Wilderness EMS Institute
36 Robinhood Road Pittsburgh, PA 15220-3014
Keith Conover, M.D., WEMSI Medical Director;
George Pry, EMT, WEMSI Executive Director

Testimony on Wilderness and Backcountry EMS Needs

After talking about it for several months, and with some trepidation, you finally give in. You'll accompany your three caver friends to explore the sights of one of Pennsylvania's wild caves. At their direction, you get all the proper gear together: rugged clothes and boots, a pack, leather gloves, three sources of light. You enter the cave feeling, well, relatively prepared. After the first hour or so, you actually start enjoying the water and mud-- after all, once you're totally wet and muddy, there's no point in even trying to stay clean or dry. The formations are not exactly what you expected, but beautiful nonetheless. After a while, the long 18" high belly- crawls make you vow to get kneepads when (not if, you've decided) you come back. Rappelling down the pit is fun, but you're glad that your companions are experienced at this sort of thing.

Four hours into the cave, you're at the back of group, tiring out a bit, and the cave's chill is finally seeping into your bones. You start wishing you knew the names of all those muscles you've strained, and start think about the trip back out. You're clambering across a room strewn with Volkswagen- sized boulders, and thinking about home, a hot shower, and a dry, clean bed. You hear a scream, a sudden thud, and then a curse from ahead. Jim, your group's leader, fell about fifteen feet. You hurry to his side. He's alert and oriented, and is complaining of pain in the right shoulder and left leg. He has an obvious abrasion on his cheek, and his right shoulder is deformed; it looks like a dislocation. Following standard EMS protocol, you get another member of your group to stabilize his neck. Gently pulling back his pants leg, you see a wound on the shin with the tibia exposed, but no fracture. You realize that it's four hours back to the entrance, if you were rested. Thinking about the pit and the crawlway, you realize it'll take a lot more than four hours to get Jim out. Looking at the way he can't get his right arm across his chest, you realize that he won't even fit through the crawlway in his present configuration. What do you do?

"Wilderness EMS": one usually thinks of the rescue in the mountains of California or Colorado. However, the problems of wilderness EMS are equal or perhaps greater in Pennsylvania. The central Appalachians are the country's most heavily used backcountry recreation area. The Commonwealth is criss- crossed by thousands of miles of backpacking trails, including the famous Appalachian Trail, and contains popular hunting areas, fishing and whitewater streams, climbing areas, and caves. With such an outdoor recreation area near New York, Philadelphia, Baltimore, and Washington, backcountry emergencies are common and becoming more so. Small and large aircraft crisscross Pennsylvania constantly, and occasionally go down in a backcountry area.

Depending on how you view it, EMS for Pennsylvania's wilderness and back- country patients is either poor or nonexistent. "Street" EMS is often inappropriate for wilderness and backcountry patients, and Pennsylvania EMS makes no specific provisions for wilderness and backcountry patients. Using the above example:

1. According to "street" protocol, the only indications for reducing a dislocation are impaired circulation or impaired sensation: "splint as is and transport." However, statements of the Wilderness Medical Society and National Association of EMS Physicians clearly state that the standard of care in the backcountry is immediate reduction, period.
   
   
2. According to "street" protocol, Jim's spine must be immobilized until cleared by a physician in an Emergency Department. However, we also know from the emergency medicine literature that staying on a backboard more than 45 minutes causes intolerable pain, and the orthopedic literature tells us that being on a backboard for more than an hour or two is liable to cause skin breakdown and require massive plastic surgery. If, after reducing the potentially distracting shoulder dislocation, Jim has no neck pain, no neck tenderness, and a normal neurological exam of the extremities, do you think he really has a c-spine fracture? Of course not. Assuming he's alert an not intoxicated, having him gently move his neck through a painless full range of motion would prove it. Wilderness EMTs are taught to "clear" the cervical spine in such a manner.
   
   
3. According to "street" protocol, the treatment for wounds is to brush off dirt, apply a clean dry dressing, and transport. The proper treatment in the backcountry, again according to national standards, is to irrigate the wound prior to dressing, and to provide antibiotics as soon as possible. Pennsylvania paramedics are not permitted to give antibiotics.

For these reasons and others, "street" EMS is inadequate for wilderness and backcountry patients. It's not clear if the definition of "EMS" found in Act 45 even applies to these patients. If it does, we're doing a bad job of serving them. Back in March, I spoke about this to Kenneth Brody, Assistant Counsel for the Department of Health. He said that one could argue that "EMS" should include wilderness and backcountry patients, or that indeed such patients are outside the bounds of "EMS." He said 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.

WEMSI and organizations such as the Appalachian Search and Rescue Conference and the National Cave Rescue Commission provide proper medical care for their patients. However, they do so not through Act 45, but through the broad generic delegated practice provisions of the Pennsylvania Medical Practice Act. This leaves all training, regulation, and quality assurance up to these organizations. Smaller search and rescue teams and EMS agencies with only occasional backcountry rescues, however, don't have the organizational advantages of these larger organizations. They would benefit from state involvement in wilderness and backcountry EMS. Too, there may be overlap and conflicts between "wilderness EMS" and "street EMS." When should wilderness EMS protocols apply, and when should "street" EMS apply?

Background References, available from WEMSI:

• Wilderness Medical Society Position Statements, 1989.
• National Association of EMS Physicians Model Clinical Guidelines.

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