Introduction to Wilderness EMS

Seth C. Hawkins

INTRODUCTION

This book has been written for health care providers serving on formal, system-based teams who provide their medical care in “wilderness” environments.

The opportunity to care for other human beings outside the normal resources of human civilization springs from an altruism that is, it appears, native to our species. Indeed, this impulse could be a foundation of civilization itself. It has been pointed out that the first hominid attempting to aid another, using only the tools at hand or no tools at all while fending off the threats of an unforgiving environment, was the first practitioner of wilderness medicine.¹ This would make the discipline of wilderness medicine the oldest of all medical specialties. The subsequent efforts of our species to improve the sophistication and tools we use for medical care, along with a host of other social and interactional evolutions, helped give rise to civilization as we know it. Analyzing this cultural evolution from hominid roots to our present social and technologic constructions is the purview of anthropology. Many generations of scholars—both in the evolution of health care as well as other social structures—shaped this as a narrative of overall progress.

But anthropologists and social theorists are now challenging the degree to which civilization has improved health. Some suggest the growth of civilization has created as many health problems as it has solved.² Somewhat ironically, humans increasingly seek to escape—at least periodically—the civilization they have built for themselves. People once had to carve civilizations out of the surrounding wilderness environment, but now must carve wildernesses out of the surrounding infrastructure of civilization. In the interim, there was a tension, for example in American settlers of the 18th century, between “a nature that they called wilderness with another nature called pastoral,” with a goal of “reclaiming large and fruitful tracts from the waste of creation [wilderness]” into more productive and secure versions of nature.³ Indeed, contemporary western ideas of nature grew out of the Industrial Revolution, especially by way of a newly enriched and expanded class of citizens⁴; in fact, the very idea of wilderness may be a problematic and reactionary concept invented by post-Industrial Revolution environmentalists more than a real ecologic phenomenon.⁵^,⁶ William Forgey, the “father of wilderness medicine” in the United States,⁷^,⁸^,⁹^,¹⁰^,¹¹^,¹² describes “a time when wilderness was really that and used by those who lived and traversed through it” in a discussion about the role of medical textbooks used in the wilderness of the 18th century (cited in Figure 1.1 of Chapter 1). Even more recently, older adults alive today have commented on the change in landscape and expansion of development, removing opportunities to experience “wilderness.”¹³ A more historical definition of wilderness was “places untamed and not under control of humans,” and as discussed above, was contrasted with civilization, representing “places of human control.”⁵^,¹³^,¹⁴ These themes speak to a pervasive sense, both academic and affective, that there was a time when wilderness meant something different than it does today. The paradoxical nature of wilderness in this modern context is particularly apparent when considering the legal definition of wilderness.¹⁵ In the United States, the National Wilderness Preservation System in 1964 began defining certain areas in the United States as federally designated “wilderness.” Defining management policies and legal protection for an area that, by that very definition, are intended to be free of modern human influences is clearly paradoxical and has been cited in the wilderness medicine literature.¹³ However, such definitions and protections do appear to be necessary in our modern era. Acknowledging then that wilderness now may in fact be constructed, or at least protected, by civilization itself, a more modern definition of wilderness is an area that an observer would perceive to be predominantly under the influence (including being allowed by civilization to be predominantly under the influence) of natural processes and forces.¹³ The legal definition itself has been cited for its compelling poeticism, but also criticized as being
problematically open to legal interpretation based on that very poeticism¹³ (as well as using language of the day that now might be considered excessively gendered). It reads,

A wilderness, in contrast with those areas where man and his own works dominate the landscape, is hereby recognized as an area where the earth and its community of life are untrammeled by man, where man himself is a visitor who does not remain. An area of wilderness is further defined to mean… an area of undeveloped Federal land retaining its primeval character and influence, without permanent improvements or human habitation, which is protected and managed so as to preserve its natural conditions and which (1) generally appears to have been affected primarily by the forces of nature, with the imprint of man’s work substantially unnoticeable; (2) has outstanding opportunities for solitude or a primitive and unconfined type of recreation; (3) has at least five thousand acres of land or is of sufficient size as to make practicable its preservation and use in an unimpaired condition; and (4) may also contain ecological, geological, or other features of scientific, educational, scenic, or historical value.¹⁶

It is worth noting that all four criteria are based on human perception rather than ecosystemic reality (“appears to have been affected”) or apparent functional use or value to humans (“opportunities. . . for recreation,” “practicable use,” “contain…features of… value”), reaffirming the influence of civilization and human need over preservation of unaffected areas simply for their own sake and with true ecosystemic integrity (an example of this limitation on actual integrity or true absence of human interference would be firefighting operations in wilderness areas). Clearly, this modern definition of wilderness out of civilization creates an artificial boundary beyond which a “wilderness” is constructed, with varying degrees of authenticity to a truly natural, remote, and “untouched” state. Some sources argue that this federalization of land—especially in the American West—for public use and wilderness protection has been universally praised, consistently supported by Congress, and is expected to grow.¹³^,¹⁴^,¹⁷ But a more sensitive analysis points to federalization of land—especially in the American West—for public use as one of the most contentious of social decisions. This controversy dates back to the mid-19th century and continues up to the present day in very immediate and significant ways. Examples of such modern-day controversy include actions by both the public, such as illegal extremist occupation of a national wildlife refuge in southern Oregon in 2016 protesting federal land use policies, and the government itself, such as recent legislative and executive branch efforts to transfer land away from direct federal control, with President Trump calling federal land acquisitions for parks and other public use from the era of Teddy Roosevelt to today “a massive federal land grab” which “never should have happened.”¹⁸^,¹⁹ In the context of WEMS not existing without wilderness, it is heartening to see that national surveys done in 1994 and 2000 demonstrated that more than 50% of those surveyed felt 12 of 13 key wilderness values was “very or extremely important,” with “income for tourism industry” supported to that degree by less than 30% of respondents, and that the trend between the two surveys was increasing percentage of support for all 13 values.²⁰^,²¹

Interestingly, the further humans venture outside the boundaries of civilization and its medical resources and into “wilderness,” whether constructed or actual, the more by intent they risk experiences closer to that of the first hominid trying to help another than a neurosurgeon performing brain surgery in a university hospital. In other words, the more we seek wilderness, the more we need to return to our wilderness medicine roots. But in the best of worlds, we can choose those elements of civilization we bring with us, some of which can even help save our lives. The most important of these is, again paradoxically, the very characteristic that drove us to create civilization in the first place: Our minds, with their ability to build and use tools, and their capacity to problem solve. It is an unfamiliar thought to use now, as we enjoy boundless dominance over the world around us, that about 70,000 years ago, our species faced near extinction in a “population bottleneck.” Geneticists and paleoanthropologists estimated that less than 10,000 members of our species remained—and possibly 2,000 or less—in small pockets in Africa during a population bottleneck. These figures today would qualify Homo sapiens as either a threatened or even an endangered species, approaching an extinction threshold.²² The source of this bottleneck is unknown—the most likely source may be Saharan desert expansion (the largest supervolcano eruption of the last 2 million years occurred at Mt. Toba around this time and caused a “volcanic winter” during this time, which and has been speculated to also be an exacerbating feature; although the explosion is still uncontested, its significance as a population stressor is now heavily contested).²³ It was this era that also coincided with the beginning of major migrations out of Africa and of the origins of complex language, art, and sophistication in tool use. These anthropological data suggest that the challenges facing us as individuals in a hostile environment were replicated on a massive, species-wide scale around 70,000 years ago, nearly ending our existence. Significantly, a probable solution was an evolution, or even evolutionary jump, in our hominid brain, in our problem-solving capacity, and in the nascent features of our capacity to build civilization, such as language and tool use.²⁴^,²⁵,^*

In Chapter 1 we will define wilderness medicine more formally. But from an introductory perspective, it is helpful to think of wilderness medicine as medical care and problem-solving when the surrounding environment has, or has been allowed to have, more power over us than does the infrastructure (and underlying social structure) of our civilization. I would note that a cultural anthropology perspective would further argue that civilization infrastructure is itself secondarily a product of more foundational social structure. While this harkens back to the older definition of wilderness discussed above (areas distinct from civilization), the concept of relative power, and of the possibility that this has been permitted by civilizing forces, also involves the more modern definition of wilderness as itself a product of civilization and human perception.

This helps to explain why wilderness medicine has such a strong interest in not relying on civilization and its associated technology to solve problems faced in the wilderness. After all, many wilderness recreationalists are seeking an escape from civilization and technology, and one of the attractions of recreating in a wilderness setting—the location for that escape—is self-sufficiency and reliance on improvised or minimalist tools. In many ways this is an admirable trait to foster in a society that bemoans the loss of mechanical skills and autonomous thinking in a population that seems increasingly privileged and entitled. With the development of such primary skills, we can safely venture deeper and deeper into otherwise dangerous wilderness and austere areas. That is where the magic happens.

But, as with all magic, there is a price to pay.

First, intentionally putting oneself in dangerous situations without all possible resources by definition increases risk of injury or illness. While this seems self-evident, it is important to understand all the resulting consequences. Many of us seek out forbidding environments or challenge our own abilities in ways that others may see as “crazy.” This includes rock climbing, swiftwater kayaking, and other sports once thought “extreme” because the price of mistake or failure can be high. Often in pursuing these sports we deliberately relinquish equipment or routes that might be helpful in emergencies. This includes carrying the most minimalist medical kit possible, not bringing any electronic tools due to philosophical convictions about “wilderness” (see the discussion about post-Industrial Revolution conceptions of wilderness that follows), free solo climbing not using the ropes and gear common in traditional and sport climbing, choosing more dangerous wilderness routes or strategies for the thrill of the danger, and similar decisions based on philosophical convictions or adventure-seeking rather than necessity. This can create the need, or complicate the ability, for others to assist such individuals in danger. This is not to argue against such practices in themselves, but to suggest that those impulsions pushing us into the wilderness in the first place can, when taken further, make it more difficult to care for each other once we are there. In addition, at least one wilderness medicine school has noted that environments defined as “remote” from a medical standpoint are shrinking due to technology and user expectation, even if the actual land area remains unchanged. The 6th edition of NOLS Wilderness Medicine notes that

communication technology now offers the chance of quick transport from remote areas to urban medical care, and many wilderness visitors have come to expect such service. In fact, much of what we call wilderness medicine is really a simple extension of modern emergency medical services (EMS) into the wilderness by cell phone and helicopter instead of into a city by telephone and ambulance.²⁸

So while there may be continued interest in protecting the magic, there is also interest in mitigating its cost. Whether that sensitive balance can be tipped in favor of cost mitigation without loss of magic is heavily debated in wilderness communities, where it is often termed “acceptable risk.”^29(p.xv) In the context of that discussion, it is fascinating to read a wilderness medicine school define much of what we call wilderness medicine as increasingly a simple wilderness extension of EMS—the very topic of this book.

A second point, more relevant to this book, is that training in wilderness medicine has traditionally and historically focused on what to do until help arrives. This is the core of “first aid” types of medical care (discussed in more detail in the Regulation section of Chapter 1). One of the most improbable public health stories of 20th-century America is the rapid and successful development of a sophisticated and relatively unified EMS system organized to ensure that help would indeed be arriving. As discussed in Chapter 1, many today are not aware that the entire 911 system, and the availability of credentialed and highly trained field medical providers it dispatches to citizens in need, is less than half a century old, and yet is already taken for granted as a necessary community resource. We will also demonstrate in Chapter 1 that throughout the 20th century there was unprecedented attention to medical care in wilderness areas (“wilderness medicine”), intensifying as the century progressed. As EMS and wilderness medicine evolved and commingled in the later part of that century, a merged subdiscipline evolved.

While the field of wilderness medicine in the 21st century has grown far more expansive, an early and core principle of wilderness medicine was that it taught skills allowing a condition to be temporized in the field until “formal health care” or more traditional EMS care could be applied.³⁰ In some cases, this was via routine health care after leaving the wilderness. However, for more serious emergencies, training on what to do “until help arrives” presupposes help will be arriving. More specifically for wilderness medicine, it presumes that wilderness EMS help is available, accessible, deployable into the wilderness, and functional and effective in that environment.

The endeavor to satisfy that expectation—which, as noted earlier, harkens back to the very roots of our shared hominid experience—is the precise topic of every remaining page of this book.

THE STRUCTURE OF THIS BOOK

This textbook divides into three sections.

Section 1 discusses principles of WEMS systems. This includes an overview of the history and current state of WEMS systems, including definitions of terms, in Chapter 1; a review of WEMS educational offerings for further training in this field in Chapter 2; and specific discussions of how incident command (Chapter 3), medical oversight (Chapter 4), medicolegal considerations (Chapter 5), equipment needs (Chapter 7), research (Chapter 8), and pharmacology (Chapter 11) are implemented in a WEMS context. In Chapter 6, we discuss how WEMS providers interface with professional organizations and guides as well as other health care professionals. Chapter 9 explores the ways wilderness event medicine overlaps with, or works within, a WEMS structure. And in one of our most innovative chapters, Chapter 10, we discuss the ways in which neurobiology and psychopharmacology are driving a new treatment modality, known as psychological first aid, designed to improve patients’ and providers’ resiliency, self-efficacy, and capacity building in austere environments. The experience of wilderness itself is often a means to combat social trends toward entitlement and selfishness. Discussions in this chapter encourage individual self-efficacy at the psychological level, a critical skill in wilderness rescue operations.

Section 2 discusses the management of specific medical conditions. We begin with a discussion of survivalism and personal safety in Chapter 12. The ability to operate safely in their niche wilderness environment is a fundamental need for all WEMS providers. This chapter also provides important skill sets that can be taught to the public (eg, potential subjects and patients) before their emergency situation arises, providing the opportunity for preventive search and rescue (SAR).³¹ We then discuss cold injuries (Chapter 13), heat illnesses (Chapter 14), lightning injuries and WEMS management of storms (Chapter 18), management of animal bites and envenomations (Chapter 19), and management of psychiatric and behavioral emergencies in the wilderness (Chapter 23). We ascend to altitude to discuss low-pressure altitude physiology and illnesses in Chapter 15; we submerge into water to discuss drowning in Chapter 16; and then descend to even greater aquatic depths to discuss high-pressure diving physiology and illnesses in Chapter 17. In Chapter 20, we divide our discussion of infectious disease management into two parts: The first addresses infectious diseases associated with wilderness environments, and the second addressing more commonplace infectious diseases and their management that happen to occur in the wilderness environment. We discuss the management of general trauma conditions occurring in a wilderness setting in Chapter 21, and the management of general medical conditions occurring in a wilderness setting in Chapter 22.

In Section 3, we describe the medical interface WEMS providers must make with technical rescue operations. Our book is intended primarily for EMS medical providers working in a wilderness environment. However, this wilderness environment means that WEMS providers must have technical skills, and often (just as in the front country, with the common combination of Fire-Rescue-EMS operational teams) WEMS operators must combine technical rescue skills with medical skills. An introductory chapter frames this issue in Chapter 24, covering principles of basic rigging, patient packaging, and rope skills requisite for nearly all specialty fields. Then we move on to specific technical rescue interfaces, including chapters on high and low angle rescue (Chapter 25); swiftwater rescue (Chapter 26); open water rescue (Chapter 27); the use of vehicles in rescue operations and medical care (Chapter 28); caving rescue (Chapter 29); general SAR and mountaineering rescue on terrain without snow or glaciers (Chapter 30); and finally SAR, mountaineering, and ski rescue in alpine environments where there is snow or glaciated peaks (Chapter 31).

WORDS MATTER IN WILDERNESS EMS

Why Words Matter

Another central function of this book is both to establish and use appropriate language in characterizing WEMS operations and theory. We must acknowledge the importance of the language we use, and the care with which we need to use it. It has been argued elsewhere that, in medical care in particular, “words matter.”³² Wilderness medicine authorities such as Auerbach and Lemery have proposed that inherent in wilderness medicine is the need to act as good stewards of natural resources, and specifically those wilderness areas we use.³³^,³⁴ This has become relatively noncontroversial. Similarly, but far more provocatively, McEntyre advances the theory that we must also consider what it means to be good stewards of language. She argues that language is life-sustaining and that “caring for language is a moral issue.”³⁵ We would take the concept of the life-sustaining element of language further and argue that caring for language is also a clinical issue. Wilderness EMS is a medical field where, in particular, words have many different meanings, with extensive legal and medical potency and complexity. From a more pessimistic perspective, Orwell argued that “the decline of a language must ultimately have political and economic consequences”³⁶—and the consequences for clinical medicine are equally dire. A theory in linguistic anthropology—most compellingly captured by Whorf’s work in the early 20th century on linguistic relativity and linguistic determinism—suggests that language critically influences the way one interacts with and understands one’s world, and may even mutually construct such interactions, rather than merely reflecting them.³⁷ We create language, but conversely, the language we use may be operative in framing—or
even creating—our reality, both clinically and globally. In the late 20th century, linguistic anthropologists further developed a theory of entextualization of language in medicine that explains how nuances of communication and language can fundamentally affect diagnosis, treatment, patient satisfaction, and even patient outcome itself.³⁸ For this reason, we have put considerable thought into the words we use and how we use them in this text.

The idea that “words matter” not only morally, but also clinically, goes even further. As explained in Chapter 10, new neuropsychiatric findings have suggested that the words we choose as caregivers have a significant impact on the outcome of our patients, warranting even more care in our use of language. As posited earlier, of the tools of civilization that we choose to take into the wilderness, our minds and our problem-solving are the most powerful, and a critical form of those tools is language. The usefulness of these tools is either heightened or degraded by our ability to transfer this knowledge into workable form through language. Therefore, the power of language to assist in problem-solving is almost immeasurable—but misused, the potential damage can be equally vast. To express this in a WEMS example, otherwise brilliant team leaders at a command center are nonetheless useless if, when given a radio, they are utterly incapable of communicating instructions to a team in the field. Words matter, as does care in their use.

In keeping with that principle of care in the use of language, Table I.1 describes words we will be using in this book, and encourage among the WEMS community, along with their less preferable alternates. Word choice is often dismissed as “mere semantics” (although do not forget the actual definition of semantic is fundamentally related to meaning, not to trivial detail, despite its popular use), or worse, as “political correctness.” Without getting into that social debate, we have found, as shown below, that the medical functionality of these words is directly tied to their correct use. Our agenda is not political but medical and clinical—the ultimate goal in promoting careful language is to improve patient care as well as the capabilities and knowledge base of caregivers. Choices in word use are like other evolutions or clinical decisions in medicine, as will become apparent throughout this book. For example, in Chapter 6, we discuss issues in the interfacing of WEMS teams and traditional EMS or medical teams, with one of the significant challenges being shared language conventions. Chapters 21 and 24 discuss the very real differences implied by changing discussion from “spinal clearance” to “selective spinal immobilization” to “spinal motion restriction” (SMR) and ultimately to “spinal cord protection,” (SCP) all describing activities that are similar in operation but very different in meaning. In Chapter 25, we describe the difficulties in WEMS field operators and emergency medical dispatchers (EMDs) often experience in understanding route names used by climbers. A similar problem exists for both paddlers and hikers as well as any recreationalists using route
names unique to their community. In Chapter 25, we also point out that multiple such recreational communities have different names for the same environmental features, creating a modern Babel in the wilderness, and severely complicating WEMS operations. Emphasizing a somewhat different use of language, we point out in Chapter 6 that “exceptional documentation leads to exceptional continuity of care,” with the reverse being true as well: That continuity of care and handover failures have been identified as one of the most frequent sources of medical error. As mentioned earlier, Chapter 10 describes the potentially therapeutic benefits of language itself in the wilderness.

Table I.1 Precision and Accuracy in WEMS Terminology

Preferred Word/Phrase/Initialism	Less Preferred Word/Phrase/Initialism
Advanced Practice RN (APRN)	Advanced Care Provider Advanced Practice Provider Mid-Level
Drowning	Dry drowning Wet drowning Secondary drowning Delayed drowning
ECG	EKG
ED	ER
Non-fatal drowning	Near-drowning
OEC technician	OEC-T
Out-of-hospital or OOH	Prehospital (unless patient known to be delivered to hospital)
Overwhelmed	Traumatized (for emotional trauma)
PA	Physician assistant Physician’s assistant Advanced care provider Advanced practice provider Mid-level
Patient (after care established)	Victim
Spinal cord protection	Spinal immobilization Spinal motion restriction
Structured activities, community support therapy	Counseling Treatment
Subject (before care established)	Victim
Suspension syndrome	Suspension trauma

Word choice demonstrably impacts clinical outcomes and error. For example, we acknowledge the work by the Institute for Safe Medication Practices and others in identifying abbreviations that can be misunderstood and lead to medical error. In this book we follow the conventions established by the ISMP, the US Food & Drug Administration, The Joint Commission, and the 2004 National Summit on Medical Abbreviations.³⁹^,⁴⁰^,⁴¹

In wilderness medical care, words demonstrably do matter. Our goal for words should be the same as our goal for medical data: that it be precise, accurate, and meaningful.

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