Wilderness EMS Institute

[logo]

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

March 27, 1995

ATTN: Chuck Stutzman, Chair
PEHSC EMT/Paramedic Committee
Maple Building, Suite 210
5012 Lenker Street
Mechanicsburg, PA 17055-2437

Dear Mr. Stutzman:

SUBJECT: Wilderness EMS

At the request of members of the PEHSC EMT/Paramedic Committee, I am providing background material on the scope of the wilderness EMS problem in Pennsylvania. By copy of this letter, I will ask Robert Cooney of the PEHSC MIS Committee to help address the problems described below in future Pennsylvania EMS reporting. As per the request, I will distribute copies of this letter to the members of the Committee at the next meeting.

As discussed at the previous meeting, statistics on Pennsylvania's wilderness and backcountry EMS problems are poor to nonexistent. "Wilderness" is checked on less than 1% of trip sheets; however, some wilderness patients are evacuated by search and rescue teams and only enter the EMS system when they reach the road. The trip sheet may not reflect the true nature of the problem. Too, one of the members of the Committee noted that when he tried to submit a trip sheet for a wilderness problem with a 5-hour on-scene time, it was returned by the state as an invalid entry. It was pointed out that a good search and rescue team leader may not call for an ambulance or helicopter until the patient nears the road or the helicop- ter LZ, making the recorded on-scene time short even though the evacuation was long.

I had asked Yijin Zhang, PEHSC Research Assistant, to send me an analysis of the number of trip sheets each year that (1) have the "wilderness" box checked, (2) have an on-scene time of 1 hour or more, and (3) have a total transport time of 1 hour or more. The printout for 1992 that she sent shows that my questions were poorly worded in terms of the data that is actually collected. Nonetheless, the report has a total of 1,673 calls tagged as "wilderness." There is a wide distribution of causes of these calls.

I suspect that a sizable portion of these calls are close enough to the road that no special wilderness EMS adaptations are needed. If we eliminate all calls with a median time under 100 minutes, though, there are still 508 calls. Looking at the data, I suspect that some fraction of these are not true "wilderness" calls. However, the times represent only "road" time, and may not include evacuation to the road unless the ambulance crew performed the evacuation. Therefore, some of the times shorter than 100 minutes may still represent a long patient contact time.

Therefore, analysis of the PEHSC database for 1992 suggests that there are about 500 wilderness medical incidents a year in Pennsylvania.

Another way to get an estimate is to look at search and rescue (SAR) statistics.

There is no central reporting of backcountry SAR in Pennsylvania, nor of backcountry EMS. However, there is a way to use the available data to make a reasonable estimate.

We have been attempting for the past several months to get current data from Virginia, a state that keeps centralized records for almost all search and rescue incidents. However, due to the recent loss of their state SAR Coordinator, they have been unable to provide this data. However, a paper presented at the annual conference of the National Association for SAR in 1986 [Mechtel G, Shea G, Baker A. Volunteer SAR in the Mid- Atlantic Region. Fairfax, VA: National Association for SAR Response '86 Proceedings, pp. 85-105] gives the following figures for the number of SAR incidents in this area:

We have also heard from VA DES that the number of SAR operations in VA has gone ups substantially since 1986, though we still don't have exact figures. Virginia has centralized SAR reporting, and is similar to Pennsylvania in geography, extent of backcountry recreation, and in many other ways, though slightly smaller in area. In Virginia, there are about 100 lost person SAR operations each year. If we scale this up by 25% for Pennsylvania's larger size and increases since 1986, we get a yearly total of 125 searches. The total number of patients who required medical care and the length of the evacuation are not at present readily available from the DES data, but based on the standard breakdown of the ASRC data quoted in the NAEMSP textbook chapter [Conover K. Wilderness. In: Kuehl AE, ed. National Association of EMS Physicians' Prehospital Systems and Medical Oversight, 2E. St. Louis: Mosby, 1994.], we can estimate that about 25% of these are "Status II" (alive but requires evacuation), for a total 31 Status II backcountry patients a year.

Of the approximately 40% Status I patients (able to evacuate self), a minority (probably about 30% of that 40%) are still in need of medical evaluation and treatment and are transported to an Emergency Department for evaluation after they are evacuated. These are also deserving of backcountry evaluation and treatment. Thirty percent of 40% of the yearly total (125) equals 15.

Combining the Status I and Status II patients who require medical care in the backcountry, we arrive at 46 search patients a year. Of these, probably about a quarter are close enough to a road so that backcountry EMS modifications aren't needed, leaving 35 patients.

The grand total estimate, then, for Pennsylvania search subjects requiring backcountry medical care is 35/year.

This doesn't include rescues without a search component or downed aircraft incidents. It's hard to estimate the number of these. However, based on the statistics in the above-cited mid-Atlantic SAR paper, about 35 downed aircraft "finds" are made every year. The majority of these are fatal crashes, but one or two people survive each year; they are likely to be critically injured and will benefit from backcountry medical care.

We can estimate on a review of cave rescues, of which the majority (probably more than 80%) are reported to the National Speleological Society. I am enclosing two year's worth of cave rescue summaries from the periodical American Caving Accidents. According to John Appleby, National Cave Rescue Commission Eastern Regional Coordinator, the NCRC's Eastern Region, due to increased cave exploration, now is seeing 12 yearly cave search and rescue incidents in the five-state region (the total for 1994 thus far), and of these 12, 5 were in Pennsylvania. Mr. Appleby says "All 5 PA missions involved fall victims, typically with lower extremity injuries. One did include rib and head injury. Two were ambulatory, and required only assistance in moving. Two were packaged and transported as per usual methods. One, a fall victim in J-4 cave, had to be removed from the SKED to com- plete the extrication. Unfortunately, this was the head, rib, and injury I mentioned above. Fortunately, no additional injury was caused by the extrication." This only accounts for rescues that were extensive enough to require a callout of NCRC personnel, i.e., that went beyond local capabilities. There are probably an equal number of cave rescues handled without calling in the National Cave Rescue Commission, for a yearly total of 10. There are probably a similar number of rock climbing injuries in the state. Thus 2 downed-aircraft patients, plus 10 each of caving and climbing accidents, results in a total of 22.

Thus, from two methods we can fairly reliably estimate about 77 patients requiring prolonged wilderness care in Pennsylvania each year, some of which, such as cave rescues, will require many-hour evacuations.

Since the estimate by the first method is about 500, and by the second method about 75, the number of true wilderness/backcountry patients in Pennsylvania is probably inbetween, on the order of 100-200 a year. We believe this is sufficient documentation of a significant number of patients to have PEHSC proceed with addressing their unmet emergency medical needs.

I should also note that the Wilderness EMS Institute, though a Pennsylvania medical response agency, provides mutual aid to multiple other states. (WEMSI is currently working with the Atlantic EMS Council to include wilderness EMS in the revised reciprocity agreement that is being developed by the Council.) Enclosed is an example of WEMSI personnel doing a rescue last summer in Virginia, as reported in the latest edition of the Wilderness Medicine Letter (a PA EMS trip sheet was also filed from this rescue).

The type of injuries in the wilderness and backcountry are outlined in the enclosed reprint of a chapter from the new NAEMSP EMS textbook.

Having discussed the scope of the problem, let us also present the reasons for including wilderness within EMS in Pennsylvania:

1. Improving Care:
   Having a state-sanctioned wilderness EMS system helps set an expected standard of care for wilderness and backcountry patients, encouraging better patient care throughout the Commonwealth.
   
   
2. Statewide QI:
   Having wilderness EMS under state control provides the advantages of a uniform statewide Quality Improvement program.
   
   
3. Interagency Cooperation:
   Each backcountry patient usually involves extended care by multiple EMS providers, and patient contact times make each one the equivalent of multiple "street" patients. A uniform statewide program helps improve cooperation between these agencies.
   
   
4. Centralized Program:
   Wilderness patients present infrequent but complex medical problems and may push or exceed the limits of existing EMS systems. This is especially true given that most EMS agencies will see a wilderness search or rescue rarely. This does argue for a centralized approach to Wilderness EMS for Pennsylvania.
   
   

This letter has been reviewed by, and modified based on the comments of, Subcommittee members Robert Cooney, David Lindell, William C. Wingo, Joseph A. Walsh, by NCRC Eastern Regional Coordinator John Appleby, and by Winnie Pennington of the Virginia Department of Emergency Services.

Thank you.

Yours truly,

[signed]

Keith Conover, M.D., Medical Director; Chair, PEHSC
EMT/Paramedic Wilderness EMT Subcommittee

Designed by a member of