April 18, 1996
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.
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Wilderness EMS is different from "street" EMS, as outlined in publications of national medical organizations such as the Wilderness Medical Society and National Association of EMS Physicians (references available from WEMSI on request). WEMSI recognizes the limitations of "street" EMS protocols, standing orders, and on-line medical command, and has established protocols, standing orders, and on-line medical command specific to cave and wilderness search and rescue.
Dr. Conover has been appointed Medical Director for Pennsylvania by the Board of Directors of the Appalachian Search and Rescue Conference (ASRC), and Regional Medical Director by the Eastern Regional Coordinator, National Cave Rescue Commission. In both positions, he has been authorized to establish medical protocols, and has established a formal agreement to have WEMSI provide on-line and off-line medical direction for both.
These protocols shall have the same force as a physician's order. The only acceptable reasons to deviate from these protocols, by physician's order, are:
an accredited WEMSI Wilderness Command Physician is in direct radio, field phone or telephone contact with those at the patient's side, or
a physician is at the patient's side and has accepted full responsibility for the patient's care, or
a non-WEMSI physician is in direct radio, field phone or telephone contact with WEMSI personnel at the patient's side, and in the estimation of the personnel at the patient's side, has a good understanding of the problems at hand.
WEMSI personnel should refuse a physician's order if it seems inappropriate, particularly if it conflicts with these protocols. WEMSI personnel should always inform the physician that they are refusing his or her order.
These protocols shall be followed whenever:
a patient of any state or country being cared for by ER-NCRC personnel, OR a patient in Pennsylvania is being cared for by Appalachian Search and Rescue Conference personnel, OR a patient is being cared for by personnel of another wilderness EMS agency for which WEMSI has agreed to provide medical direction; AND
the patient is in a cave, or backcountry area, or disaster area, or has not yet reached a ground or air ambulance.
If a patient is being cared for by both WEMSI personnel and local EMS personnel, these protocols take precedence over local EMS protocols.
Once the patient reaches a ground or air ambulance, however, the responsibility of WEMSI personnel comes to an end, and the local EMS agency protocols and standing orders take over. The only exception is due to WEMSI personnel's specialized training in managing certain problem such as hypothermia. If the patient has a problem about which WEMSI personnel have special training, then the highest-trained WEMSI medical person will ride to the hospital with the patient. (To do otherwise would be abandonment: allowing someone with less training to take over patient care.) If, during transport, WEMSI personnel find a significant conflict between their protocols or standing orders and those of the transporting EMS agency, they should attempt to contact their own Wilderness Command Physician and ask the Wilderness Command Physician to speak to the local command physician. If they cannot reach a Wilderness Command Physician, they should contact the local command physician directly themselves, explain that the specific protocols and standing orders related to wilderness patients that conflict with local ones, and request a decision from the local command physician.
These protocols apply both to patients which WEMSI personnel are rescuing, and to members of search and rescue teams who become injured or ill when in the backcountry or underground.
Unless there are specific notations about different skill levels, protocols apply to personnel of all skill levels (First Aid/First Responder, Wilderness EMT, Wilderness Paramedic, etc.) The generic term "medic" used herein refers to WEMSI medical personnel of any level of training. Specific training levels noted in these protocols include Wilderness EMT and WEMSI Wilderness EMT. Wilderness EMT includes WEMSI, WMA, NASAR, SOLO, WMI, and WPT certification. WEMSI Wilderness EMT refers specifically to the WEMSI WEMT certification.
A protocol is a general way to deal with a specific problem. It generally does not require a physician's order (though these specific protocols should be taken as orders of the Region Medical Coordinator). These protocols included common cave rescue and wilderness search and rescue problems. There are separate protocols for three levels of provider (First Aider/First Responder, EMT, EMT-paramedic).
A standing order is a specific physician's order to be carried out when not in direct contact with a physician. (E.g., "If patient has evidence of significant soft tissue infection, fever over 102øF with abdominal pain or suspected urinary tract infection or pneumonia or ear infection or sinus infection; and if transport to a hospital will take more than four hours; and if patient has no history of allergy to ceftriaxone (Rocephin®) or to other cephalosporins such as Keflex® or Ceclor®, or history of anaphylactic allergy to penicillin; then give two (2) grams of ceftriaxone. Give IV push if an IV is available, else give by deep IM injection.") Depending on state EMS and medical regulations, there may be various levels of standing orders in each state.
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