Wilderness Emergency Medical Services and Response Systems

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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.

Major disasters from 2000 to 2010:

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.

Shelter

When one goes into areas of destruction, it is not wise to count on housing being available.

Each person needs to carry his or her own shelter; in tropical climates, it is recommended to sleep under mosquito netting at night to avoid bug bites.

Check the weather conditions, and carry an appropriate sleeping bag or bedroll for the anticipated climate conditions. Remember, in the tropics, 15.5° C (60° F) is considered cold. A sleep sack may be sufficient, but a bedroll or a sleeping bag should still be packed.

Know how to and be prepared to bivouac, and be able to make an emergency shelter from a sheet of plastic or tarp.

Sustenance

Food and water: As with shelter, one cannot assume that there will be potable water or adequate food supplies. It is not reasonable to use up the resources of the people whom you have come to help.

Food: Carry enough food for the team (preferably food that does not require a lot of cooking or preparation time). It is best to carry food that can be eaten without cooking, such as protein bars, or food that cooks quickly in boiling water, such as macaroni and cheese, instant potatoes, rice, or premade meals.

Water: One must be prepared to disinfect all drinking water.

Staying Well

Immunizations/vaccinations: Go to the Centers for Disease Control and Prevention website (http://www.cdc.gov) and click on “Travelers’ Health” for information about travel vaccines and common diseases in the intended area of travel.

Team members should have received the usual childhood vaccinations plus hepatitis A and B, inactivated poliovirus vaccine, and typhoid immunization. Make sure that tetanus and diphtheria immunizations are up to date, and consider yellow fever and meningococcal vaccines.

Antimalarials: Malaria is treatable but not necessarily curable. Obtaining malaria prophylaxis is common sense.

Use insect repellents and insecticides. Do everything possible to avoid being bitten by insects. Use insect repellents, wear appropriate protective clothing, and sleep under mosquito netting.

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.

2 Currently, there are about 800,000 certified and licensed basic emergency medical technicians (EMT-Basics), EMT-Intermediates, and EMT-Paramedics in the United States.

3 A growing number of wilderness EMTs are trained in the skills of extended victim care in the backcountry environment. There are an increasing number of courses available for training.

4 Key skill elements of medical training for wilderness medical and rescue training include:

a Thorough victim assessment and monitoring skills

b Technical skills and the authority to perform:

(1) Airway management, including endotracheal intubation, laryngeal mask airway, Combitube, and other advanced airway skills

(2) Shock management, including include intravenous therapy

(3) Use of the pneumatic antishock garment (these garments are no longer recommended for treatment of shock, but they are still useful for management of a fractured pelvis or intra-abdominal bleeding)

(4) Oxygen administration and its limitations

(5) Use of appropriate medications:

(a) Epinephrine for anaphylactic reactions

(b) Antibiotics for major open or penetrating wounds, protruding intestines, and compound fractures

(d) Pain medications for musculoskeletal trauma

(e) Albuterol for bronchodilation

(f) Aspirin and nitroglycerin for chest pain

(6) Field rewarming techniques

(7) Field reduction of angulated fractures and dislocations

c Victim packaging and transportation skills

5 Key skill elements of technical training for rescue personnel in the United States include:

a Appropriate climbing skills for terrain (e.g., rock, ice, snow, glacier)

b Radio communication skills and protocols

c Helicopter and fixed-wing protocols

d Training for and expertise in the use of the Incident Command System in field protocols

Sequence of Events During Backcountry Rescue

The principles and standards of a wilderness or mountain rescue (i.e., extended care rescue)—including organization, specialized skills and knowledge, and essential components of the team—can best be illustrated by reviewing the sequence of events during a typical backcountry rescue in North America (Box 36-3).

Occurrence of the Critical Event

The critical event occurs when an individual who is participating in an activity away from immediate help is suddenly stricken by injury or illness. The key factor is immobilization. The fact that the injured or ill person cannot self-evacuate or move to seek shelter or stay warm results in the need for a rescue. After the victim or others in the party realize this, the need to seek help becomes obvious.

Making the Decision to Get Help

Before anyone leaves to seek assistance, the victim’s companions should perform a physical examination, record the victim’s vital signs, determine the level of consciousness, and provide appropriate emergency care, which may entail moving the victim into protective shelter. Victim information should be summarized in a note that accompanies the individuals who are going for help. A map depicting the victim’s exact location and a list of the other party members that notes their level of preparedness to endure the environmental conditions should be included. The individuals who are going for help should carry appropriate provisions. To prepare information adequately generally takes 30 minutes to 1 hour. However, thorough preparation rarely occurs. Often someone suddenly yells, “I’ll get help” and then disappears, running down the trail with sparse vital knowledge.

With improvements in and availability of communications technology, such as cellular phones and global positioning systems, backcountry adventurers may have more rapid access to the EMS system from the mountains. Whether this will increase the number of inappropriate callouts remains to be determined. Recent reports indicate that reliance on fallible technology may be responsible for outdoors people using poor judgment in terms of trip planning. Because they assume that help is just a phone call away, hikers are taking more risks.

Notifying the Emergency Medical System

Eventually the messenger notifies someone in authority that an emergency has occurred and that help is needed. Usually the request is made to a central 9-1-1 system. If no central service is available, a local dispatch agency is notified. The agency contacts the closest emergency medical service, which can be a rescue squad, ambulance corps, fire department, or first response team.

Activating the Emergency Medical System

Notification of an emergency usually occurs by means of pagers worn by individual members. An alert tone is followed by an oral message that describes the emergency, its location, and the type of response required.

At this point, a wide variety of events can occur that involve agencies both within and outside of the EMS system. Even in areas of the United States with well-organized extended care rescue teams, the team may be notified last. Ideally, the team should be notified immediately, but all too often this is not the case. Instead, local agency responders are notified and rush around trying to determine how quickly they can reach the victim.

Notifying and Mobilizing the Extended Rescue Team

The first step is to notify team members. In many parts of the United States, organized and coordinated extended rescue teams do not exist, so a “team” is created out of a group of relatively untrained volunteers who are willing to hike in and assist. The task of further organizing and coordinating the rescue effort generally falls on the shoulders of a local rescue squad, fire service, or police department, which may or may not be willing and prepared to manage and execute an extended or technical rescue.

For parts of the United States in which backcountry use is common and backcountry accidents occur regularly, extended care rescue teams have generally evolved from local EMS squads with skilled outdoor enthusiasts. Some teams that offer local search and rescue capabilities may be coordinated locally (e.g., the Appalachian Mountain Club, Stonehearth Open Learning Opportunities, Mountain Rescue Service in the White Mountains of New Hampshire); other teams may be part of a nationwide system that responds to incidents throughout the country and that is coordinated on a regional or national level (e.g., the National Cave Rescue Commission). The future may involve the Federal Emergency Management Agency or even the Department of Homeland Security. Coordination of extended care rescue teams may also come under the jurisdiction of a law enforcement body, such as state conservation officers (e.g., New Hampshire Fish and Game), a sheriff’s department (e.g., the Los Angeles County Sheriff in California), or a statewide coordinating system (e.g., the Pennsylvania Search and Rescue Council). Organized teams can be quite sophisticated with regard to their dispatching function so that all members can be notified simultaneously, or they may use a more “low-tech” telephone tree to call out members.

Assembling and Organizing the Rescue Team

After members are notified, they assemble at a common location (i.e., a rescue station) to organize the rescue effort. The first task is to define the type of rescue and to establish equipment needs. Estimating the time that it will take to effect the rescue and assessing the need for other agency involvement and assistance are also primary tasks. The questions to be answered and variables to be considered may include:

1 Time of day: Will this be a night rescue?

2 Weather: What are the current weather conditions at the rescue location? What is the forecast?

3 When did the accident occur?

4 What are the supposed injuries?

5 How many victims are there?

6 How many people are in the party?

7 How well prepared are they?

8 Does anyone in the party have medical expertise?

9 Do we know the exact location, or is this a search and rescue?

10 Is a “hasty team” needed? Has it left for the scene yet?

11 Is each of the team members prepared? Does each have personal equipment, a bivouac kit, a headlamp, food, and water?

12 Is each member trained and skilled in this particular type of rescue?

13 Who is on the medical team?

14 Who is on the evacuation team?

15 Is the team equipment organized and divided up?

16 How urgent is the situation? Is a helicopter required? If so, is one available?

17 Are the weather conditions appropriate for an air rescue?

18 Will multiple agencies be involved? If so, are radio frequencies coordinated?

After the team is assembled and all pertinent issues have been addressed satisfactorily, then the team is transported to the trailhead (i.e., the launch point) to begin the search.

Commonly a hasty team will start out ahead of the main team. When the hasty team has enough information to locate the victim, team members travel as lightly as possible, with only enough gear to ensure their own safety and to equip them to manage the victim’s primary injuries. The goal is to reach the victim as quickly as is reasonably possible and to deliver primary care; the hasty team will then apprise the rest of the team regarding the victim’s condition, equipment needs, and environmental concerns.

Locating the Victim

How long it takes to locate the victim varies tremendously, depending on distance, terrain, weather conditions, mode of transportation, and whether the victim’s exact location is known. A general rule of thumb for a team that is responding on foot is that it will take 1 hour for each mile traveled through the backcountry. If a search is involved, all bets are off. A search and rescue effort can involve many agencies, individuals, and days (see Chapter 37).

Providing Appropriate Extended Emergency Care

After the victim has been located, appropriate medical care can be provided. The rescue team should ensure its own safety; wet clothes should be replaced with warm, dry clothing, and members should check for emerging problems within their group. While the medical team cares for the victim, the evacuation team secures shelter, prepares warm drinks, establishes and maintains communications, and plans and organizes the evacuation.

Companions of the victim may have been affected by the environment while waiting for the rescue team to arrive and may require assistance. They may need to be assessed and treated for hypothermia, frostbite, heatstroke, heat exhaustion, or dehydration.

Regardless of what transpired before the medical team arrived, a complete victim assessment is essential. Do not assume that all of the injuries have been found or that all medical conditions have been managed properly (Box 36-4).

BOX 36-4 Victim Assessment

Secondary Survey: What Is Wrong and How Serious Is It?

Vital Signs: Indicate the Condition of the Victim

Respiratory rate and effort

Pulse rate and character

Blood pressure: systolic/diastolic

Level of consciousness: AVPU (awake, verbal, painful, unconscious) or Glasgow Coma Scale

Tissue perfusion: skin color, temperature, and moisture

Capillary refill (<2 sec)

Victim examination: head-to-toe examination to locate injuries

AMPLE History

Allergies

Medicines

Past medical history

Last in and out: food/drink and voiding

Events leading up

SOAP Note: To Record and Organize Victim Data

Subjective: age, gender, mechanism of injury, and chief complaint

Objective: vital signs, victim examination, and AMPLE history

Assessment: problem list

Plan: plan for each problem

“Re-SOAPing” the Patient

Subjective: Is the victim comfortable, too hot, too cold, hungry, thirsty, or in need of urination or defecation?

Objective:

Vital signs: are they stable? Record these.

Victim examination: recheck all dressings, bandages, and splints. Are they still controlling bleeding? Are they too tight or too loose? (Swelling limbs can cause bandages or splints to impede circulation, thereby resulting in ischemic injuries or worsening frostbite or snakebite.)

Assessment: Has the initial assessment changed?

Plan: Is the rate of evacuation still the same?

In the extended care environment, the victim must be monitored for changing conditions that indicate an underlying problem. Awareness of environmental emergencies is particularly important, with constant care needed to prevent hypothermia, frostbite, heatstroke, heat exhaustion, and dehydration. To do this, it is necessary to monitor the victim and write a new SOAP note or to “re-SOAP” the patient every 15 minutes.

Evacuating the Victim to the Appropriate Facility

While providing emergency care, part of the team is designated as the evacuation team. This group has evaluated the various options for evacuation. To properly evaluate the situation, the first information that the group needs is provided by the medical team leader, who needs to know the status of the victim to establish the pace. If the victim’s condition is stable, time is less important; if the victim’s condition is critical, time is also critical.

The evacuation team must explore different options. If speed is a consideration, weather conditions are reviewed, and availability of a helicopter-assisted rescue is determined. If a helicopter is not an option, the fastest route out is established. If time or speed is not critical, the safest means of evacuation that is easiest on the victim and rescuers is defined. A general rule for duration of an evacuation is that it will take 1 to 2 hours for every 1 mile to be covered, which requires six well-rested litter bearers for every 1 mile. Thus, a 4-mile carryout will require a 24-member litter team and can take 4 to 8 hours to complete. Eventually, the team reaches a trailhead, and the victim is transferred to an ambulance for transport to a hospital emergency facility.

Returning to Base

The team returns to base to reorganize equipment in preparation for the next extended rescue and to debrief. Because people are exhausted and hungry, the debriefing session is often canceled. However, establishing a mechanism to debrief after the rescue effort is imperative so that team members can learn from the shared experience, discuss victim care, and work through problems. Whenever several different emergency organizations with disparate rescue and emergency personnel combine to perform a complex rescue, there may be tension, conflicting egos, and concerns about the medical care provided or the evacuation plan used. These problems deserve to be discussed and managed in real time as expediently as possible so that teams will cooperate successfully in the future, improve their performance, and provide the best possible patient care during the next rescue. This process minimizes the burnout syndrome that can occur with volunteer teams.

Team Organization and Function

Organization of an extended care rescue team is based on both training of individuals and type of rescue. The structures of teams can vary from loosely knit groups of friends with no leadership hierarchy to paramilitary organizations with rigid leadership roles.

Team members require personal knowledge, experience, and expertise with regard to the particular aspect of extended care and rescue in which they will participate as well as knowledge and expertise concerning the principles of extended emergency care, extended rescue techniques, and technical rescue skills.

Personal Knowledge, Experience, and Expertise

Individuals who want to be part of an extended rescue team need to acquire outdoor skills before they become part of a rescue team. Every member must have extensive knowledge of likely environmental emergencies, including hypothermia, frostbite, heat syndromes, snakebite, dehydration, and lightning strike. Each individual must also understand the general principles of weather behavior. Rescuers need to be comfortable with route finding, maps and compasses, personal preparedness, and bivouac and survival skills. The knowledge, skills, and equipment that a skilled outdoors person should possess are often referred to as “the 10 essentials” (Boxes 36-5 and 36-6). The same skills, knowledge, and equipment that are commonly used by the outdoor enthusiast are essential on a mountain rescue.

BOX 36-5 The 10 Essentials

1 Attitude

Positive belief that you can make things better; the will to survive

2 Fuel to burn: food

High-carbohydrate foods that require no preparation

High-carbohydrate foods that can be made into beverages

3 Quench your thirst: water with appropriate electrolyte supplementation

A minimum of 2 L per day to survive and 4 L per day to thrive

Up to 3 L per hour if active

Ability to make more disinfected water and to supply electrolytes

4 Stay warm and dry: clothing

Warm clothing that retains heat, even when wet

Waterproof raingear, both top and bottom

5 Get dry: shelter

Ability to improvise shelter or to bivouac

A bivouac kit (see Box 36-6)

6 Get warm: fire

Ability to heat water (e.g., stove, candle, fire)

Ability to build a fire (e.g., waterproof matches, tinder)

Ability to make kindling or tinder (e.g., folding knife)

7 Know where you are going: navigation

Map, compass skills, and route-finding skills

Ability to move about at night (e.g., headlamp)

8 Know the environment: weather

Basic understanding of weather patterns

Knowledge of how to react in severe weather (e.g., lightning)

9 Getting help: signaling

Whistle (preferably plastic)

10 Providing help: first-aid kit

Basic small personal trauma kit

Extended Rescue Techniques and Skills

Specific skills and techniques that are applicable to a particular situation include those of search and rescue, vertical and technical rock climbing, and white-water navigation. Snow or winter camping or avalanche rescue may be required, depending on the environment. Extended rescue teams should require their members to have, at a minimum, the working knowledge and equipment described in Box 36-7.

BOX 36-7 Knowledge, Skills, and Equipment Needed by Extended Rescue Teams

Mountaineering Skills

Understanding fabrics, clothing systems, and their seasonal variations (see Chapter 70)

Fabrics and fibers

Layering techniques

Vapor barrier systems

Waterproof fabrics and raingear systems

Footgear

Personal protection equipment

Helmets

Harnesses

Gloves

Goggles or sunglasses

Hearing protection

Backcountry equipment

Internal or external frame packs and soft packs

Shelter (natural and human made)

Specialty equipment: snow shoes, crampons, ice axes, stoves, and skis

Backcountry travel

Route finding

Map and compass: map reading, dead reckoning, and types of maps; compass reading, bearings, magnetic versus true bearing, triangulation, and global positioning systems

Survival skills: the 10 essentials

Shelter and warmth; emergency bivouac kits

Food and water

Understanding how backcountry travel and rescue vary with seasons

Understanding how backcountry travel and rescue vary with different environments:

Alpine

Desert

Forest

Water (e.g., swamp, river, lake, ocean)

Tropics

High altitude

Low-impact camping and rescue work

Basics of weather and weather forecasting

Principles of barometric pressure

Clouds and their significance in weather forecasting

Prevailing weather patterns in the rescue area

Personal fitness

Physical conditioning

Nutrition and hydration requirements for different activities

Mountain and Extended Emergency Medical Skills

Emergency medical training should be at a minimal level of first responder or higher (i.e., emergency medical technician, paramedic, registered nurse, nurse practitioner, physician’s assistant, or physician). Regardless of the level, training must include specific information about wilderness and extended emergency care procedures.

Topics of Extended Care Training and Principles Should Include the Following:

Patient assessment system

Cardiopulmonary resuscitation

Airway management, including endotracheal intubation and needle decompression for tension pneumothorax

Shock and control of bleeding, including intravenous therapy for fluid resuscitation

Long-term wound care and prevention of infection

Musculoskeletal injury management, including specific information about diagnosis and long-term management of:

Sprains and strains

Fractures, including how to reduce or realign angulated fractures

Diagnosis and reduction of dislocations

Management of compound fractures

Management of chest injuries, including decompression of a tension pneumothorax using needle thoracostomy

Spinal cord injury diagnosis and management

Head injury, including recognition and management of increasing intracranial pressure

Management of environmental emergencies

Hypothermia and frostbite, including use of intravenous fluids

Heatstroke and heat exhaustion, including use of intravenous fluids

Dehydration and nutrition, both acute and during evacuation

Lightning injuries

Animal attacks, insect bites, and reptile and marine envenomations, including anaphylactic reactions and use of epinephrine and antihistamines

Contact dermatitis, such as that caused by poison ivy, poison oak, and poison sumac

Sunburn and snowblindness

High-altitude injuries, including acute mountain sickness, pulmonary edema, and cerebral edema

Drowning

Diagnosis and management of acute medical emergencies:

Chest pain (e.g., myocardial infarction, angina, costochondritis)

Shortness of breath (e.g., asthma, anaphylaxis, pneumothorax)

Seizures and cerebrovascular accidents

Acute abdomen (e.g., peritonitis, constipation, diarrhea)

Pyelonephritis

Septic shock

Victim lifting and handling techniques

Improvising techniques (i.e., “emergency medicine barehanded”; see Chapter 19)

Training involving the Incident Command System

Blood-borne pathogens and infectious disease prevention

Monitoring of bodily functions (i.e., hunger, thirst, and bodily waste management)

General understanding and appreciation for the difference between urban (short-term) and wilderness (long-term) emergency care

Mountain and Extended Rescue Skills

Understanding equipment that is used in wilderness search and rescue operations, including its maintenance and care

Ropes, slings, carabiners, harnesses, and helmets

Litters, litter harnesses, and haul systems

Litter patient packaging equipment

Basic radio communications

Care and maintenance of communications equipment

Procedures and protocols

Basic helicopter operations and procedures

Approaching a helicopter

Safety considerations

Landing zones

Haul techniques

Interagency relations

Basic understanding of search procedures

Basic understanding of rescue procedures

Basic understanding of the Incident Command System and its use in search and rescue management

How to care for and handle ropes

Rappelling, belaying, and braking techniques

Specific rescue training

Water search

White-water safety and rescue

Avalanche safety and rescue

Technical or vertical (rock) safety and rescue

Cave safety and rescue

Leadership

Leadership and “followship” training

Ability to use the Incident Command System

Knowledge is acquired over time. Specific medical, rescue, and technical skills are obtained and retained through courses, continuous training, and refresher programs. The Appendix at the conclusion of this chapter provides a list of schools, institutes, and organizations that are involved in wilderness medicine and mountaineering research, standards development, and training programs.

Wilderness and Mountain Rescue Team Organization

The organization of wilderness and mountain rescue teams is the area in which there exists the greatest diversity, because no universal standard has been established. Teams vary from local mountain rescue teams with extreme skills and qualifications for providing mountain rescue care to informal collections of friends without leadership. Other more professional teams are operated under the jurisdiction of law-enforcement agencies and involve paramilitary hierarchy and leadership. This diversity is particularly noticeable in the United States, because most teams are composed of volunteers who are not reimbursed for their rescue efforts.

In Europe, mountain rescue teams are professional and employ full-time personnel. They charge for rescue efforts, with the fees providing money for personnel, equipment, helicopters, technical gear, and ongoing training. As with any profession, standards have evolved. As a result, there are more standards in Europe than in the United States. Still, there is variation across Europe from country to country, especially with regard to leadership and organization.

In many parts of the world, especially remote and wild areas, organized and available rescue teams do not exist. If someone is in need of help, the expedition team necessarily becomes the rescue team.

Training of Wilderness Emergency Medical Technicians

The best way to develop an appreciation for the vast difference between what is required of the traditional (urban) EMT and what is required of the extended care or wilderness EMT (WEMT) is to compare their respective course curricula.

The Department of Transportation (DOT) is responsible for developing and updating the EMT-Basic, EMT-Intermediate, and EMT-Paramedic curricula in the United States. These curricula are considered the minimum national standards for EMT students to qualify for the National Registry or for an individual state practical and written examination. Passage of such an examination enables a student to become certified as a National Registry or state EMT-Basic, EMT-Intermediate, or EMT-Paramedic.

A national standard for WEMT curricula does not exist. Despite lack of a DOT-like standard, there are several similar curricula for wilderness emergency care at the EMT level. On the basis of recommendations from the Wilderness Medical Society and other groups that address wilderness prehospital emergency medicine, these curricula adhere to the same principles of long-term patient care, so can be used for comparison with the standard DOT curriculum.

A WEMT course typically contains all of the material in the DOT EMT course curriculum plus the things that are necessary for acquiring the attendant skills for long-term wilderness emergency care. Typical EMT courses require about 100 hours, with an additional 10 hours of emergency department observation time. The WEMT module carries an additional 48 to 80 hours of training. There are EMT wilderness modules available that are postgraduate courses that have been designed to train EMTs in long-term patient care.

A typical WEMT course outline appears in Box 36-8. The topics in boldface are unique to WEMT programs; the other topics are required in a DOT EMT course. Hours per topic illustrate the time required for both EMT and WEMT training. This outline is arranged in the current DOT EMT recommended format, with the WEMT material added on a per-topic basis; topics are not necessarily listed in the order that they would be taught in a particular course. An explanation of the extended emergency medical care material that must be learned by WEMTs follows.

BOX 36-8 Emergency Medical Technician and Wilderness Emergency Medical Technician Course Curricula and Hours Per Topic

1 Introduction to emergency care

Wilderness versus urban emergency care (1 hr)

Backcountry rescue gear inspection (1 hr)

Medical-legal issues (1 hr)

Blood-borne pathogens

Overview of human systems—anatomy and physiology (2 hr)

The human animal—our natural physiologic limits (2 hr)

2 Patient assessment systems

Primary survey—airway, breathing, and circulation (1 hr)

Secondary survey (1 hr)

Patient assessment practice (2 hr)