Based on an actual patient case, the 2019 NAEMSP session “Mountain Medicine: Where Ambulances Can’t Go” reviewed how wilderness (“backcountry”) EMS response protocols must function differently from those of “front country” EMS so providers working in these austere environments can better serve their patients. Led by Will Smith, MD, a paramedic and former colonel of the U.S. Army Reserve Medical Corps. who now serves as medical director for the U.S. National Park Service, guides backcountry EMS folks toward being better field operators.
Wilderness EMS systems can encompass ski patrol teams, search and rescue teams, combat medics, and traditional front country EMS serving more rural areas. Though the terrains and population numbers differ between these groups, the challenges remain similar, like long response times due to distance, inclement weather, the higher risk of providers getting injured, or ambulance and medical helicopter accidents occurring in remote areas—all of which backcountry EMS agencies should anticipate and prepare for.
Smith began his session playing the 9-1-1 call audio involving a 61-year-old male experiencing chest pain. The call came from the man’s wife, who reported to the dispatcher they were skiing at Maverick Peak (Wash.) with two others when he started feeling unwell. The group pulled to the side of the trail and placed the 9-1-1 call. When the man became unresponsive, dispatchers advised the group members to take turns performing CPR until EMS arrival.
In remote environments like this, the chain of survival is crucial when response times can easily exceed an hour. Smith said in Jackson, Wyo., where he practices emergency medicine, there are frequent public service announcements reminding civilians of the two important steps to remember in the event that they witness someone go into cardiac arrest: 1) Call 9-1-1 right away, and 2) push hard and fast, which his wife and friends did, said Smith, noting the crew had later confirmed the patient had a STEMI, which caused him to go into cardiac arrest.
Smith said hospitals in his area gets calls like this one to five times per month. During remote rescues like the one in this case, an incident command post will set up to monitor the event. EMS agencies need to know how they fit into that system, he said; otherwise, they’ll lose accountability and command.
Care On and Off Scene
The difficult circumstances of wilderness medicine mean appropriate intervention is critical. “Examine your care,” said Smith. “What’s working and what’s not working?”
In situations similar to the case of the patient in cardiac arrest, termination of resuscitation protocols may need to be tweaked. It depends on your environment, though, so determine what works best for your system.
Studies on what prehospital providers have been doing wrong in the field have improved patients’ survival rates . Always be learning, educating and researching to ensure the best, evidence-based care for your patients, especially when they have been stuck in remote areas without medical care for prolonged periods of time.
The delivery of high-quality medical care required in these environments is just as vital as a smoothly-running operation to avoid negatively impacting that care. Time is of the essence. Should you stay and play or load and go? This decision should be based on the phases of care and the location (Smith recommended agencies refer to the Tactical Combat Casualty Careguidelines and the textbook Wilderness EMS by Seth C. Hawkins for improving training for operating in austere regions).
Sometimes extracting a patient from a tactical situation and providing care later is better. Consider the prospective or existing threats posed to the providers and patient. On the other hand, if CPR is needed and you take five minutes to get the patient in a litter, it will kill the patient. Swift evaluation of the scene is crucial in making the most appropriate decisions in the care and transportation process.
“Know what resources you have in your system,” said Smith. “Knowing the appropriate product selection for your setting is important.” Think ahead of time if there are additional resources that may be needed. For example, if you’re extracting a patient who needs CPR in a litter or toboggan, quality CPR isn’t going to happen. Requesting a mechanical CPR device in advance would provide the more suitable alternative method of care in a case like that.
When choosing between ground or air transportation, perform a risk vs. benefit analysis. A helicopter, for example, is a great choice for the right reasons, but can be extremely risky. Smith said the mindset of their search and rescue crews is if they go out in the helicopter, they might not come back. They also carry 24-hour survival packs with them in the event of getting stranded.
In the cardiac arrest case, the helicopter had nowhere to land, so it remained hovering and the crew was sent down to recover the patient. The short haul crew ended up evacuating the patient’s wife and friends as well because it was getting dark and they were exhausted—a reminder that technical skills must be current and well-practiced. It took the crew one hour and 33 minutes to reach the patient, who was eventually stabilized during transportation and maintained good neurological status on the way to the hospital.
The total time between the 9-1-1 call being placed to the patient reaching the cath lab was three hours and 30 minutes. With no room for wasted time in remote environments, Smith emphasized how critical it is for agencies operating in the wilderness to establish protocols that are the most appropriate for their environment and available resources. EMS providers and physicians should be trained to effectively operate under these harsh conditions with the ability to balance the risk of rescuing and recovering patients based on the phases of medical care.
Check out the “The Fine Line” podcast, hosted by Backcountry Zero, which features stories from Teton County Search and Rescue where Will Smith volunteers
Valerie Amato is assistant editor of EMS World. Reach her at email@example.com.