Report and Preliminary Recommendations: Wilderness EMT
by Keith Conover, M.D., and Cliff Roth, EMT-P
for the EMT-Paramedic Committee,
Pennsylvania Emergency Health Services Council

April 30, 1990

1. The idea of "the Wilderness EMT" is an important concept in that:
1. it identifies the need for special training for EMTs who will provide prehospital care in wilderness and backcountry environments, and
2. it identifies those providing prehospital care in wilderness and backcountry environments as members of the EMS system.
2. Pennsylvania has a need for specially trained Wilderness EMTs based on the following evidence:
1. Pennsylvania has a population of 12 million people living in close proximity to many wild and backcountry areas. Roughly 2/3 (Fifty-nine percent) of Pennsylvania is wooded, much of which is state or national parks, forests, or game lands. Pennsylvania has more miles of trails than any other state. Pennsylvania also has a large number of caves heavily used by recreational cavers. Thus, our state has a very high outdoor recreational usage, and attracts many people from out of state for outdoor recreation. Thus, the potential for wilderness and backcountry illness and injury is very high.
2. Pennsylvania does not keep good records of wilderness search and rescue operations, so estimates must be drawn from comparisons with nearby states. For instance, Virginia is of roughly the same size as Pennsylvania, with a similar number of wild and backcountry areas. (The PEHSC Rescue Task Force plans to use its new Rescue Report Form to gather, among other information, wilderness search and rescue statistics.)
3. A study presented to the National Association for Search and Rescue in 1987 estimates, based on comparisons with Virginia and an analysis of data gathered by the Pennsylvania DER, that Pennsylvania has 150 to 200 wilderness or backcountry search and rescue operations each year. [Mechtel G, Shea G, Baker A. Volunteer SAR in the Mid-Atlantic States. National Association for Search and Rescue, 1987.]
4. Based again on data from Virginia, we may estimate that from lost person searches and downed aircraft searches, roughly 1/3 of the operations will find the subject alive and well enough to walk out with assistance, 1/3 will find the subjects dead (including aircraft crashes with multiple deaths), and roughly 1/3 will find the subject requiring prehospital care. Thus, a reasonable estimate is that some 50 to 80 people a year will require wilderness prehospital care in Pennsylvania.
5. Using data gathered by the Appalachian Search and Rescue Conference (Eastern Region, Mountain Rescue Association), we may estimate that the average time of evacuation for ill or injured backcountry patients will be 4.5 to 5 hours, with some rescues lasting up to 12 hours. Data from the Eastern Region of the National Cave Rescue Commission suggests that cave rescues in the state will last longer, averaging some 8 hours, with some rescues lasting 24 to 36 hours.
6. The scope of practice of EMTs and Paramedics in the wilderness is much the same as on the street, but with some differences. These differences are required because proper prehospital care on the street may NOT be proper in the backcountry. The Wilderness Medical Society has identified several problems that require different care in the wilderness than in the street. These are outlined in the Society's Position Statements. [Wilderness Medical Society. Position Statements, 1989.] Wilderness Medical Associates has recently approached the National Association of State EMS Directors and the National Association of EMS Physicians asking them to endorse the protocols they have developed for the National Association for Search and Rescue. The Center for Emergency Medicine of Western Pennsylvania together with the Appalachian Search and Rescue Conference have jointly been developing a peer-reviewed curriculum to train EMTs and Paramedics in these specifics.
7. A specific question that we must address at the state level is: If a person is licensed to practice as an EMT, does the person need an additional license to practice as a Wilderness EMT? The knowledge and skills required of Wilderness EMTs are slightly different from those of "street" EMTs, but is the difference enough to require a different license? Since Wilderness and non-wilderness EMTs are doing the same job but in different environments, can we just certify Wilderness EMTs (as in ACLS, BTLS, and PHTLS), without them needing a new, separate license?
8. We may argue that there is no need for Wilderness licenses beyond the EMT's "standard" EMT-basic/-Intermediate/-Paramedic licenses. Wilderness EMTs will be performing the same level of skills as their non-wilderness counterparts, as adapted for the wilderness: basic Wilderness EMTs will be restricted to non-invasive therapy, leaving IV's and drugs for the Wilderness EMT-Paramedic. Thus, there should be little concern for licensing Wilderness EMTs, provided they hold proper EMT licenses.
9. However, many standard EMT and Paramedic techniques require minor modifications to be effective in the backcountry. A variety of wilderness-oriented EMT-Basic courses teach these differences to EMTs, including WEMT courses offered nationwide by SOLO, and by Wilderness Medical Associates through the National Association for Search and Rescue.
10. The Center for Emergency Medicine of Western Pennsylvania and the Appalachian Search and Rescue Conference (Eastern Region, Mountain Rescue Association) jointly sponsor a Wilderness Emergency Medicine Curriculum Development Project [now the Wilderness EMS Institute]. For the past 5 years, this project has been drawing in emergency medicine, wilderness medicine, mountain rescue, and cave rescue experts to develop a curriculum for training EMTs and Paramedics, at a sophisticated level, how to practice their specialty in the wilderness. This curriculum is nearing completion, and will be offered for public use in the next few months. (It will be available to other organizations including Wilderness Medical Associates and SOLO, who has expressed strong interest in using for their educational programs). The Commonwealth of Virginia has already used preliminary versions of the ASRC--CEM WEMT curriculum for two Pilot WEMT classes offered jointly by their state EMS and Emergency Services Departments.
11. Most skills and techniques covered in the ASRC--CEM curriculum or included in existing courses may require different protocols and standing orders for the wilderness, but are well within the current scope of practice of Pennsylvania EMTs and Paramedics (e.g., a basic EMT irrigating a wound before starting an eight-hour evacuation, or an EMT-P placing a Foley catheter for urine output monitoring during a 12-hour cave rescue). One may indeed make a strong case that ALL of the WEMT's skills and techniques are within the existing scope of practice of EMTs and Paramedics.
12. However, there are a few WEMT techniques that will require at least "stretching" of the EMT’s scope of practice. Let us closely examine an example: dealing with anterior shoulder dislocations in the wilderness.
13. The current teaching for street EMTs is "never attempt to reduce a dislocated shoulder."[American Academy of Orthopaedic Surgeons. Emergency Care and Transportation of the Sick and Injured, 3E. Chicago: AAOS, 1981. p150.] However, the standard street treatment of a knee dislocation without a pulse is to attempt reduction: ``If distal pulses are absent, one attempt should be made immediately to realign the limb and thus reduce the compression of the popliteal artery. The EMT should gently straighten the deformity by applying gentle longitudinal traction in the axis of the limb."[American Academy of Orthopaedic Surgeons. Emergency Care and Transportation of the Sick and Injured, 3E. Chicago: AAOS, 1981. p160.]
14. Even with a good distal pulse, reducing an anterior shoulder dislocation in the wilderness makes good sense; at the minimum, it will reduce pain and suffering, and it may well avoid the need for reduction under general anaesthesia at the hospital (when spasm has been intensifying for many hours, reduction may be impossible without general anaesthesia). (Although the risk of death under anaesthesia is small, it is significant, especially when a simple backcountry maneuver could eliminate the need for anaesthesia altogether.) Indeed, the Wilderness Medical Society has a position statement that says: "The common anterior shoulder dislocation can usually be reduced without too much difficulty and the sooner this is attempted, the easier it will be." [Iserson KV, Ed. Orthopedic Injuries in the Wilderness III: Guidelines for Individuals with Advanced Skills. In: Wilderness Medical Society Position Statements 1989. Point Reyes Station, CA: Wilderness Medical Society, 1989.]
1. EMT-Basics have always been trained to use axial traction to straighten angulated limbs; the very first EMT textbook said: ". . . a severely angulated fracture should be straightened prior to splinting, for this may lessen the chance of permanent damage to blood vessels and nerves around the fracture site. . . . Straightening an angulated fracture may cause the patient momentary pain, but this should lessen when the fracture is straightened and splinted. If the straightening can be performed immediately after the fracture occurs, the patient may experience little or no pain; frequently there is numbness around the site for several minutes following a severe fracture. . . . Gently but firmly grasp the extremity with both hands. Place one hand just below the site of fracture and the other hand farther down the extremity. If possible, have someone provide countertraction . . ."[American Academy of Orthopaedic Surgeons. Emergency Care and Transportation of the Sick and Injured, 1E. Chicago: AAOS, 1971. p95.]
2. The logical argument can be summarized: EMTs are taught to use axial traction to straighten fractures, AND EMTs are taught to reduce certain dislocations when medically appropriate, AND the standard for care of the anterior shoulder dislocation in the wilderness is reduction; THEREFORE, EMTs who have been trained by a physician to reduce anterior shoulder dislocations should be able to do so within the scope of their EMT license.
15. Another parallel to WEMT training is with the EMT continuing education courses BTLS (Basic Trauma Life Support) and PHTLS (PreHospital Trauma Life Support). These courses teach new skills to EMTs, and offer certification. However, the states so not see this training as needing a new level of licensure.
16. To return to the original question: Does WEMT training require a new license? The answer will depend on the state EMS laws. If state laws or EMS regulations specifically prohibit EMTs from reducing shoulder dislocations or performing other skills of a WEMT, then separate WEMT licensure would be needed.
3. Another problem lies with the current drug list for paramedics. Orthopedic surgeons have unanimously recommended that patients with open fractures faced with an evacuation of more than an hour or two should receive IV or IM antibiotics as close to the time of injury as possible, but the current drug list prohibits wilderness EMT-Ps from giving such antibiotics.
4. A simple solution is to require EMTs to complete a recognized WEMT class before a command physician will provide command for these wilderness-specific variations. (We would also recommend that command physicians wishing to give command to WEMTs attend the Wilderness Command Physician course to be offered at the Center for Emergency Medicine of Western Pennsylvania.) Another alternative is to develop state guidelines and certify and license Wilderness EMTs at both EMT and Paramedic levels.

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