Keith Conover, M.D.
36 Robinhood Road
Pittsburgh, PA 15220-3014

9/10/87

Richard Flinn, Executive Director,
Pennsylvania Emergency Health Services Council
c/o PEHSC RBBS

Dear Mr. Flinn:

SUBJECT: PEHSC consideration of issues in Wilderness EMS

I sent this letter to you via the PEHSC BBS computer system a few weeks ago, but perhaps you didn't receive it; so, I'm sending you a printed copy, as well.

At the last meeting of the Rescue and Hazardous Materials Task Force, we discussed the problems of applying the EMS regulations to wilderness search and rescue and to large multi-casualty incidents. You suggested I make a formal request for a PEHSC subcommittee to investigate these problems. Hence, this letter.

As you know, I represent the Pennsylvania Search and Rescue Council to the PEHSC Rescue Task Force. I wear some other "hats," too, and I should list them:

• member, Board of Directors, Appalachian Search and Rescue Conference,
• active certified member of the Mountain Rescue Association,
• medical advisor, Eastern Region, National Cave Rescue Commission,
• representative from the Wilderness Medical Society to the ASTM committee on search and rescue,
• member, Emergency Medicine Committee, National Association for Search and Rescue, and
• staff physician for the Center for Emergency Medicine of Western Pennsylvania (at Mercy Hospital) and part-time ER physician at Sewickley Valley Hospital.

As you see, I have multiple interests in EMS (and particularly in wilderness EMS). Because many of these organizations have similar goals, it is sometimes difficult to tell which organization I'm representing. The main reason I am pursuing active PEHSC participation in wilderness EMS, is that I am the coordinator for a joint Appalachian Search and Rescue Conference -- Center for Emergency Medicine of Western Pennsylvania Wilderness Emergency Medicine Curriculum Development Project, described in the Prospectus and Addendum you so kindly distributed to the EMS Councils. This project enjoys the support of the Pennsylvania SAR Council and the participation of many organizations and individuals nationwide. Since Pennsylvania is becoming a national center for the development of wilderness prehospital care, we (speaking for the Pennsylvania SAR Council in general and the Appalachian Search and Rescue Conference in particular) would like to work closely with PEHSC to address some of the issues discussed below and in the Prospectus.

"Special rescue" EMS teams, such as medically-oriented wilderness search and rescue teams, must often provide prehospital EMS services far away from an ambulance, and in hostile environments (examples: a cross-country skier stranded and hypothermic in a winter storm on top of Laurel Mountain; a hiker with a broken ankle on the Appalachian Trail in freezing rain at night; or a man pinned under a hundred-pound boulder at the bottom of a two-hundred-foot pit in the back of a cave). Such incidents may be rare, but they arouse the intense interest of the press and public, they last longer than most other EMS incidents, they employ many different EMS and rescue resources and bring out issues of command, control, and coordination, and for EMS and other emergency service managers, they are a potent source of suits and other legal/management problems. Therefore, we believe that Wilderness EMS is worthy of close scrutiny by PEHSC.

Because of the unique problems of wilderness rescue, specialized organizations evolved to deal with them. In the early days, wilderness rescue teams assumed that the patient's first medical care would be at the hospital. Over the years, the prehospital EMS system flowered, and the patient would see medical care beginning at an ambulance at the end of the trail or at the entrance of the cave. Now that special rescue team members are becoming EMT's (and EMT-P's, and RN's, and M.D.'s), medical care is now often brought directly to the victim. But, despite high standards and outstanding volunteer support, these special rescue teams find it hard to integrate their services into the mainstream of prehospital EMS. Why?

Wilderness rescues are rare in any given county, so it is hard to justify a special rescue team for each county. Most teams have members in several counties, and generally respond even to areas of the state where they have no members. (For difficult operations, some organizations, such as the Appalachian Search and Rescue Conference and the National Cave Rescue Commission, draw rescuers from several states, often flown in by the U.S. Air Force). Since most EMS systems operate on a county or municipal level, wilderness rescue teams operating across many different jurisdictions find it hard to integrate with all the local EMS system: their services are rarely needed in the county, so it is hard to persuade the local "street" EMS services to accept them, and they routinely provide services outside the county, making it hard to obtain county EMS funding.

A simple way to avoid this problem, you might say, would be to simply include a local EMT-P when a wilderness rescue team comes into a given jurisdiction. This has been a policy for many years (the Eastern Region, National Cave Rescue Commission has been offering a weekend "Orientation to Cave Rescue" to local medics for about 10 years), but in practice, this has been only marginally satisfactory.

The first major problem is safety: not every EMS agency can provide an EMT-P with the training and personal equipment for wilderness travel, land navigation, night operations in winter storms, and use of ropes in cave and mountain rescue situations. Moreover, if the wilderness rescue team discovers inadequacies in the EMT-P's outdoor equipment or capabilities, it may put the EMT-P and the rescue team, not to mention the victim, at risk of injury or death. Even in relatively safe situations, some EMT-P's are reluctant to go into the field without the heavy ambulance-based equipment they are trained to use. (I could also tell stories about EMT-P's and M.D.'s carried, kicking and screaming, to a victim; but I won't.)

Even if one could assure an adequately trained local EMT-P, another question arises: most wilderness rescues are in areas where standard EMS communications are at best marginal, so local EMT-P's will often have to go on written standing orders. Are local prehospital protocols really adequate to deal with the special problems of wilderness rescues? (E.g. hypothermia and major infections during an eighteen-hour evacuation.) We are working to establish reliable patient-to-ER communications for backcountry and cave rescues, and even toying with some very advanced techniques (using satellites as orbiting repeaters), but the plans are in their infancy. There are strong arguments for having different protocols for wilderness rescues, even at the EMT level (e.g. the care of a shoulder dislocation with no distal pulse).

This brings up another question: if we can establish reliable communications from the patient's side, should the local ER command physician be asked to manage these difficult problems, or should we consult a specialist for this? We believe in specially trained command doctors, and hope to establish a roster of physicians with special training in the management of wilderness rescue problems. Though such doctors may be few and far between, communications to a distant Wilderness Command Physician will be little problem once we can assure communications from the back of a cave or from a deep valley in a wilderness area.

The Prospectus you received earlier addresses these questions in more detail, and we tentatively suggest the following:

• Special training for Wilderness EMT's and EMT-P's (see below).
• Standing orders for Wilderness EMT's and EMT-P's on the state, EMS Council, or team level, rather than the local level.
• Quality control and case review for Wilderness EMT's and EMT-P's on the state, EMS Council, or team level, rather than the local level; this should of course be coordinated with the local EMS Councils and EMS agencies.
• Standard training for Wilderness Command Physicians, with each team having its own medical director providing command, or, better, a uniform system whereby any Wilderness Command Physician could provide command to any Wilderness EMT-P.

Some of these goals could be achieved by cooperative agreements between the wilderness EMS agencies and the EMS Councils, as suggested by some EMS Council administrators at the last Rescue Task Force meeting, but we suspect that a state wide solution would be better and more enduring.

At this point, let me outline our concept of training and requirements for the Wilderness EMT or EMT-P:

• state EMT or EMT-P certification required
• state wilderness search and rescue or cave rescue certification required
• must complete an approved Wilderness EMT class on adaptation of SAR and EMT training
• must be a member of a state-licensed Wilderness EMS agency (either a search and rescue team that has been granted EMS agency status, or an EMS agency that has demonstrated a wilderness search and rescue capability).

These are a few of the questions raised by careful consideration of the problem of wilderness EMS. (Some may apply to large mass casualty incidents, too.) As we discussed at the Rescue Task Force meeting, it would be ideal if the EMS regulations had the flexibility to deal with these areas, thus keeping adequate control of "special rescue" EMS and ensuring its quality. Therefore, I would like to respectfully request that you consider a special subcommittee to investigate wilderness EMS and related issues, perhaps drawing from the Rescue and Hazardous Materials Task Force, the Medical Advisory Committee, and the EMT and Paramedic Committee.

Thank you very much for your time and consideration. Please feel free to call me at home (412-561-3413), at Mercy Hospital ER (412-232-8364/-8222) or at Sewickley Valley Hospital ER (412-749-7076).

Sincerely yours,

Keith Conover, M.D.

Designed by a member of