[WEMSI 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

March 7, 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: 94-SGD-038

Thank you for your letter of February 23. Our letters must have crossed in the mail; I wrote you on February 16, and that letter contains a large amount of documentation regarding some of the topics covered in your letter. I'd like to ask for further direction regarding a few particulars of your letter, specifically about the medical kit draft you received.

My previous letter details how, for some wilderness search and rescue (SAR) teams, wilderness medical technicians operate under physician medical direction. These technicians are not acting as EMTs under state EMS law, but as technicians under delegated practice via the medical practice act. At present, physicians with these SAR teams carry medications with them, and issue medications to their technicians as needed during a rescue. As we understood it, this is entirely consistent with the medical practice act, though it does not provide either the physicians or technicians with any of the protection against civil liability that EMS law provides. However, I believe I speak for all wilderness SAR medical technicians in the following. Victims of wilderness injury or illness are in such extreme distress that questions of civil liability are entirely overpowered by the moral imperative to provide medically appropriate care.

SAR team physicians also write prescriptions to members for a medical kit for personal use. Example: a team is searching a cave for a lost person. The team is six to ten hours from the entrance, and completely out of contact with their physician. (During cave rescues we string field phone wire, but this is impractical for searches with many teams in the cave.) A team member develops diarrhea and fever. He would then use his own medical kit to take loperamide and ciprofloxacin, and see the physician when he exits the cave.

Since these medications are prescribed by a physician for that particular team member, there should be no legal complications for him carrying the medications. Only if the team member were to administer medication to another individual could the team member be accused of practicing medicine without a license.

There are situations where a wilderness medical technician might consider administering personal medications to another individual. Let me give a particular example.

A man falls deep within a Pennsylvania cave. He suffers an open tibia-fibula fracture, grossly contaminated with guano. The standard of care is to clean the wound and give antibiotics as soon as possible to help prevent osteomyelitis. Three hours after the patient falls, several cave rescue personnel reach the entrance. Four hours after this (seven hours after the fall), the first group of rescuers reaches the patient. By this time, a cave rescue physician has reached the entrance, and can talk directly with the rescuers at the patient's side via field phone. Rescuers have been trained to use antibiotics to treat various problems through a formal training program. It will take another four hours for the physician's medications to be carried into the patient, but the rescuers have antibiotics with them. It will take eighteen hours to bring the patient to the entrance, then another two hours to the hospital. In such a case, should the rescuers at the patient's side give the antibiotics they have, or should they delay until the physician can bring his antibiotics to the patient? Medically speaking, the answer is to give antibiotics as soon as possible. The same reasoning would apply to pain medications, though the need is not quite as acute (though I suspect the patient might argue this point).

The medical practice act's generic "technician" provisions provide a method for providing proper medical care to wilderness patients now. However, there should be a formal mechanism for training, certifying, and permitting wilderness medical technicians to administer medications. In particular, they must be able to administer medications in addition to those on the approved "street" prehospital drug list promulgated by the Division of Emergency Medical Services Systems. These issues are addressed in part in my previous letter.

Thank you for your recommendations to interface with the PEHSC; WEMSI has already started this. As you suggested, I contacted the Commonwealth Attorney General's office about wilderness medical technicians dispensing medications; they referred me to Kenneth Brody, Assistant Counsel for the Department of Health. He noted that the Medical Practice Act provides very broad general license for physicians to use technicians as desired, and the system I described above and in my previous letter falls under these provisions. As far as these technicians carrying medications a physician prescribed for them, he said that is within the license of a physician. As far as administering these medications to others, he suggested I contact the State Medical Board. I then spoke to April L. McClaine, Legal Counsel, State Board of Medicine. Her tentative opinion was that wilderness medical technicians dispensing medication from their personal medical kit, with physician direction either in person, by radio or field phone, or by written standing orders, would be consistent with the provisions of the medical practice act. She noted that, in a somewhat parallel situation, the Board recently decided to view PAs prescribing medications based on a physician's standing orders as if it were an order of the physician. She will bring up wilderness medical care at a future meeting of the Board. She suggested I contact the DEA regarding any special provisions regarding wilderness medical technicians carrying Schedule II or III drugs. I spoke to Dennis M. Johnson of the DEA Pittsburgh office, and he explained that for controlled drugs as part of the personal wilderness medical kit, WEMSI would have to have a single physician order the scheduled drugs on a form 222 and then issue them to the individual wilderness medical technicians. WEMSI would also be responsible for keeping records of administration of any of these drugs.

As I mentioned in my last letter, 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." One may interpret "emergency medical services" to include services to 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. On the other hand, one could interpret "emergency medical services" as strictly limited to care in or near ambulances. I spoke at length today to Kenneth Brody, about this. He said that one could argue this either way, but that a specific legislative mandate would be necessary to provide an unambiguous Division of EMS control over medical care of patients in the wilderness or backcountry. I suggested that a Vote to Recommend specific legislation by the PEHSC EMT/Paramedic Committee might be the correct way to approach this, and he concurred.

We of WEMSI and the search and rescue community look forward to working with you to help extend quality prehospital care to Pennsylvania's forests, whitewater streams, caves, and mountains. We also hope to extend the benefits of Pennsylvania's EMS legislation to wilderness providers as well as those in ambulances. Please also consider these topics yourself and give us the benefit of your expertise. We look forward to your reply. Thank you very much.

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: Personal Medical Kit document;
Dr. Ham's letter;
previous letter and attachments (to Long, Regional EMS Councils, McClaine, Brody, Johnson);
Act 45 (To McClaine)

cc: WEMSI Staff; PEHSC EMT/Paramedic Committee;
    Mr. Robert Long (PEMA);
    Regional EMS Councils;
    April L. McClaine, Legal Counsel, State Board of Medicine;
    Kenneth Brody, Asst. Counsel, Department of Health;
    Dennis M. Johnson, DEA

Designed by a member of