific suggestions:

• Identify Personnel:
  Sign-in forms will have places for "WEMT" "WEMT-P" "FTM" and "FTL" --
  so we can tell who has the training we need for the rescues.
• More Detailed Medical/Evacuation Plan:
  include the following in the Medical/Evacuation Plan protocol:
• Evacuation Team TAF:
  "Create a Task Assignment Form for the Evacuation Team with adequate personnel, including specific names, and equipment for the task and where it is. Make sure that as personnel at Base change to update the personnel on the TAF as needed. Attach the TAF, with maps ready to mark the subject’s location, to the Medical/Evacuation Plan."
• Minimum Rescue Personnel:
  "When possible, assign two FTLs and two WEMT-Basics or better to respond with the Evacuation Team."
• Stripping Base for the Evacuation Team:
  "If the Evacuation Team includes members of Base Staff, indicate staff members to go and who is to replace their functions:"
  Stripping the base isn’t ideal. But it’s better than not having a trained evacuation team at all, which is what’s been happening recently.
• Medical Direction:
  "Establish a link to a Wilderness Command Physician (WCP) by calling the local WEMT’s WCP, or if the local WEMTs don’t have a certified WCP, call WEMSI at 1-800-232-5921 and have the WEMSI WCP on call to provide medical direction to WEMTs on the evacuation team."

Kenneth Brody, the EMS lawyer for the Department of Health, has ruled that backcountry care is outside the scope of the existing Pennsylvania EMS system (see the Legal Issues in Pennsylvania section of www.wemsi.org for more). Though "street" providers can provide Good Samaritan-type care in backcountry situations, it cannot be considered a regular part of their EMS scope of practice. This means that going outside their "street" protocols to provide acceptable backcountry care (e.g., reducing dislocations, giving oral fluids, giving antibiotics) is questionable. Note also that, according to the EMS law, regular Command Physicians cannot provide medical direction for backcountry patients, except as an exceptional circumstance. If they end up in court, "regular" Command Physicians providing medical direction for backcountry rescues will probably be held to national standards such as those established in the Wilderness Medical Society Practice Guidelines, not to standard regional "street" protocols.

From a patient-care perspective, it is preferable to have Wilderness EMTs under the direction of Wilderness Command Physicians caring for the patient until the he or she reaches an ambulance. WCPs can provide direction to WEMTs outside the EMS system, through the Pennsylvania Medical Practice Act's generic Delegated Practice provisions. For PSARC/DCNR searches, this could be the WEMT’s usual WCP or, if the on-scene WEMTs don’t have a WCP, it could be the WCP on call for the Wilderness EMS Institute.

I think we might be able to get approval for this policy at the highest level, i.e., a vote from the Medical Advisory Committee of the Pennsylvania Emergency Health Services Council. This would also require an agreement between WEMSI and PSARC for WEMSI to provide wilderness EMS direction for PSARC searches, if and only if no local Wilderness Command Physicians are available.

Well, this may be somewhat controversial, but I think something along these lines will make rescues during searches a lot better, and improve the quality of patient care. What about rescues that aren’t part of a search? Well, that’s a much more difficult situation, due to the number of agencies involved. But I think if we can attack the search problem first, we can create a model that will serve us well on straight rescues as well.

Thank you for your thoughts about these ideas.

Keith Conover, M.D., FACEP

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