PROPOSED ADDITIONS TO THE PENNSYLVANIA
EMERGENCY MEDICAL SERVICES LAW

(Act of 1985, P.L. 164, No. 45)

REGARDING WILDERNESS EMERGENCY MEDICAL SERVICES

from the Wilderness EMS Institute, Pittsburgh, Pennsylvania

(a project of the Appalachian Search and Rescue Conference and the Center for Emergency Medicine of Western Pennsylvania)

[footnotes at end of document --KC]

Technical Contacts:

Keith Conover, M.D., Medical Director
Wilderness EMS Institute
36 Robinhood Road
Pittsburgh, PA 15220-3014
412-561-3413 (H)
412-232-8222 (W)

Jack Grandey, EMT-P, Pre-hospital/ALS Officer
Wilderness EMS Institute
862 N. Beechwood St.
Philadelphia, PA 19130
215-232-8105 (H)
215-471-7170 (W)

Introduction

There's good news and bad news about wilderness EMS in Pennsylvania. The bad news is that the Commonwealth should be providing for those acutely ill or injured in the backcountry, we're failing to do so, and life and limb are at risk thereby. Not only that, wilderness and backcountry rescues are high-profile events with a great attraction for the press. The good news is that

  1. legislators can take care of this problem by amending the state EMS law, and

  2. it won't cost much if anything to implement, because there are volunteer resources already available.

Patient Needs

Wilderness and backcountry patients need four main things so they can get adequate care. Many EMS systems, even ostensibly "urban" ones, may need to provide care in a wilderness or similar context. "Wilderness" incidents may be rare, but they strain system resources and attract publicity. The prudent EMS medical director will plan for such events; this both ensures high quality patient care and assures that the publicity will be favorable. Planning for wilderness EMS requires the following:

Legislative and Regulatory Needs-- Overview

The existing EMS system cannot meet the needs of wilderness and backcountry patients for the following reasons:

  1. The present EMS system assumes that providers will only care for the patient for a short period. Wilderness and backcountry patients measure their trip to the hospital in hours, or in the case of some cave rescues, days. The EMS structure must change to train enough prehospital personnel to provide proper care for wilderness and backcountry patients, and to allow them to perform needed skills and administer needed medications. Wilderness medics must be able to give antibiotics, reduce shoulder dislocations, and place Foley urinary catheters.

  2. The existing training for medical command physicians is entirely inadequate for wilderness and backcountry patients. The EMS structure must change to allow for and ensure qualified physicians for both on-line and off-line medical direction of wilderness medical personnel. The requirements for a good Wilderness Command Physician are stringent, and only a few Wilderness Command Physicians are needed. Qualified Wilderness Command Physicians are likely to be spread throughout the Commonwealth. Therefore, it makes sense to allow a wilderness "command facility" to be composed of select individuals throughout the Commonwealth. It is also cost-effective solution.

  3. The existing EMS structure deals with rescue in only an incidental way, and wilderness rescue not at all. For wilderness and backcountry patients, the search and rescue skills of the team coming after them are probably more important than their medical skills. The EMS structure must change to recognize that search and rescue are critical components of EMS, at least as far as wilderness and backcountry patients are concerned. Requirements for a "Wilderness EMS Agency" must include search and rescue training, equipment, and capability. The existing EMS system assumes that EMS must be based in an ambulance or other vehicle. Medical care for wilderness and backcountry patients is provided out of the packs of those who hike, climb, crawl, or rappel to the patient. The EMS structure must change to recognize that EMS can be delivered without a vehicle. Most of the search and rescue teams that care for Pennsylvania's backcountry patients don't have an ambulance, and they provide the bulk of the wilderness and backcountry care. The search and rescue team is the backcountry patient's "ambulance."

  4. The current EMS law defines the scope of practice of emergency medical technicians and paramedics " . . . shall not include diagnosis and treatment of nonurgent care . . . " The EMS law must change to allow wilderness medics to provide care for common simple medical problems. Wilderness search and rescue teams are often away from civilization for hours or days, especially during searches. The wilderness medic is their only source for medical care, and often problems crop up that would be nonurgent in the city. But in the backcountry, these "nonurgent" problems may lead to significant morbidity if not treated. If nothing else, the "nonurgent" problem may cause the team to abort their task and return to base. A urinary tract infection may progress to debilitating pyelonephritis, with high fever, severe abdominal pain, vomiting, and inability to hike back out.

  5. The current EMS regulations do not consider the needs of wilderness and backcountry patients. Regulations applicable to the backcountry should consider the papers and journals of organizations such as the National Association of EMS Physicians, Wilderness Medical Society, and Wilderness EMS Institute. Wilderness EMS regulations must also be formulated with close attention to physicians and other health professionals with knowledge of the unique characteristics of wilderness EMS.

  6. The existing EMS structure provides little encouragement for wilderness providers to work within it. Some organizations already provide wilderness medical services under the broad generic delegated practice provisions of the Medical Practice Act. Trying to force wilderness providers to come under the EMS Act would be difficult. Changing the Medical Practice Act to restrict the broad generic practice provisions for this one situation would seem a difficult and unrewarding legislative task. Any comprehensive legislated and regulated Wilderness EMS system must provide enough advantages to persuade agencies providing wilderness medical care to bring themselves under the EMS system.

Specific Proposals for Additions

As a rough guide only, we suggest the following additions to the Pennsylvania EMS law. First, additions to the definitions. Additions are in italics [well, italics don't come across in ASCII, sorry -KC]:

  1. "Advanced wilderness life support unit." The assembled personnel and equipment to provide advanced life support in a wilderness/backcountry context.

  2. "Basic wilderness life support unit." The assembled personnel and equipment to provide basic life support in a wilderness/backcountry context.

  3. "Emergency medical services." The services utilized in responding to the needs of an individual for immediate medical care in order to prevent loss of life or aggravation of physiological or psychological illness or injury. This includes services delivered by both ambulance personnel and by wilderness/backcountry EMS personnel in the wilderness/backcountry context.2

  4. "Evacuation." The transportation of patients from a wilderness/backcountry site, over wild or mountainous terrain, through cave passages, or past other obstacles, without automotive vehicles, marine craft, or aircraft, to a point routine EMS vehicles may access.

  5. "Medical command facility." The distinct unit, whether within a facility or an administratively established system of physicians on a regional or statewide basis, that contains . . . 3

  6. "National Cave Rescue Commission." A national organization that coordinates cave rescue and provides cave rescue training and certification.

  7. "Pennsylvania Search and Rescue Council." A Pennsylvania organization, with volunteer team and state agencies as members, that provides search and rescue training standards and search and rescue coordination.

  8. "Providers of emergency medical services." Any facility, basic life support service, advanced life support service, or wilderness life support service.4

  9. "Wilderness/backcountry context." Situations in which EMS delivery is far from regular vehicle access, that is, where individual EMS team members must carry equipment and supplies over a significant distance of wild or mountainous terrain, and continuing to provide such care during evacuation to a routine vehicle access site. EMS in the wilderness/backcountry context is complicated by one or more of the following four factors:
    1. remoteness as far as logistics and access;

    2. a significant delay in the delivery of care to the patient;

    3. a natural environment that is stressful to both patients and rescuers; or

    4. lack of equipment and supplies.

  10. "Wilderness Emergency Medical Technician." A person who holds current Pennsylvania Emergency Medical Technician, EMT-paramedic or health professional certification, or recognized equivalent from another state, and who holds current certification as a Wilderness EMT by an organization recognized by the Secretary as adhering to the wilderness prehospital emergency care curriculum of the Wilderness Medical Society.5

  11. "Wilderness EMS Institute." A national medical organization that provides detailed training curricula for wilderness medical training, and that provides medical direction for wilderness/backcountry EMS in Pennsylvania and other states.

  12. "Wilderness life support service." An entity which regularly engages in the business or service of providing emergency medical care and evacuation of patients in a wilderness/backcountry context within this Commonwealth. The term includes Advanced Life Support services that may or may not evacuate patients.

  13. "Wilderness Medical Society." A national medical organization that sets standards for wilderness medical care and training.

  14. "Wilderness medic." A Wilderness EMT who has completed training to the Wilderness EMT Curriculum of the Wilderness EMS Institute and who has been accredited by the Wilderness EMS Institute to administer medications and other wilderness medical treatment.

Next, a recommended addition to section 4 (4) on the emergency medical services system:

Recommended addition to section 5 (9):

Recommended additions to section 11:

  1. Section 11 (e), Scope of practice of emergency medical technician and EMT-paramedic:

  2. Section 11 (g), drug administration:

  3. Section 11 (h), standing orders:

Next, some recommended additions to section 12.

  1. Add licensing for Wilderness/backcountry EMS to section 12 (a): Minimum standards for ambulance service. Also, consider changing title of section 12 to Minimum standards for prehospital/interhospital emergency medical service.



  2. Add the following to section 12 (c): Fees.


  3. Add the following to section 12 (d): Rules and regulations.


  4. Add the following to section 12 (f):

  5. Add the following new section between sections 12 (g) and (h):






Footnotes

  1. Conover K. Wilderness. in Kuehl AE [Ed]. National Association of EMS Physicians' Prehospital Systems and Medical Oversight, 2E (formerly the EMS Medical Directors' Handbook): Mosby Lifeline, 1994.

  2. This would provide the legislative mandate to allow the Division of EMS Systems to manage wilderness/backcountry EMS.

  3. This would allow accredited Wilderness Command Physicians around the state to serve as a distributed "command facility."

  4. This would permit members of search and rescue teams to provide EMS even though the SAR team doesn't own an ambulance.

  5. The term "Wilderness EMT" is now in nationwide use.

  6. "Wilderness providers will be asked to provide incidental medical care for team members' minor injuries and illnesses. In wilderness rescue, sending a team member back to a search base for medical care might be disastrous; a team member or two must accompany the victim, and the depletion of the team may delay an evacuation for hours, perhaps even resulting in the patient's death. Since mountain rescue often stresses team members to the limit, injuries and illnesses that might be minor at home loom larger in the wilderness, which is another argument for wilderness providers to provide "primary care" for the team. While wilderness providers need not be Physician's Assistants capable of providing all routine primary care services, one may argue that they should be able to care for minor injuries and medical problems common in the wilderness. Physicians serving as medical advisers to wilderness EMS agencies should take this into account in selecting training for prehospital personnel, and when providing protocols and standing orders for wilderness providers. Training prehospital providers to administer over-the-counter or even prescription oral medications runs counter to existing EMS training. But, prohibiting providers from administering simple medications when distant from medical facilities (and even drug stores) makes little sense. The major question is which level of provider the medical director should permit to use oral medications. Comparison of pretest and final test results at Center for Emergency Medicine pilot Wilderness EMT classes showed excellent understanding of pharmacology principles and oral drug use even by EMT-Basics. The choice will usually be the medical director's, and depends on the specific background training of the different levels of prehospital providers." --Conover K. Wilderness. in Kuehl AE [Ed]. National Association of EMS Physicians' Prehospital Systems and Medical Oversight, 2E (formerly the EMS Medical Directors' Handbook): Mosby Lifeline, 1994.

  7. This is needed not only for wilderness emergency medical technicians to give important oral medications in the wilderness/backcountry context, but also for basic EMTs trained to the new national standard curriculum who will be expected to administer medications such as albuterol and sublingual nitroglycerine.


Wilderness Emergency Medical Services Institute

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