Safety

Shelter

Sustenance

Sanitation

Staying Well

Stress and Sanity

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

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).

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.

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).