Chapter 36 Wilderness Emergency Medical Services and Response Systems

The “wilderness” in wilderness medicine has broadened in scope. Skills that are learned for providing wilderness medical care now apply equally to several other situations. These wilderness skills have proved invaluable in the context of military operations as well as in disaster settings. The military has special needs for providing care during combat, and the disaster arena requires not only the knowledge and skills of providing immediate long-term victim care but also knowledge regarding preparedness and self-preservation.

2001—Gujarat earthquake, India	20,000 deaths
2003—Bam earthquake, Iran	30,000 deaths
2004—Indian Ocean earthquake and tsunami	230,000 deaths
2005—Kashmir earthquake, Pakistan	85,000 deaths
2005—Hurricane Katrina, United States	1800 deaths
2008—Sichuan China earthquake	70,000 deaths
2008—Cyclone Nargis, Burma (Myanmar)	150,000 deaths
2010—Haitian earthquake	270,000+ deaths

These natural disasters have cost hundreds of thousands of lives, displaced and made homeless millions of people (mostly the poorest of the poor), and cost billions of dollars; they have a global impact that will continue for decades. Tens of thousands of volunteers and other relief workers sprang into action and made tremendous personal sacrifices to assist at the disaster sites.

Disaster medicine is by far the largest arena in which the skills of wilderness, extended care, and remote medicine are practiced. Wilderness and mountain rescues performed around the world require a great deal of training and skill to be successful, but these activities pale in comparison with the efforts that are involved in disaster relief.

As a result of increasing recognition and use of wilderness medical skills in disaster settings, this chapter focuses on wilderness and mountain rescue training and response systems, and includes essential information about disaster training and response systems.

Regardless of the situation, the starting point is always with immediate dangers and self-preservation. We begin with the knowledge and skills necessary to minimize the inherent risks that come with disaster response and relief work. This brief section provides a list of the principles to consider with regard to being prepared to respond, help, and unselfishly serve others in their time of need.

The principles that will help one to prepare to respond and serve are:

Safety

Make a plan. First and foremost, the basis of personal and team safety is having a well thought-out plan, putting it into action, and sticking to it, if possible.

There is safety in numbers. Always try to travel in a group, and try to work together as a group. Keep the team together.

Travel during the day. Traveling during the day is inherently much safer than traveling at night.

Know where you are going. Know how to get there; know how to use a map, compass, and global positioning system; know who is going to meet you when you arrive at your destination.

Are there any local concerns? Find out well in advance if there are any local issues with regard to safety or if there are dangerous areas that should be avoided.

Ask questions. Don’t guess. Most people are happy to answer questions and to be helpful.

Have an evacuation plan. You need to know what to do if someone in your group becomes sick or injured. The plan should include how to evacuate them to home or to a well-staffed and up-to-date medical facility.

It is a good idea to have some form of evacuation insurance from a group such as Global Rescue, the American Alpine Club, or the Divers Alert Network.

If you have evacuation insurance, make sure to carry the details of the policy on one’s person at all times, with appropriate contact information and telephone numbers. Never leave it at home or back at base camp. This information needs to be available at the time of the crisis so that the plan can be easily and accurately activated.

Stress and Sanity

Post-traumatic stress disorder: One of the most difficult tasks is trying to determine whether you are emotionally prepared to face destruction and human suffering.

During the deployment, gather several times daily to share experiences, expectations, and concerns in a format that is comfortable and nonconfrontational and that invites open and honest communication.

Have a plan to get together and share stories after everyone has returned home. Post-traumatic stress disorder can be prevented and is treated by talking about the tough work, the difficult things that you saw and did, and the sense of disappointment or even failure that can haunt you after you are back home.

Today, medicine is replete with improving communications, computer-assisted diagnosis, futuristic imaging technology, faster and luxurious emergency medical vehicles, and highly skilled trainees. However, the physical world that we explore is still rugged and enduring: majestic mountains, spectacular shorelines, wild rivers, dense tropical rain forests, polar ice sheets without horizons, arid deserts, vast oceans, and hazards beyond imagination. We enter and must sometimes be rescued, treated, and saved. First response is critical.

The wilderness will always have the ability to place humans in situations in which immediate help is simply not available. When in the wilderness—whether it is preexisting or created by a disaster—people must know how to survive and be able to perform emergency medicine barehanded, without all of the technical wizardry that exists in a modern ambulance or an emergency department.

The anatomy of disaster response and its limitations are very similar to those found on a mountain or backcountry rescue. Time and distance work against rescuers, when notification of the emergency can be delayed and initial information may be inaccurate. The weather conditions at the site of the emergency may be poor, hostile, and rapidly changing. Terrain can make travel very difficult, slow, or even impossible. Manpower, equipment, and resources will be very limited and hard to obtain. Human responders require specialized training, skills, and knowledge of everything from self-preservation skills to emergency care skills in an extended care environment.

What continues to change as emergency medical service (EMS) evolves is the scope of practice of prehospital medicine. The important expansion features are patient complexity and time to definitive care.

The usual method of assessing EMS needs is to consider the quantity of knowledge needed to provide emergency care on the basis of the complexity of the medial problems. Education begins with first aid and basic life-saving concepts and then progresses as the complexity of patient care increases. Each next level requires more hours of study to obtain the knowledge necessary to treat specific medical problems. For example, First Responder training takes about 60 hours; basic emergency medical technician (EMT-Basic) training takes 120 hours or more, EMT-Intermediate training takes about 220 hours or more, and EMT-Paramedic takes more than 1000 hours.

Another way to look at the provision of emergency medical care is to consider how long it will take to bring the patient to definitive care and how the patient’s condition will change over time. When taking time into consideration, there are four distinct areas of patient care, each of which requires its own unique knowledge and skill set. The four time-dependent areas of patient care are the “first 5 minutes”; emergency care delivered during the “golden hour;” “extended care” during the ensuing hours; and, finally, “remote care,” when there is no definitive care available.

First response: 5 minutes

Emergency care: 1 hour

Extended care: 24 hours

Remote medicine: No definitive care available

First Response

First responders are the first to arrive on the scene. They provide the initial assessment and emergency care; they can be fire, police, rescue, EMS, or military personnel, or they may be Good Samaritans who have arrived at the scene of a crisis. In a wilderness, remote, or disaster situation, they may be search and rescue team members or fellow hikers. This is when the skills of rapid assessment, recognition, and treatment of potentially life-threatening problems frequently make the difference between life and death. It is within the first 5 minutes of an encounter during which the greatest good is typically done for the greatest number of people.

Prehospital Emergency Care

The “golden hour” is best served by well-trained, staffed, and funded EMS systems that are capable of rapid response and transport to hospitals where there are adequate emergency departments. The name states the goal: it should take less than 1 hour from the onset of injury or illness for the patient to be treated and transported to definitive care.

Extended Emergency Care

Standards for long-term or extended patient care were developed for wilderness, rural, and marine environments as well as for the military and for disaster response teams. This level of emergency medical training takes into consideration what to do when patient care extends beyond the golden hour.

Remote Medicine

Remote medicine is enacted in remote locations, during expeditions when there is delay to rescue, and when there is no place to take a victim.

Whether an accident or medical crisis occurs in the wilderness, in the backcountry, on the high seas, or at a disaster site away from access to immediate assistance, the chain of events set in motion hopefully leads to a successful rescue and lives saved. However, how it unfolds varies tremendously, depending on the part of the world in which the critical events occur. Currently no national or international standards exist for wilderness EMS and response. Instead, the configurations of personnel and policies reflect local, national, and international influences. In the United States, wilderness EMS is the most diverse, because it is provided by a broad range of agencies and by individuals with a wide variety of training and certification levels that range from first aid to paramedic. Canadian wilderness EMS is generally provided through the military, whereas in European wilderness situations civilian physicians have a prominent role.

The skills that have been developed for providing long-term patient care in the wilderness are proving to be beneficial in medical and rescue assistance in the disaster response and relief setting. Although there is not a great effort to produce national or international standards for wilderness or disaster relief, there are national and international organizations that have their own command structures, response systems, and response criteria. It may be that organizations or structures such as the American Red Cross, Federal Emergency Management Agency, or Department of Homeland Security will address these issues and develop standards for communications, response, and medical and rescue techniques. The challenge will be to create a system-wide or nationwide set of standards that can be used when diverse entities come together during an emergency to provide relief so that they will be able to function well together.

In the world of mountain rescue, the American Alpine Club’s Safety Committee gathers, reviews, and analyzes mountaineering accidents that have occurred throughout North America and publishes an annual report entitled Accidents in North American Mountaineering. The data collected illustrate both the necessary diversity of wilderness and mountain rescues and current limitations of the field (Box 36-1).

BOX 36-1 Mountain Search and Rescue Factors in the United States

1 Search and rescue is the responsibility of national parks, state parks, county sheriffs, or state conservation officers, depending on the state or park.

2 Most backcountry and technical rescues are carried out by volunteer rescue groups.

3 Ninety percent of all rescues are carried out on foot rather than with airlifts by helicopter or fixed-wing aircraft.

4 At least 95% of rescues are performed without physicians present, instead making use of the skills of First Responders, emergency medical technicians, and paramedics, who may or may not be trained in wilderness medicine and rescue techniques.

5 Only two major climbing areas—Yosemite and Grand Teton National Parks—use helicopters extensively.

6 Only Denali National Park uses fixed-wing aircraft extensively and helicopters occasionally.

7 Only three national parks have rangers who are trained specifically for technical rescue, advanced medical support, and helicopter operations: Yosemite, Grand Teton, and Mt Rainier National Parks.

8 National and state parks are not mandated with a “duty to rescue.” However, virtually all parks provide rescue service, and most parks have a budget for these activities.

9 Many roadside climbing areas and popular backcountry areas are not within the jurisdictions of parks. Technical and backcountry rescues carried out at these locations are often performed by local rescue squads, fire departments, and ambulance units, usually without the benefit of specialized training or technical backcountry skills.

Several states have established (or are in the process of establishing) working protocols for providing care in the wilderness or “extended care” environment. With increased natural and human-made disasters, EMS systems worldwide have suddenly found themselves essentially operating in a “wilderness” setting as a result of prolonged exposure to a hostile environment, delayed evacuation and transport times, and a lack of medical resources and direction. Prehospital personnel in extended care situations find themselves providing care for much longer than the golden hour and discover that their street-oriented skills are often inadequate.

Internationally, the Union Internationale des Associations d’Alpinisme (i.e., the International Mountaineering and Climbing Federation, http://www.uiaa.ch), which is headquartered in Bern, Switzerland, has established criteria and courses for postgraduate training in mountain medicine for physicians. After fulfilling these requirements, physicians in the European Union become certified in wilderness medicine and can practice the relevant skills in an appropriate arena. There is now a similar program for physicians being offered in the United States by the Wilderness Medical Society (http://www.wms.org). The Society has produced a curriculum to address various wilderness medical topics for a total of about 100 contact hours. On completion and qualification, the individual becomes a Fellow of the Academy of Wilderness Medicine.

In the United States, the foundation has been set for national standards for providing emergency care and rescue by adoption and implementation of the Incident Command System (ICS). This system of command and communication was developed by the U.S. Forest Service for coordinating forest firefighting tactics in the western United States, where many different agencies had to work together while fighting large-scale forest fires. The ICS command system has been improved and adopted by many state and local agencies, and has quickly become the command system standard for all emergency response organizations, especially when it becomes necessary to orchestrate the operations of several agencies that are working together.

The assimilation of ICS into police, fire, rescue, and EMS has offered a solution to the single biggest problem facing these services: how to coordinate and interface a variety of teams that are working on the same rescue effort. When each team works within its own set of operating procedures, standing orders, leadership protocols, terminology, and egos, it is often virtually impossible to effectively and safely coordinate a major rescue effort.

The ICS works well, and organizations such as the National Fire Academy and various state police, fire, rescue, and EMS offices nationwide have adopted and implemented this system at all levels of emergency response. ICS is now the standard for responding to any emergency situation, whether it is a single department answering a call about a minor motor vehicle crash or a complex search and rescue effort involving many agencies and rescue teams. ICS is the foundation of emergency response because it establishes a common language and command structure that allows everyone involved to anticipate how the effort is going to proceed, what their individual and team jobs are, who is in charge, and how to communicate with each other. As the ICS becomes widely adopted and used, it will help to establish a national standard on which national prehospital standards—including wilderness and extended care protocols—can be built.

Most states have produced a set of working protocols for providing prehospital emergency care. However, few have attempted to write protocols for providing emergency care in the wilderness or in the extended care environment. At the time of this writing, Maine, New Hampshire, and Alaska have tackled some of the issues associated with providing wilderness care. New Hampshire is the only state that has written a complete set of emergency medical protocols for the wilderness, extended, or long-term patient care environment.

Wilderness emergency medicine is a combination of emergency medical training and outdoor wilderness skills. Although it is essential to blend these elements, it is not necessarily natural or easy to do so. The art and science of prehospital emergency medicine began more than 40 years ago in the United States, and has evolved into a highly regimented and well-defined subspecialty of emergency medicine. Today there are highly trained First Responders, including EMTs and paramedics, as well as organized EMS systems. Each state has an independent EMS system and its own regulations; a truly national standard does not yet exist. The only national prehospital EMS standard that currently exists is the testing and evaluation and certification standards developed by the National Registry of EMTs.

A national standard for prehospital care has emerged in the EMS Agenda for the Future, which was first published in 1996. This is an effort to steer EMS across the United States toward a more consistent and cohesive set of skills, protocols, and scopes of practice. It is an excellent document that will hopefully lay a foundation for standards of care; however, at this time, it does not contain a wilderness or extended care section.

The National Registry of EMTs offers individual state EMS systems standardized written and practical examinations for First Responders, EMT-Basics, EMT-Intermediates, and EMT-Paramedics. This guarantees that, regardless of where someone was trained, he or she will be tested using the same standard. Because a central agency to monitor persons who have been trained in providing wilderness care does not exist, there is no registry of trained individuals. Organizations have been training people in wilderness medicine for the past 35 years. Currently, there are more than 100 different organizations, schools, and individuals who offer various forms of wilderness medical training. It is reasonable to estimate that more than 500,000 persons have some sort of certificate training in prehospital wilderness EMS.

Training programs that focus on rapid response, rapid intervention, and rapid transport to advanced care facilities exist nationwide. Prehospital personnel are prepared to work within the framework of the golden hour, when time is precious and critical actions save lives. This is a nationally accepted urban standard to which all EMS personnel are currently trained. Although this standard is appropriate for evaluating and training urban EMS personnel and response systems, it is often not adequate for rural, wilderness, mountain, or extended EMS personnel and response systems. In these situations, patient care is measured in hours and days rather than in minutes.

Traditional EMS recognizes rapid notification (i.e., the 9-1-1 system), dispatch, response, assessment, thorough prehospital care, transport, evaluation, and critical care in a hospital emergency department. Rapidity is the most critical factor that distinguishes urban emergency medical care from wilderness emergency medical care. However, time is not the only difference. Wilderness emergency medicine is governed by a complex set of medical skills and protocols, equipment requirements, and other specialized skills, including different attitudes or psychological requirements, each of which combines premeditated action with improvisation. A productive mental attitude comes largely from the individual’s training, expertise, and experience in the outdoors.

In mountain and wilderness outdoor activities, including mountain and wilderness rescue, haste truly makes waste, which may, in certain circumstances, cost lives. As a result, wilderness and mountain rescue teams must achieve a balance between the urgency of the situation and the necessity for adequate preparation. This is not an easy or natural blend of emotions and skills. On the one hand, trained EMS professionals are always primed and ready to go and feel comfortable moving rapidly, acting quickly, and thinking on their feet. On the other hand, skilled outdoors people are always eager and willing to travel into the backcountry, but they understand the necessity of thorough preparedness. This attitude ensures not only that each team is prepared but also that each individual is prepared. The team must be organized from a leadership perspective and know where it is headed, what injuries to anticipate, and how weather will affect the rescue. The team counts on each individual member being physically and mentally prepared. This difficult task requires recognition of the differences between short-term and long-term care during a rescue so that a safe and successful extended care rescue can be achieved. Box 36-2 outlines key skills that training needs to include.

BOX 36-2 Rescue Personnel and Training in the United States

1 Most technical rescue personnel in the United States are climbers or skiers who have added wilderness rescue techniques and medical training to their skills.