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The development and current status of wilderness prehospital emergency care in the United States
Journal of Wilderness Medicine 1, 93-102 (1990)
The development and current status of wilderness prehospital emergency care in the United States WARREN D. BOWMAN Department of Internal Medicine, Billings Clinic, Billings, MT, USA
Care of the ill and injured in the United States, as in most Western countries, has evolved along two separate 'tracks.' The first, which can be called the 'professional medical track,' includes physicians, nurses, and related professionals who undergo rigorous and lengthy training, testing, and certification in order to be employed full time in caring for patients. These professionals are regulated by their professional organizations and by government licensing agencies, but in general are allowed to provide any type of medical service for which they have been trained. 'First track' replenishment and maintenance is the primary job of the many medical and nursing schools, professional societies, and research institutions with a combined annual budget of billions of dollars. The second, or 'prehospital emergency care' track, is occupied by all other emergency care workers, among them many whose primary occupation is not patient care. These persons care for simple injuries and illnesses not requiring the services of an advanced health care professional, provide initial care to the seriously injured and ill, and offer transport to definitive medical assistance. The second track was originally informal, but since the appearance of the Emergency Medical Services (EMS) system (described below) it has developed its own bureaucracy, regulatory structure, and organized system for training and continuing education. There is some overlap between the first and second tracks; for example, full time paramedics, although concerned mainly with prehospital care, are occasionally employed as assistants in hospital emergency departments or as flight (helicopter) attendants. In the US, the initial formal first aid teaching program was developed by the American Red Cross (ARC) in 1909. The original ARC first aid textbook, Red Cross First Aid, by Colonel Charles Lynch, was published in 1910, followed by First aid to the injured in 1911. The familiar 'green book' - the American Red Cross-first aid textbook - was published in 1933. Early first aid emphasis was on demonstrations and industrial first aid programs. With initiation of the lay instructor program in 1926, growth and expansion of first aid in the US was assured [1]. Millions of Americans have been trained in first aid by the ARC; for many years, the ARC first aid courses were the main source of training as well as the standard for prehospital care. In the early 1970s, the ARC expanded its first aid training into two levels: Standard First Aid for the average non-professional [2] and Advanced First Aid and Emergency Care for non-professionals who use first aid occupationally or in volunteer activities [3]. The latter group includes law officers, forest rangers, ski patrollers, rural ambulance attendants, and so forth. The armed forces also had a need for well-trained corpsmen to handle large numbers of field casualties. The corpsmen were trained primarily in the management of battle injuries; their training was more advanced than that for civilian first aiders and included 0953-9859/90 $03.00
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the use of intravenous infusions of plasma products and crystalloids, and such drugs as morphine. Starting in the late 1930s, medical advances gradually brought most infectious diseases under control, allowing death and disability due to injury to assume relatively more importance. By the mid-1960s, injuries had become the leading cause of death and disability in children and young adults. In 1966, the National Research Council produced a landmark report, Accidental death and disability: the neglected disease of modern society [4] which called attention to the poor quality of prehospital care. This report led to the development of the EMS system, a nation-wide and interdependent network of hospital emergency departments and emergency vehicles manned by physicians, nurses, and a new category of medical paraprofessional: the emergency medical technician (EMT). As a guide for EMT training, the National Traffic Safety Administration of the Department of Transportation (DOT) developed the National EMS Standard Curriculum (most recently revised in 1984) [5], on which have been based the courses in emergency medical techniques taught in every state. Although there are national standards and a national registry, EMT training, certification and recertification are the prerogatives of the individual states. There is considerable variation among states as to nomenclature, licensing levels, and techniques taught; in many regions, the variations depend upon the personal biases of the control physicians. EMTs were taught to reach patients promptly and to provide state of the art emergency care and transportation to the appropriate medical facility. The first EMTs were called EMT-B ('basic'), or EMT-A ('ambulance-based'). Their training was similar to, although more intense than, advanced ARC training, with greater emphasis on anatomy, physiology, assessment, basic life support, management of injuries due to trauma, rescue from crashed vehicles and ambulance handling. All EMTs in this category were originally limited to the use of suctioning and simple oropharyngeal and nasopharyngeal airways. Currently, most states allow use of the esophageal obturator and similar airways and the pneumatic anti-shock garment (PSAG). In some states, additional training modules are available: the defibrillator module (EMT-D), which teaches the use of manual, automatic, and/ or semi-automatic defibrillators, and the epinephrine module (EMT-E), which teaches injection of epinephrine for anaphylactic shock. The American Academy of Orthopedic Surgeons (AAOS) and the American College of Surgeons (ACS) have been involved in EMS from the first, as has the American College of Emergency Physicians (ACEP). The AADS published the first edition of Emergency care and transportation of the sick and injured in 1971; the book is currently in its fourth edition [6]. This and similar books [7-10] have been produced as textbooks for EMT programs. In the early 1980s, the First Responder program was developed to train law enforcement officers and others who did not need full EMT training [11]. A need for more advanced skills training in prehospital care soon arose. This led to several advanced categories of Emergency Medical Technician, notably the EMTIntermediate (EMT-I)and the Paramedic (EMT-P). The EMT-I possesses EMT-B skills, advanced skills in assessment, and an understanding of hypoxia and shock, and is trained in the use of esophageal obturator and similar airways, the PSAG, and the administration and maintenance of intravenous infusions. In some states, the EMT-I is also trained in endotracheal intubation. The EMT-P is trained in all EMT-Band EMT-I skills plus endotracheal intubation, cardiac defibrillation, needle cricothyroidotomy, chest tube
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placement, collection of blood samples, and the use of many ALS drugs. In some states, early field reduction of bony dislocations is allowed, especially recurrent shoulder dislocations. All EMT categories require at least nominal physician supervision. In reponse to its unique needs, the National Park Service established the Park Medic program in 1983. This training program, developed by Good Samaritan Hospital in Phoenix, Arizona, trained the Park Ranger to a level midway between the EMT-I and EMT-P. Park Medics are allowed to use ALS drugs, initiate intravenous infusions, place endotracheal tubes, and perform needle thoracotomies and needle cricothyroidotomies, but not cardiac defibrillation [12]. The EMS system was designed to meet the greatest perceived needs: urban and rural accidents accessible by road or helicopter, where the patient could be transferred to a medical facility within a short time. Because of the short transport times and the use of motorized vehicles, definitive care, such as washing of wounds, insertion of urinary catheters, or routine reduction of fractures was not deemed necessary. Physician control by telephone or radio was possible (when not possible, field protocols were available), and there were few limits upon the weight or amount of equipment which could be brought to the victims. The EMS system produced a dramatic improvement in urban and highway-related prehospital care. The National Research Council continues to note that each year, one in three Americans is injured and more than 140000 die from trauma [13]. With the explosive increase in outdoor recreational activity after World War II, it became apparent that there was need for modification of the second track of patient care to form yet a third track. People were participating in activities such as mountain climbing, wilderness skiing, caving, backpacking, kayaking, and rafting, which took them into wilderness areas many miles from the roadhead. Recreational parties needed selfhelp training, as did wilderness search and rescue groups. The concept of 'second aid,' 'back-country first aid,' or 'wilderness EMT' (referred to hereinafter as 'wilderness prehospital emergency care' or 'WPHEC') gradually emerged. This acknowledged the alterations in standard prehospital emergency care protocols required when orthodox care with rapid hospital interfacing was not available because of distance, difficult transportation or inadequate communication. The features of the third track appeared slowly, beginning with inclusion of chapters on first aid or 'second aid' in such books as the Sierra Club's Manual of ski mountaineering, first published in 1942 [14]. This manual advised the reader to become well grounded in ARC first aid and predicted that procedures in the text which 'go a bit beyond first aid' would be within the ability of the well-trained ski mountaineer. It departed from orthodox first aid principles in medical areas appropriate to the wilderness environment. It advised cleansing of wounds and open fractures, rapid thawing of deep frostbite in a warm water bath (although a temperature of 130°F was recommended), the use of prescription pain medications and antibiotics, and application of eye ointment containing local anesthetic for snow blindness. Injuries peculiar to the winter wilderness not discussed in orthodox first aid textbooks were covered in detail. WPHEC is based on the same principles of anatomy, physiology and pathophysiology as is orthodox emergency care. This is essential in a wilderness environment where the emphasis is not on 'what to do until the doctor comes,' but rather on what to do 'for wilderness situations to which the doctor is not comip.g' [15]. By informal agreement among physicians experienced in wilderness medicine, specific ways in which WPHEC
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differs from urban emergency care include [16, 17]: (1) It is practiced in the remote, outdoor environment, where extreme conditions of heat, cold, altitude, and storm are common and difficulties in obtaining food, water, and shelter are significant. Physical hazards, such as snow avalanches, rockfalls, flash floods, wildfires, and lightning may be present. Hazardous microorganisms, insects, marine animals, land animals, and plants may endanger the health of wilderness travellers, and pre-existing medical conditions may recur or flare at awkward times. (2) Definitive medical care may be hours or days away because of distance, adverse environmental conditions, lack of transportation, or difficulties in communication. Urban protocols that assume rapid transportation to a medical facility may be irrelevant. (3) Illnesses rarely seen in the urban environment, such as acute mountain sickness and deep frostbite, may be encountered. (4) The EMS requirement that there be routine physician control by telephone or radio may be unrealistic or impractical. More reliance on field protocols is necessary. (5) It may be desirable to train intelligent and motivated non-professionals to carry out advanced procedures for common injuries and illnesses, in which a treatment delay of more than a few hours may cause adverse effects which outweigh the possible risks of the procedures. (6) There is a need for rescuers to learn basic nursing and subsistence care for an injured or ill person in order to sustain the patient for days before medical assistance can be reached. (7) Certain standard urban treatment protocols, such as that for cardiac arrest, may be unrealistic or even hazardous to rescuers. (8) The amount of first aid equipment that can be carried by the average wilderness recreational group, or even the best-equipped wilderness search and rescue group with helicopter support, is limited; improvization will be necessary. There are many similarities between WPHEC and the care available in isolated areas, such as small Alaskan villages accessible only by boat or air. There is also analogy to disaster emergency care, where medical supplies, food, water, and medical facilities may be destroyed, the number of casualties overwhelming, triage essential, and urban protocols which call for maximum resuscitative efforts and rapid transportation to a medical facility impossible to follow. In the late 1960s, the rise in popularity of expeditionary mountaineering and small boat sailing to remote areas was accompanied by the appearance of a number of wilderness medicine and first aid textbooks. These were comprehensive, medically sophisticated, well written, and designed primarily for members of recreational groups, rather than for rescue groups. The advanced techniques that were recommended tended to intimidate lay readers who had been reared on traditional first aid and prehospital care. [18-24] More recent books published during the 1980s include comprehensive discussions of all types of wilderness emergencies, from either the first aid or the professional medical standpoint [25-29]. During the 1970s, an increasing interest in wilderness medicine stimulated development of a number of symposia, the prototype of which was the 1975 Mountain Medicine Symposium in Yosemite National Park, organized by Dr Charles Houston and sponsored by the Yosemite Institute [17]. Since that time, there have been one to several major similar symposia each year, held in different parts of the US and Canada, and sponsored by a variety of organizations.
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During the 1970s and 1980s, a number of courses in WPHEC were developed. These were of two types: (a) Programs which stayed within the EMS system in order to take advantage of EMS licensing. These were either 'complete' courses through which the student was eligible to take the national or state EMT licensing exams, or 'wilderness modules' requiring prior EMT training or the equivalent. Physician supervision and control was required for 'Wilderness EMTs (WEMTs).' These courses tended to be designed for recreational trip leaders and members of rescue groups. (b) Programs covering many or all of the same topics, but staying outside the EMS system. These tended to be designed for recreational group members. Physician participation was encouraged, but physician control was not required. Various strategies have been employed to avoid the hazards of violating state medical practice legislation ('practicing medicine without a license'), federal narcotics laws, and various liability statutes, since many such advanced procedures, no matter how necessary in the wilderness environment, are generally illegal for anyone except licensed physicians, or for nurses, physician assistants, and paramedics under physician supervision. In the US, the medical liability and illicit drug crises have made improvements in WPHEC more difficult to obtain than they would otherwise have been. For example, this affects the proposition that bony realignment can logically be extended to cover the reduction of dislocations, and prescription pain medications legally prescribed by a physician for use by a member of a rescue group. [30,31] Other efforts have included attempts to change standards of care by working with state EMS agencies to develop new consensus standards for wilderness care through national organizations such as the American Society for Testing and Materials (ASTM), the National Association for Search and Rescue (NASAR), and the Wilderness Medical Society. The establishment in 1987 of a Wilderness Task Group of the EMS Committee by ASTM looked promising at first, but recent bylaw changes within ASTM will apparently preclude the development of any clinical standards or guidelines [32]. There exists no standard WPHEC curriculum, but a review of existing courses [3344] discloses many common topics: (1) Orthodox emergency care and emergency medical techniques. If not included, EMT, advanced ARC first aid training, or equivalent training, such as the National Ski Patrol's Winter Emergency Care course, may be a pre-requisite. (2) Extended care of the victim, including stabilization of body temperature, provision for food and water, elimination of body wastes, psychological support, etc. (3) Wilderness rescue, 'packaging', and transport. (4) Environmental illnesses and injuries, such as frostbite, hypothermia, high altitude illness, land and marine animal bites, insect stings, etc. (5) Wilderness survival techniques. (6) Assessment and treatment of medical illnesses. (7) Use of prescription and non-prescription drugs, including: (a) Antibiotics. (b) Pain medications. (c) Gastrointestinal drugs. (d) Drugs for high altitude illness. (8) Improvization of first aid equipment and transportation devices. (9) Wound management.
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(10) Re-alignment of displaced fractures and dislocations. (11) Modifications of standard, urban CPR protocols. (12) Modifications in standard protocols as appropriate for the wilderness environment. (13) Use of advanced techniques, such as the insertion of thoracostomy and endotracheal tubes, cricothyroidotomy, intravenous fluids, bladder catheterization, etc. (14) Expedition medicine education, including tropical and other exotic diseases, vaccinations, and sanitation, including the provision of disinfected water and properlyprepared food. (15) Suggestions for contents of first aid kits. At the present time, the major training courses in WPHEC within the EMS system are: (1) National Association for Search and Rescue Medical Programs [31,32]. These include a 56-hour course in Wilderness Emergency Medical Technique (WEMT) and a 64-hour Wilderness First Responder course, provided for NASAR under contract by Wilderness Medical Associates (WMA) of Bryant Pond, Maine. Prior certification as an EMT or equivalent is required for the WEMT course, which consists of four modules: (a) General medicine: patient assessment, review of the mechanisms of illness and injury, modified treatment procedures for the wilderness context, common major and minor wilderness medical problems. (b) Trauma: modified techniques for wound management and treatment of fractures, dislocations, and spine injuries. (c) Environmental medicine: Illnesses caused by cold, heat, and high altitude; near drowning, diving medicine, lightning injuries, sun exposure; wilderness poisons, bites and stings. (d) Wilderness Rescue: The Incident Command System, personal preparedness, map and compass, litters and evacuation, radios. WMA also offers a 32-hour Wilderness First Aid course for fishermen, hikers, climbers, and other lay persons, and a 12-16 hour Wilderness Medicine Workshop, tailored for specific needs. (2) Stonehearth Open Learning Opportunities (SOLO) of Conway, NH. SOLO offers a 60 hour Wilderness Module for the EMT or equivalent, a 180 hour WEMT course which includes basic EMT training plus the Wilderness Module, an 80 hour Wilderness First Responder Course, and two 16 hour courses, one on Backcountry Medicine for non-professionals and one on Wilderness Trauma Life Support for medical professionals and other experienced persons. The WEMT course includes basic EMT skills as appropriate to remote environments, as well as long term management, environmental emergencies, common wilderness problems, backcountry extrication, and transport and rescue techniques [34]. (3) The Appalachian Search and Rescue Conference's Wilderness Emergency Medicine program offered in cooperation with the Center for Emergency Medicine of Western Pennsylvania. This is a 50 hour Wilderness EMT course (EMT certification and search-and-rescue training are prerequisites) that includes a discussion of the wilderness environment, general medicine, patient assessment, environmental emergencies, wilderness medical problems, wilderness trauma and surgical problems, pharmacology, and packaging, evacuation and transport [35]. Courses in WPHEC are being taught in several colleges, notably the University of
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Alaska, some of which are outside the EMS system. The National Outdoor Leadership School (NOLS) teaches a 140 hour WEMT course and an 80 hour Wilderness First Responder course to its staff members [36]. Colorado Outward Bound teaches a 56 hour Wilderness Emergency Medical Care course and a 140 hour Wilderness EMT course to its staff members and the public [37]. The American Alpine Institute of Bellingham, Washington, teaches a 35 hour course for members of wilderness recreation groups emphasizing the hazards of rugged environments. This course is suitable for all medical skill levels, from lay person to MD, with advanced ARC First Aid training a prerequisite [38]. The Mountain Medicine Institute of Oakland, California, offers a series of mountain medicine lectures on environmental hazards, fitness, injury and illness prevention, and backcountry illnesses and injuries [39]. Courses in Wilderness First Aid sponsored by the American Red Cross are taught in a number of ARC chapters, including Whatcom County, Washington, and the cities of Oakland, Palo Alto and Van Nuys, California. These courses lead to certification in either ARC Standard or Advanced First Aid and include wilderness modules [39]. Large regional climbing organizations, such as the Mountaineers and the Mazamas, include courses in Mountaineering First Aid as part of their curricula. The Mazamas offer a 30 hour course designed mainly for climbing trip leaders based on ARC Standard First Aid, and a Progression course based on ARC Advanced First Aid [39]. The Mountaineers currently offer two courses to members and the general public: (a) Mountaineering Oriented First Aid (MOFA), a 27 hour course based on the ARC Standard First Aid Course that includes CPR, splinting and bandaging, and a more comprehensive secondary survey, and (b) Advanced Progression Mountaineering Oriented First Aid, a 33-36 hour course based on the ARC Advanced First Aid Course that includes extrication, childbirth, water hazards, helmet removal, and traction splinting [40]. Every 1-2 years there are short courses in mountain medicine offered by institutions of higher education such as the University of Washington (Seattle), the University of California-Davis and the University of California, San Diego [41], and organizations such as the Wilderness Medical Society [42] and Rainier Mountaineering [43]. These courses are usually offered jointly to physicians, nurses, paramedical personnel, and nonprofessionals. The Wilderness Medical Society includes a symposium on the current status of wilderness medicine within its Annual Meeting each year. The course offered by Rainier Mountaineering is a 6 day course on Mt Rainier that includes field work and lectures on wilderness, cold weather and high altitude medicine, third world medicine, water purification, and basic mountaineering. A recent effort to gain approval for WPHEC procedures which go beyond approved urban prehospital emergency care has been undertaken by Dr Peter Goth of NASAR and WMA to request that state EMS agencies review proposed wilderness clinical guidelines in four specific areas [44]: (1) Spine injury: Current urban EMT protocols require placing a patient on a spine board in any situation where the mechanism of injury might have been expected to cause an unstable injury of the neck or back. The new wilderness protocol would not require this in the absence of positive signs or symptoms, provided that the patient's mental status is normal. (2) Cardiorespiratory arrest: Current urban protocols require that CPR be started in all cases of cardiorespiratory arrest, and be continued until (a) effective spontaneous
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circulation and ventilation have been restored, (b) the patient's care is transferred to another responsible person who continues CPR, (c) a physician, physician-directed person or team, or other properly trained EMS person assumes responsibility, (d) the patient is pronounced dead by a physician, or (e) the rescuer is exhausted and unable to continue resuscitation [45]. The new wilderness protocol would modify this: (a) in the normothermic patient, by allowing the rescuers to discontinue CPR (and repeated attempts at defibrillation, if this is applicable) after 30 minutes if a spontaneous pulse has not been restored; and (b) in the hypothermic patient, by not starting CPR if it would put rescuers at risk, if the core temperature is less than 60°F (15°C), the chest wall is frozen, the victim has been submersed for more than one hour in cold water, obvious lethal injury is present, or CPR would significantly delay evacuation to controlled rewarming. In addition, chest compressions would not be started unless there was strong evidence of lack of cardiac activity, because of the danger of precipitating fibrillation in the cold, non-fibrillating myocardium. (3) Wound care: Urban protocols call for dressing open wounds without any attempt to cleanse them before transporting the patient to a medical facility, and leaving impaled objects in place. The new wilderness protocol calls for cleansing wounds if a transport time of over two hours is expected. Bleeding is controlled, foreign material is removed, the surrounding skin is washed with soap and clean water, and the wound itself irrigated with clean water before being dressed. In high risk wounds (bites, puncture wounds, open fractures or dislocations, and very dirty wounds), dilute (1 %) povidone-iodine is applied to the wound and the dressing; the injured area is immobilized. Abrasions and minor burns are cleaned with soap and clean water and antiseptic dressings are applied to the wounds. Easily removable impaled objects are removed if transport time is greater than two hours. (4) Dislocations: urban protocols require that dislocations be splinted as are fractures. The new wilderness protocol allows realignment of simple dislocations (shoulder, patella, ankle and digits) by gentle traction into an anatomic position if possible, if transport time will exceed two hours. After repositioning, the body part is splinted in the anatomic position. The attempt is discontinued if resistance to movement is encountered or if pain is significantly increased; in such a case, the member is splinted in the injured position. At the date of this writing, these wilderness guidelines have been approved by the National Association of State Emergency Medical Services Directors, the National Park Service, and the State of Maine, and have been sent for approval to the State EMS agencies of Colorado, Alaska, New Mexico, and Nevada [44]. If approved by a state EMS agency, training programs for state EMS providers working under wilderness conditions could be based on the new guidelines and the new guidelines could be used by EMS physician sponsors to develop wilderness field protocols. These protocols would be used only in those situations where EMS personnel were working in the specialized context of delayed or prolonged transport, trained in the modified procedures and techniques, operating within the designated scope of practice, and authorized by the appropriate EMS agency and local or regional medical control or physician sponsor to apply the modified treatment procedures or techniques [44].
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References 1. Malatak, J. American Red Cross National Headquarters, Washington, DC 20006, personal communication. 2. The American National Red Cross. American Red Cross standard first aid and personal safety. Garden City, NY: Doubleday & Co., 1973. 3. The American National Red Cross. Advanced first aid & emergency care. Garden City, NY: Doubleday & Co., 1973. 4. National Academy of Sciences. Accidental death and disability: the neglected disease ofmodern society. Washington, DC: National Academy Press, 1966. 5. US Department of Transportation, National Highway Traffic Safety Administration Emergency medical technician-ambulance: national standard curriculum. 3rd ed. Washington, DC: US Government Printing Office, 1984. 6. American Academy of Orthopedic Surgeons. Emergency care and transportation of the sick and injured. Menasha, WI: George Banta 1971. 4th ed., 1987. 7. Grant, H. and Murray, R. Emergency care. Washington, DC: R.J. Brady, 1971. 8. Caroline, N. Emergency medical treatment. Boston: Little, Brown & Co., 1982. 9. State Department of Education, Columbus, Ohio. Emergency victim care. Ohio State University, 1971. 10. Hafen, B. and Karren, K. Prehospital emergency care & crisis intervention. Englewood, CO: Morton Publishing Co., 1981. 11. Bergeron, J. 1st responder. Bowie, MD: Robert J. Brady Co., 1982. 12. Samaritan Health Service. National Park Service: park medic core curriculum. Washington DC: National Park Service, Department of the Interior. 13. Committee on Trauma Research & Commission on Life Sciences, National Research Council and Institute of Medicine. Injury in America. Washington, DC: National Academy Press, 1985. 14. Kimball, H. First aid. In Brower, D., ed. Manual of ski mountaineering. San Francisco: 3rd ed. Sierra Club, 1962. 15. Wilkerson, J. ed. Medicine for mountaineering. 3rd ed. Seattle: The Mountaineers, 1985. 16. Bowman, W. Outdoor emergency care. Denver: National Ski Patrol, 1988. 17. Houston, C. and Cummings, S., eds. Proceedings: Yosemite Institute mountain medicine symposium. Yosemite Institute, 1976. 18. Darvill, F. Mountaineering medicine. Berkeley, CA: Wilderness Press, 1965. 12th ed., 1989. 19. Wilkerson, J., ed. Medicine for mountaineering. Seattle: The Mountaineers, 1967. 2nd ed., 1975, 3rd ed., 1985. 20. Mitchell, D. Mountaineering first aid Seattle: The Mountaineers, 1972. 2nd ed., 1975, 3rd ed., 1985. 21. Eastman, P. Advancedfirst aid afloat. Cambridge, MD: Cornell Maritime Press, 1972. 2nd ed., 1974. 22. Bowman, W. Extended out of ski area first aid for ski mountaineers and nordic ski patrollers. Denver: National Ski Patrol, 1976. 23. Eastman, P. Advanced first aid for all outdoors. Cambridge, MD: Cornell Maritime Press, 1976. 24. Forgey, W. Wilderness medicine. Pittsboro, IN: Indiana Camp Supply, Inc., 1979. 3rd ed., 1987. 25. Auerbach, P., Geehr, E., eds. Environmental Medical Emergencies, Topics in Emergency Medicine, Rockville, MD: Aspen Systems Corp., October, 1980. 26. Auerbach, P., Geehr, E., eds. Management of Wilderness and Environmental Emergencies, New York, Toronto, London: McMillan, First Edition 1983, Second Edition (published by C.V. Mosby, New York, London, Toronto) 1989.
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27. Kizer, K., ed. Environmental Emergencies, Emergency Clinics of North America, Phila., London: W.B. Saunders, 1984. 28. Auerbach, P., Medicine for the Outdoors, Boston, Toronto: Little, Brown & Co., 1986. 29. Bowman, W., Outdoor Emergency Care, Denver: National Ski Patrol, 1988. 30. Bowman, W. Current status of backcountry first aid. In Response 87 (Conference Syllabus for 1986 annual meeting of the National Association for Search and Rescue, Orlando, FL, May 13-17,1986. 31. Bowman, W. Appendix B: WIlderness emergency care module. In Outdoor emergency care. Denver: National Ski Patrol, 1988. 32. Goth, P., personal communication regarding Wilderness Medical Associates, RFD 2, Box 890, Bryant Pond, ME 04219. 33. Goth, P. Update on NASAR wilderness medicine programs. Response (Winter, 1989): 24. 34. Hubbell, F. and Frizzell, L., personal communication regarding SOLO, RFD 1, Box 163, Conway, NH 03818. 35. Conover, K., personal communication regarding the Center for Emergency Medicine of Western Pennsylvania, 190 Lothrop, #113, Pittsburg, PA 15213. 36. Schimelpfenig, T., personal communication regarding the National Outdoor Leadership School, PO Box AA, Lander, WY 82520. 37. Lindsay, L., personal communication regarding Colorado Outward Bound, 945 Pennsylvania St., Denver, CO 80203. 38. Gooding, D., personal communication regarding the American Alpine Institute, 1212 24th St., Bellingham, WA 98225. 39. Donelan, S. Wilderness first aid programs: directory. Wilderness First Aid (1989). 40. Seattle Mountaineers, 715 Pike St., Seattle, WN 98101, personal communication. 41. Davidson, T., personal communication regarding the 1989 course, University of California, San Diego, Office of Continuing Medical Education, M-017, La Jolla, CA 92093-0617. 42. Wilderness Medical Society, PO Box 397, Point Reyes Station, CA 94956, personal communication. 43. Rainier Mountaineering Inc., 535 Dock Street, Suite 209, Tacoma, WN 98402, personal communication. 44. Goth, P., personal communication. 45. 1985 National Conference on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC), Standards and Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC), Part VII: Medicolegal Considerations and Recommendations, lAMA (1986); 255: 2981.
The development and current status of wilderness prehospital emergency care in the United States WARREN D. BOWMAN Department of Internal Medicine, Billings Clinic, Billings, MT, USA
Care of the ill and injured in the United States, as in most Western countries, has evolved along two separate 'tracks.' The first, which can be called the 'professional medical track,' includes physicians, nurses, and related professionals who undergo rigorous and lengthy training, testing, and certification in order to be employed full time in caring for patients. These professionals are regulated by their professional organizations and by government licensing agencies, but in general are allowed to provide any type of medical service for which they have been trained. 'First track' replenishment and maintenance is the primary job of the many medical and nursing schools, professional societies, and research institutions with a combined annual budget of billions of dollars. The second, or 'prehospital emergency care' track, is occupied by all other emergency care workers, among them many whose primary occupation is not patient care. These persons care for simple injuries and illnesses not requiring the services of an advanced health care professional, provide initial care to the seriously injured and ill, and offer transport to definitive medical assistance. The second track was originally informal, but since the appearance of the Emergency Medical Services (EMS) system (described below) it has developed its own bureaucracy, regulatory structure, and organized system for training and continuing education. There is some overlap between the first and second tracks; for example, full time paramedics, although concerned mainly with prehospital care, are occasionally employed as assistants in hospital emergency departments or as flight (helicopter) attendants. In the US, the initial formal first aid teaching program was developed by the American Red Cross (ARC) in 1909. The original ARC first aid textbook, Red Cross First Aid, by Colonel Charles Lynch, was published in 1910, followed by First aid to the injured in 1911. The familiar 'green book' - the American Red Cross-first aid textbook - was published in 1933. Early first aid emphasis was on demonstrations and industrial first aid programs. With initiation of the lay instructor program in 1926, growth and expansion of first aid in the US was assured [1]. Millions of Americans have been trained in first aid by the ARC; for many years, the ARC first aid courses were the main source of training as well as the standard for prehospital care. In the early 1970s, the ARC expanded its first aid training into two levels: Standard First Aid for the average non-professional [2] and Advanced First Aid and Emergency Care for non-professionals who use first aid occupationally or in volunteer activities [3]. The latter group includes law officers, forest rangers, ski patrollers, rural ambulance attendants, and so forth. The armed forces also had a need for well-trained corpsmen to handle large numbers of field casualties. The corpsmen were trained primarily in the management of battle injuries; their training was more advanced than that for civilian first aiders and included 0953-9859/90 $03.00
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the use of intravenous infusions of plasma products and crystalloids, and such drugs as morphine. Starting in the late 1930s, medical advances gradually brought most infectious diseases under control, allowing death and disability due to injury to assume relatively more importance. By the mid-1960s, injuries had become the leading cause of death and disability in children and young adults. In 1966, the National Research Council produced a landmark report, Accidental death and disability: the neglected disease of modern society [4] which called attention to the poor quality of prehospital care. This report led to the development of the EMS system, a nation-wide and interdependent network of hospital emergency departments and emergency vehicles manned by physicians, nurses, and a new category of medical paraprofessional: the emergency medical technician (EMT). As a guide for EMT training, the National Traffic Safety Administration of the Department of Transportation (DOT) developed the National EMS Standard Curriculum (most recently revised in 1984) [5], on which have been based the courses in emergency medical techniques taught in every state. Although there are national standards and a national registry, EMT training, certification and recertification are the prerogatives of the individual states. There is considerable variation among states as to nomenclature, licensing levels, and techniques taught; in many regions, the variations depend upon the personal biases of the control physicians. EMTs were taught to reach patients promptly and to provide state of the art emergency care and transportation to the appropriate medical facility. The first EMTs were called EMT-B ('basic'), or EMT-A ('ambulance-based'). Their training was similar to, although more intense than, advanced ARC training, with greater emphasis on anatomy, physiology, assessment, basic life support, management of injuries due to trauma, rescue from crashed vehicles and ambulance handling. All EMTs in this category were originally limited to the use of suctioning and simple oropharyngeal and nasopharyngeal airways. Currently, most states allow use of the esophageal obturator and similar airways and the pneumatic anti-shock garment (PSAG). In some states, additional training modules are available: the defibrillator module (EMT-D), which teaches the use of manual, automatic, and/ or semi-automatic defibrillators, and the epinephrine module (EMT-E), which teaches injection of epinephrine for anaphylactic shock. The American Academy of Orthopedic Surgeons (AAOS) and the American College of Surgeons (ACS) have been involved in EMS from the first, as has the American College of Emergency Physicians (ACEP). The AADS published the first edition of Emergency care and transportation of the sick and injured in 1971; the book is currently in its fourth edition [6]. This and similar books [7-10] have been produced as textbooks for EMT programs. In the early 1980s, the First Responder program was developed to train law enforcement officers and others who did not need full EMT training [11]. A need for more advanced skills training in prehospital care soon arose. This led to several advanced categories of Emergency Medical Technician, notably the EMTIntermediate (EMT-I)and the Paramedic (EMT-P). The EMT-I possesses EMT-B skills, advanced skills in assessment, and an understanding of hypoxia and shock, and is trained in the use of esophageal obturator and similar airways, the PSAG, and the administration and maintenance of intravenous infusions. In some states, the EMT-I is also trained in endotracheal intubation. The EMT-P is trained in all EMT-Band EMT-I skills plus endotracheal intubation, cardiac defibrillation, needle cricothyroidotomy, chest tube
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placement, collection of blood samples, and the use of many ALS drugs. In some states, early field reduction of bony dislocations is allowed, especially recurrent shoulder dislocations. All EMT categories require at least nominal physician supervision. In reponse to its unique needs, the National Park Service established the Park Medic program in 1983. This training program, developed by Good Samaritan Hospital in Phoenix, Arizona, trained the Park Ranger to a level midway between the EMT-I and EMT-P. Park Medics are allowed to use ALS drugs, initiate intravenous infusions, place endotracheal tubes, and perform needle thoracotomies and needle cricothyroidotomies, but not cardiac defibrillation [12]. The EMS system was designed to meet the greatest perceived needs: urban and rural accidents accessible by road or helicopter, where the patient could be transferred to a medical facility within a short time. Because of the short transport times and the use of motorized vehicles, definitive care, such as washing of wounds, insertion of urinary catheters, or routine reduction of fractures was not deemed necessary. Physician control by telephone or radio was possible (when not possible, field protocols were available), and there were few limits upon the weight or amount of equipment which could be brought to the victims. The EMS system produced a dramatic improvement in urban and highway-related prehospital care. The National Research Council continues to note that each year, one in three Americans is injured and more than 140000 die from trauma [13]. With the explosive increase in outdoor recreational activity after World War II, it became apparent that there was need for modification of the second track of patient care to form yet a third track. People were participating in activities such as mountain climbing, wilderness skiing, caving, backpacking, kayaking, and rafting, which took them into wilderness areas many miles from the roadhead. Recreational parties needed selfhelp training, as did wilderness search and rescue groups. The concept of 'second aid,' 'back-country first aid,' or 'wilderness EMT' (referred to hereinafter as 'wilderness prehospital emergency care' or 'WPHEC') gradually emerged. This acknowledged the alterations in standard prehospital emergency care protocols required when orthodox care with rapid hospital interfacing was not available because of distance, difficult transportation or inadequate communication. The features of the third track appeared slowly, beginning with inclusion of chapters on first aid or 'second aid' in such books as the Sierra Club's Manual of ski mountaineering, first published in 1942 [14]. This manual advised the reader to become well grounded in ARC first aid and predicted that procedures in the text which 'go a bit beyond first aid' would be within the ability of the well-trained ski mountaineer. It departed from orthodox first aid principles in medical areas appropriate to the wilderness environment. It advised cleansing of wounds and open fractures, rapid thawing of deep frostbite in a warm water bath (although a temperature of 130°F was recommended), the use of prescription pain medications and antibiotics, and application of eye ointment containing local anesthetic for snow blindness. Injuries peculiar to the winter wilderness not discussed in orthodox first aid textbooks were covered in detail. WPHEC is based on the same principles of anatomy, physiology and pathophysiology as is orthodox emergency care. This is essential in a wilderness environment where the emphasis is not on 'what to do until the doctor comes,' but rather on what to do 'for wilderness situations to which the doctor is not comip.g' [15]. By informal agreement among physicians experienced in wilderness medicine, specific ways in which WPHEC
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differs from urban emergency care include [16, 17]: (1) It is practiced in the remote, outdoor environment, where extreme conditions of heat, cold, altitude, and storm are common and difficulties in obtaining food, water, and shelter are significant. Physical hazards, such as snow avalanches, rockfalls, flash floods, wildfires, and lightning may be present. Hazardous microorganisms, insects, marine animals, land animals, and plants may endanger the health of wilderness travellers, and pre-existing medical conditions may recur or flare at awkward times. (2) Definitive medical care may be hours or days away because of distance, adverse environmental conditions, lack of transportation, or difficulties in communication. Urban protocols that assume rapid transportation to a medical facility may be irrelevant. (3) Illnesses rarely seen in the urban environment, such as acute mountain sickness and deep frostbite, may be encountered. (4) The EMS requirement that there be routine physician control by telephone or radio may be unrealistic or impractical. More reliance on field protocols is necessary. (5) It may be desirable to train intelligent and motivated non-professionals to carry out advanced procedures for common injuries and illnesses, in which a treatment delay of more than a few hours may cause adverse effects which outweigh the possible risks of the procedures. (6) There is a need for rescuers to learn basic nursing and subsistence care for an injured or ill person in order to sustain the patient for days before medical assistance can be reached. (7) Certain standard urban treatment protocols, such as that for cardiac arrest, may be unrealistic or even hazardous to rescuers. (8) The amount of first aid equipment that can be carried by the average wilderness recreational group, or even the best-equipped wilderness search and rescue group with helicopter support, is limited; improvization will be necessary. There are many similarities between WPHEC and the care available in isolated areas, such as small Alaskan villages accessible only by boat or air. There is also analogy to disaster emergency care, where medical supplies, food, water, and medical facilities may be destroyed, the number of casualties overwhelming, triage essential, and urban protocols which call for maximum resuscitative efforts and rapid transportation to a medical facility impossible to follow. In the late 1960s, the rise in popularity of expeditionary mountaineering and small boat sailing to remote areas was accompanied by the appearance of a number of wilderness medicine and first aid textbooks. These were comprehensive, medically sophisticated, well written, and designed primarily for members of recreational groups, rather than for rescue groups. The advanced techniques that were recommended tended to intimidate lay readers who had been reared on traditional first aid and prehospital care. [18-24] More recent books published during the 1980s include comprehensive discussions of all types of wilderness emergencies, from either the first aid or the professional medical standpoint [25-29]. During the 1970s, an increasing interest in wilderness medicine stimulated development of a number of symposia, the prototype of which was the 1975 Mountain Medicine Symposium in Yosemite National Park, organized by Dr Charles Houston and sponsored by the Yosemite Institute [17]. Since that time, there have been one to several major similar symposia each year, held in different parts of the US and Canada, and sponsored by a variety of organizations.
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During the 1970s and 1980s, a number of courses in WPHEC were developed. These were of two types: (a) Programs which stayed within the EMS system in order to take advantage of EMS licensing. These were either 'complete' courses through which the student was eligible to take the national or state EMT licensing exams, or 'wilderness modules' requiring prior EMT training or the equivalent. Physician supervision and control was required for 'Wilderness EMTs (WEMTs).' These courses tended to be designed for recreational trip leaders and members of rescue groups. (b) Programs covering many or all of the same topics, but staying outside the EMS system. These tended to be designed for recreational group members. Physician participation was encouraged, but physician control was not required. Various strategies have been employed to avoid the hazards of violating state medical practice legislation ('practicing medicine without a license'), federal narcotics laws, and various liability statutes, since many such advanced procedures, no matter how necessary in the wilderness environment, are generally illegal for anyone except licensed physicians, or for nurses, physician assistants, and paramedics under physician supervision. In the US, the medical liability and illicit drug crises have made improvements in WPHEC more difficult to obtain than they would otherwise have been. For example, this affects the proposition that bony realignment can logically be extended to cover the reduction of dislocations, and prescription pain medications legally prescribed by a physician for use by a member of a rescue group. [30,31] Other efforts have included attempts to change standards of care by working with state EMS agencies to develop new consensus standards for wilderness care through national organizations such as the American Society for Testing and Materials (ASTM), the National Association for Search and Rescue (NASAR), and the Wilderness Medical Society. The establishment in 1987 of a Wilderness Task Group of the EMS Committee by ASTM looked promising at first, but recent bylaw changes within ASTM will apparently preclude the development of any clinical standards or guidelines [32]. There exists no standard WPHEC curriculum, but a review of existing courses [3344] discloses many common topics: (1) Orthodox emergency care and emergency medical techniques. If not included, EMT, advanced ARC first aid training, or equivalent training, such as the National Ski Patrol's Winter Emergency Care course, may be a pre-requisite. (2) Extended care of the victim, including stabilization of body temperature, provision for food and water, elimination of body wastes, psychological support, etc. (3) Wilderness rescue, 'packaging', and transport. (4) Environmental illnesses and injuries, such as frostbite, hypothermia, high altitude illness, land and marine animal bites, insect stings, etc. (5) Wilderness survival techniques. (6) Assessment and treatment of medical illnesses. (7) Use of prescription and non-prescription drugs, including: (a) Antibiotics. (b) Pain medications. (c) Gastrointestinal drugs. (d) Drugs for high altitude illness. (8) Improvization of first aid equipment and transportation devices. (9) Wound management.
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(10) Re-alignment of displaced fractures and dislocations. (11) Modifications of standard, urban CPR protocols. (12) Modifications in standard protocols as appropriate for the wilderness environment. (13) Use of advanced techniques, such as the insertion of thoracostomy and endotracheal tubes, cricothyroidotomy, intravenous fluids, bladder catheterization, etc. (14) Expedition medicine education, including tropical and other exotic diseases, vaccinations, and sanitation, including the provision of disinfected water and properlyprepared food. (15) Suggestions for contents of first aid kits. At the present time, the major training courses in WPHEC within the EMS system are: (1) National Association for Search and Rescue Medical Programs [31,32]. These include a 56-hour course in Wilderness Emergency Medical Technique (WEMT) and a 64-hour Wilderness First Responder course, provided for NASAR under contract by Wilderness Medical Associates (WMA) of Bryant Pond, Maine. Prior certification as an EMT or equivalent is required for the WEMT course, which consists of four modules: (a) General medicine: patient assessment, review of the mechanisms of illness and injury, modified treatment procedures for the wilderness context, common major and minor wilderness medical problems. (b) Trauma: modified techniques for wound management and treatment of fractures, dislocations, and spine injuries. (c) Environmental medicine: Illnesses caused by cold, heat, and high altitude; near drowning, diving medicine, lightning injuries, sun exposure; wilderness poisons, bites and stings. (d) Wilderness Rescue: The Incident Command System, personal preparedness, map and compass, litters and evacuation, radios. WMA also offers a 32-hour Wilderness First Aid course for fishermen, hikers, climbers, and other lay persons, and a 12-16 hour Wilderness Medicine Workshop, tailored for specific needs. (2) Stonehearth Open Learning Opportunities (SOLO) of Conway, NH. SOLO offers a 60 hour Wilderness Module for the EMT or equivalent, a 180 hour WEMT course which includes basic EMT training plus the Wilderness Module, an 80 hour Wilderness First Responder Course, and two 16 hour courses, one on Backcountry Medicine for non-professionals and one on Wilderness Trauma Life Support for medical professionals and other experienced persons. The WEMT course includes basic EMT skills as appropriate to remote environments, as well as long term management, environmental emergencies, common wilderness problems, backcountry extrication, and transport and rescue techniques [34]. (3) The Appalachian Search and Rescue Conference's Wilderness Emergency Medicine program offered in cooperation with the Center for Emergency Medicine of Western Pennsylvania. This is a 50 hour Wilderness EMT course (EMT certification and search-and-rescue training are prerequisites) that includes a discussion of the wilderness environment, general medicine, patient assessment, environmental emergencies, wilderness medical problems, wilderness trauma and surgical problems, pharmacology, and packaging, evacuation and transport [35]. Courses in WPHEC are being taught in several colleges, notably the University of
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Alaska, some of which are outside the EMS system. The National Outdoor Leadership School (NOLS) teaches a 140 hour WEMT course and an 80 hour Wilderness First Responder course to its staff members [36]. Colorado Outward Bound teaches a 56 hour Wilderness Emergency Medical Care course and a 140 hour Wilderness EMT course to its staff members and the public [37]. The American Alpine Institute of Bellingham, Washington, teaches a 35 hour course for members of wilderness recreation groups emphasizing the hazards of rugged environments. This course is suitable for all medical skill levels, from lay person to MD, with advanced ARC First Aid training a prerequisite [38]. The Mountain Medicine Institute of Oakland, California, offers a series of mountain medicine lectures on environmental hazards, fitness, injury and illness prevention, and backcountry illnesses and injuries [39]. Courses in Wilderness First Aid sponsored by the American Red Cross are taught in a number of ARC chapters, including Whatcom County, Washington, and the cities of Oakland, Palo Alto and Van Nuys, California. These courses lead to certification in either ARC Standard or Advanced First Aid and include wilderness modules [39]. Large regional climbing organizations, such as the Mountaineers and the Mazamas, include courses in Mountaineering First Aid as part of their curricula. The Mazamas offer a 30 hour course designed mainly for climbing trip leaders based on ARC Standard First Aid, and a Progression course based on ARC Advanced First Aid [39]. The Mountaineers currently offer two courses to members and the general public: (a) Mountaineering Oriented First Aid (MOFA), a 27 hour course based on the ARC Standard First Aid Course that includes CPR, splinting and bandaging, and a more comprehensive secondary survey, and (b) Advanced Progression Mountaineering Oriented First Aid, a 33-36 hour course based on the ARC Advanced First Aid Course that includes extrication, childbirth, water hazards, helmet removal, and traction splinting [40]. Every 1-2 years there are short courses in mountain medicine offered by institutions of higher education such as the University of Washington (Seattle), the University of California-Davis and the University of California, San Diego [41], and organizations such as the Wilderness Medical Society [42] and Rainier Mountaineering [43]. These courses are usually offered jointly to physicians, nurses, paramedical personnel, and nonprofessionals. The Wilderness Medical Society includes a symposium on the current status of wilderness medicine within its Annual Meeting each year. The course offered by Rainier Mountaineering is a 6 day course on Mt Rainier that includes field work and lectures on wilderness, cold weather and high altitude medicine, third world medicine, water purification, and basic mountaineering. A recent effort to gain approval for WPHEC procedures which go beyond approved urban prehospital emergency care has been undertaken by Dr Peter Goth of NASAR and WMA to request that state EMS agencies review proposed wilderness clinical guidelines in four specific areas [44]: (1) Spine injury: Current urban EMT protocols require placing a patient on a spine board in any situation where the mechanism of injury might have been expected to cause an unstable injury of the neck or back. The new wilderness protocol would not require this in the absence of positive signs or symptoms, provided that the patient's mental status is normal. (2) Cardiorespiratory arrest: Current urban protocols require that CPR be started in all cases of cardiorespiratory arrest, and be continued until (a) effective spontaneous
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circulation and ventilation have been restored, (b) the patient's care is transferred to another responsible person who continues CPR, (c) a physician, physician-directed person or team, or other properly trained EMS person assumes responsibility, (d) the patient is pronounced dead by a physician, or (e) the rescuer is exhausted and unable to continue resuscitation [45]. The new wilderness protocol would modify this: (a) in the normothermic patient, by allowing the rescuers to discontinue CPR (and repeated attempts at defibrillation, if this is applicable) after 30 minutes if a spontaneous pulse has not been restored; and (b) in the hypothermic patient, by not starting CPR if it would put rescuers at risk, if the core temperature is less than 60°F (15°C), the chest wall is frozen, the victim has been submersed for more than one hour in cold water, obvious lethal injury is present, or CPR would significantly delay evacuation to controlled rewarming. In addition, chest compressions would not be started unless there was strong evidence of lack of cardiac activity, because of the danger of precipitating fibrillation in the cold, non-fibrillating myocardium. (3) Wound care: Urban protocols call for dressing open wounds without any attempt to cleanse them before transporting the patient to a medical facility, and leaving impaled objects in place. The new wilderness protocol calls for cleansing wounds if a transport time of over two hours is expected. Bleeding is controlled, foreign material is removed, the surrounding skin is washed with soap and clean water, and the wound itself irrigated with clean water before being dressed. In high risk wounds (bites, puncture wounds, open fractures or dislocations, and very dirty wounds), dilute (1 %) povidone-iodine is applied to the wound and the dressing; the injured area is immobilized. Abrasions and minor burns are cleaned with soap and clean water and antiseptic dressings are applied to the wounds. Easily removable impaled objects are removed if transport time is greater than two hours. (4) Dislocations: urban protocols require that dislocations be splinted as are fractures. The new wilderness protocol allows realignment of simple dislocations (shoulder, patella, ankle and digits) by gentle traction into an anatomic position if possible, if transport time will exceed two hours. After repositioning, the body part is splinted in the anatomic position. The attempt is discontinued if resistance to movement is encountered or if pain is significantly increased; in such a case, the member is splinted in the injured position. At the date of this writing, these wilderness guidelines have been approved by the National Association of State Emergency Medical Services Directors, the National Park Service, and the State of Maine, and have been sent for approval to the State EMS agencies of Colorado, Alaska, New Mexico, and Nevada [44]. If approved by a state EMS agency, training programs for state EMS providers working under wilderness conditions could be based on the new guidelines and the new guidelines could be used by EMS physician sponsors to develop wilderness field protocols. These protocols would be used only in those situations where EMS personnel were working in the specialized context of delayed or prolonged transport, trained in the modified procedures and techniques, operating within the designated scope of practice, and authorized by the appropriate EMS agency and local or regional medical control or physician sponsor to apply the modified treatment procedures or techniques [44].
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References 1. Malatak, J. American Red Cross National Headquarters, Washington, DC 20006, personal communication. 2. The American National Red Cross. American Red Cross standard first aid and personal safety. Garden City, NY: Doubleday & Co., 1973. 3. The American National Red Cross. Advanced first aid & emergency care. Garden City, NY: Doubleday & Co., 1973. 4. National Academy of Sciences. Accidental death and disability: the neglected disease ofmodern society. Washington, DC: National Academy Press, 1966. 5. US Department of Transportation, National Highway Traffic Safety Administration Emergency medical technician-ambulance: national standard curriculum. 3rd ed. Washington, DC: US Government Printing Office, 1984. 6. American Academy of Orthopedic Surgeons. Emergency care and transportation of the sick and injured. Menasha, WI: George Banta 1971. 4th ed., 1987. 7. Grant, H. and Murray, R. Emergency care. Washington, DC: R.J. Brady, 1971. 8. Caroline, N. Emergency medical treatment. Boston: Little, Brown & Co., 1982. 9. State Department of Education, Columbus, Ohio. Emergency victim care. Ohio State University, 1971. 10. Hafen, B. and Karren, K. Prehospital emergency care & crisis intervention. Englewood, CO: Morton Publishing Co., 1981. 11. Bergeron, J. 1st responder. Bowie, MD: Robert J. Brady Co., 1982. 12. Samaritan Health Service. National Park Service: park medic core curriculum. Washington DC: National Park Service, Department of the Interior. 13. Committee on Trauma Research & Commission on Life Sciences, National Research Council and Institute of Medicine. Injury in America. Washington, DC: National Academy Press, 1985. 14. Kimball, H. First aid. In Brower, D., ed. Manual of ski mountaineering. San Francisco: 3rd ed. Sierra Club, 1962. 15. Wilkerson, J. ed. Medicine for mountaineering. 3rd ed. Seattle: The Mountaineers, 1985. 16. Bowman, W. Outdoor emergency care. Denver: National Ski Patrol, 1988. 17. Houston, C. and Cummings, S., eds. Proceedings: Yosemite Institute mountain medicine symposium. Yosemite Institute, 1976. 18. Darvill, F. Mountaineering medicine. Berkeley, CA: Wilderness Press, 1965. 12th ed., 1989. 19. Wilkerson, J., ed. Medicine for mountaineering. Seattle: The Mountaineers, 1967. 2nd ed., 1975, 3rd ed., 1985. 20. Mitchell, D. Mountaineering first aid Seattle: The Mountaineers, 1972. 2nd ed., 1975, 3rd ed., 1985. 21. Eastman, P. Advancedfirst aid afloat. Cambridge, MD: Cornell Maritime Press, 1972. 2nd ed., 1974. 22. Bowman, W. Extended out of ski area first aid for ski mountaineers and nordic ski patrollers. Denver: National Ski Patrol, 1976. 23. Eastman, P. Advanced first aid for all outdoors. Cambridge, MD: Cornell Maritime Press, 1976. 24. Forgey, W. Wilderness medicine. Pittsboro, IN: Indiana Camp Supply, Inc., 1979. 3rd ed., 1987. 25. Auerbach, P., Geehr, E., eds. Environmental Medical Emergencies, Topics in Emergency Medicine, Rockville, MD: Aspen Systems Corp., October, 1980. 26. Auerbach, P., Geehr, E., eds. Management of Wilderness and Environmental Emergencies, New York, Toronto, London: McMillan, First Edition 1983, Second Edition (published by C.V. Mosby, New York, London, Toronto) 1989.
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27. Kizer, K., ed. Environmental Emergencies, Emergency Clinics of North America, Phila., London: W.B. Saunders, 1984. 28. Auerbach, P., Medicine for the Outdoors, Boston, Toronto: Little, Brown & Co., 1986. 29. Bowman, W., Outdoor Emergency Care, Denver: National Ski Patrol, 1988. 30. Bowman, W. Current status of backcountry first aid. In Response 87 (Conference Syllabus for 1986 annual meeting of the National Association for Search and Rescue, Orlando, FL, May 13-17,1986. 31. Bowman, W. Appendix B: WIlderness emergency care module. In Outdoor emergency care. Denver: National Ski Patrol, 1988. 32. Goth, P., personal communication regarding Wilderness Medical Associates, RFD 2, Box 890, Bryant Pond, ME 04219. 33. Goth, P. Update on NASAR wilderness medicine programs. Response (Winter, 1989): 24. 34. Hubbell, F. and Frizzell, L., personal communication regarding SOLO, RFD 1, Box 163, Conway, NH 03818. 35. Conover, K., personal communication regarding the Center for Emergency Medicine of Western Pennsylvania, 190 Lothrop, #113, Pittsburg, PA 15213. 36. Schimelpfenig, T., personal communication regarding the National Outdoor Leadership School, PO Box AA, Lander, WY 82520. 37. Lindsay, L., personal communication regarding Colorado Outward Bound, 945 Pennsylvania St., Denver, CO 80203. 38. Gooding, D., personal communication regarding the American Alpine Institute, 1212 24th St., Bellingham, WA 98225. 39. Donelan, S. Wilderness first aid programs: directory. Wilderness First Aid (1989). 40. Seattle Mountaineers, 715 Pike St., Seattle, WN 98101, personal communication. 41. Davidson, T., personal communication regarding the 1989 course, University of California, San Diego, Office of Continuing Medical Education, M-017, La Jolla, CA 92093-0617. 42. Wilderness Medical Society, PO Box 397, Point Reyes Station, CA 94956, personal communication. 43. Rainier Mountaineering Inc., 535 Dock Street, Suite 209, Tacoma, WN 98402, personal communication. 44. Goth, P., personal communication. 45. 1985 National Conference on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC), Standards and Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiac Care (ECC), Part VII: Medicolegal Considerations and Recommendations, lAMA (1986); 255: 2981.