[Wilderness EMS Institute Letterhead]

Reply to:
Keith Conover, M.D.
36 Robinhood Road
Pittsburgh, PA 15220-3014
412-561-3413; CIS: 70441,1506
Internet:
kconover@vms.cis.pit.edu

February 16, 1994

Kum S. Ham, Ph.D., Director,
Pennsylvania Department of Health
Division of Emergency Medical Services Systems
P.O. Box 90
Harrisburg, PA 17108

Dear Dr. Ham:

SUBJECT: Wilderness and Backcountry Prehospital Care

I attended today's meeting of the PEHSC EMT/Paramedic Committee, as a new member. I joined to follow up on my discussions with this Committee about Wilderness EMT training several years ago. At the suggestion of PEHSC staff, with whom I have worked for several years, I am writing you about wilderness and backcountry prehospital care.

The Pennsylvania Search and Rescue Council now counts twenty-five member teams, including volunteer, paid, and government units. These and other search and rescue teams provide patient care in the field. The Wilderness EMS Institute would like to work with you to improve the quality of this patient care.

A few EMS agencies go after patients far up in the Pennsylvania mountains, or deep in caves, but most do not. Most wilderness patients are brought out to a waiting ambulance by search and rescue teams, and these teams provide the only medical care until reaching an ambulance. For some rescues, this may take hours, or for cave rescues, even days.

SAR team medical care generally falls into four classes:

• Some SAR teams provide first aid only, assuming EMS starts when they deliver the patient to the local EMS system. Such teams are becoming fewer with more-available EMS and wilderness medicine training.
• Some SAR teams are also "street" EMS agencies, and follow standard EMS protocols when dealing with patients in the wilderness. However, this may lead to poor patient care, as discussed below.
• Other SAR teams rely on wilderness-specific medical training rather than EMT/paramedic training. Such teams use training from Wilderness EMT or similar courses based on the Wilderness Medical Society's Wilderness Prehospital Emergency Care Curriculum (enclosed). These courses train students to follow formal wilderness prehospital care recommendations (see below), which conflict with street EMS protocols and regulations.[1] Unfortunately, some of these Wilderness EMTs are essentially "freelancing" with little physician supervision.
• A few SAR teams have physicians who respond into the field. Some such physicians provide medical care directly. Non-physician members of some teams, such as the Special Medical Rescue Team, the Appalachian Search and Rescue Conference, and the National Cave Rescue Commission, have specialized training for wilderness and similar situations. Their physicians allow them to perform medical assessment and treatment under the general principle of delegated practice.[2] In such situations, those who are certified as EMTs, paramedics, nurses, PAs, or other health professionals are not operating as such. They are acting as non-EMS medical technicians, and thus in the wilderness context are not restricted by the regulatory restrictions on EMTs, paramedics, nurses, PAs, and other health professionals.[3]

None of these four wilderness prehospital care models is optimal. WEMSI would like to work with you to develop a fifth and better alternative, closely tied to the existing EMS structure.

Act 45, Section 4, subsection 10, states: "The secretary shall plan, guide and coordinate programs to ensure that the Commonwealth's emergency medical services system shall . . . provide necessary emergency medical services to all patients requiring the services." This seems to include patients in the Commonwealth's wilderness and backcountry areas, so one can argue that the Division of EMS's program should provide for wilderness and backcountry patients.

Simply mandating existing EMS equipment and training for wilderness patients will not work. Ambulances and helicopters cannot reach most wilderness patients, and it often takes a long time (hours to days) to get patients to an ambulance or helicopter; care should start when providers reach the patient, not when the patient reaches an ambulance. Yes, helicopters can be a great help for some wilderness rescues. But they do not fly in snowstorms, and they certainly do not fit into caves. And, proper care on the street is not necessarily proper care in the wilderness or whenever transport will be long- delayed. As with street EMS, there are standards for wilderness medical care, established by national medical organizations. The Wilderness Medical Society Position Statements and the National Association of EMS Physicians Model Clinical Protocols for Delayed/Prolonged Transport are enclosed. Another source is the wilderness EMS chapter of the NAEMSP Prehospital Systems and Medical Oversight, 2E (formerly the EMS Medical Directors' Handbook), which has just been published. For many medical problems, even beyond the specific topics covered in the aforementioned guidelines, proper wilderness medical care is different from street EMS. Auerbach and Geehr's massive Management of Wilderness and Environmental Emergencies is the most definitive book reference to wilderness emergency medicine. Articles on wilderness care appear regularly in the Wilderness Medical Society's Journal of Wilderness Medicine and the National Association of EMS Physicians' Prehospital and Disaster Medicine. Important articles for wilderness EMS also appear in mainline medical journals such as the New England Journal of Medicine. Thus, wilderness medical guidelines require continuous updating. The enclosed sample draft textbook chapters from the WEMSI Wilderness EMT Curriculum give some more examples of up-to-date principles of wilderness prehospital care.

In 1987, the Center for Emergency Medicine of Western Pennsylvania and the Appalachian Search and Rescue Conference established the Wilderness Emergency Medicine Curriculum Development Project. Now the Wilderness EMS Institute, it has four goals, described in the 1987 Prospectus (enclosed).

First was to distribute the Prospectus and a questionnaire to inform the North American Wilderness EMS community about important wilderness EMS topics, and to assess the WEMS community's needs. This was accomplished in 1987 and 1988. Information from the questionnaire was used to complete the second goal: offering a first Wilderness EMT Pilot Class in 1987.

The project's third goal was to use the Pilot classes and our advisers to distill the curriculum into Lesson Plans and a Textbook. This process is nearing completion. Of course, the work will never be complete; we must regularly reevaluate and revise the curriculum based on user suggestions and new research findings. WEMSI will continue to serve as an academic resource for other wilderness EMS organizations as well.

Let me quote the 1987 Prospectus about the fourth goal:

"The final part of the Project will be to establish, in cooperation with local emergency medical services (EMS) and search and rescue (SAR) agencies, a regional Wilderness Emergency Medical Services System, with region-wide training, certification, communications systems, and support services. This WEMS system will complement existing EMS and SAR systems, providing a coordinated, statewide (or multistate) plan for dealing with wilderness medical problems in a coordinated and professional manner. It will use the most modern emergency medical knowledge and technology available, while recognizing the constraints of the wilderness environment on personnel and equipment. This Wilderness EMS system will provide a sophisticated medical component for wilderness SAR organizations and EMS agencies with wilderness responsibilities. It will not in any way supersede or replace existing EMS or SAR organizations, but will provide specialized support services to those organizations. We will teach Wilderness EMTs the fundamentals of wilderness search and rescue, but will also emphasize the need for more specialized training for search management and technical rescue. We will depend on existing regional and national search and rescue organizations (Mountain Rescue Association, Civil Air Patrol, Appalachian Search and Rescue Conference, and state Search and Rescue Councils) to provide SAR training. We will not attempt to duplicate their training.

"The Appalachian Search and Rescue Conference and Center for Emergency Medicine will work toward establishing a regional Wilderness EMS System including the western Pennsylvania region. This system may include all Pennsylvania, or perhaps even extend across several states, as does the Appalachian Search and Rescue Conference. The Wilderness EMS system will include in-hospital clinical training, written and practical testing and certification at all levels, continuing education programs, physician medical direction and on-line control, and a sophisticated communications network to extend on-line medical control as far as possible. Quality control and accountability are imperative for such a system, if it is to be accepted by the medical community. This Wilderness EMS System will be tightly integrated with existing EMS systems and wilderness search and rescue systems. This is an ambitious undertaking, and may take years to accomplish."

Our fourth goal has until now taken a back seat to completing a standard WEMT curriculum. But now that our work on the that goal is winding down, we are turning to this fourth goal.

Today, wilderness EMS suffers the same problems as did prehospital care before EMS systems: lack of standards, lack of physician supervision, lack of quality control. Incorporating wilderness care into EMS at the state level may prove a daunting task, but offers many advantages; standardization and regulation will lead to better care and wider availability of that care to those in the backcountry.

We hope to work closely with the Pennsylvania Division of EMS and PEHSC. We hope to develop a model wilderness EMS system for other North American states and provinces to emulate. We look forward to working with you to help extend quality prehospital care to Pennsylvania's forests, whitewater streams, caves, and mountains.

Thank you.

Yours truly,

[signed]

Keith Conover, M.D., Medical Director, WEMSI
Attending Staff, Department of Emergency Medicine, Mercy Hospital of Pittsburgh
Clinical Assistant Professor, Division of Emergency Medicine, University of Pittsburgh
Medical Director, Eastern Region, National Cave Rescue Commission
Medical Director for Pennsylvania, Appalachian Search and Rescue Conference

encl: Wilderness Medical Society Position Statements and WPHEC Curriculum;
NAEMSP Clinical Guidelines for Delayed/Prolonged Transport;
WEMSI Information Sheet, Curriculum Order Form,
sample draft Textbook chapters,
1987 Prospectus

cc: WEMSI Staff; PEHSC EMT/Paramedic Committee

Footnotes:

Designed by a member of