WEMS Systems

Seth C. Hawkins

INTRODUCTION

As discussed in our preceding chapter, wilderness EMS (WEMS) is the system-based practice of wilderness medicine. Therefore, it makes sense for our first chapter describing WEMS to analyze the ways it operates as a health care system.

DEFINITIONS OF TERMS

“EMS,” “wilderness,” “wilderness medicine,” and “wilderness EMS” are all terms with varying definitions. Words matter, and establishing strict definitions and using them correctly is essential to genuine understanding, as discussed in our Introduction chapter.

Definitions of Wilderness and Wilderness Medicine

In our Introduction chapter, we proposed an abstract and conceptual definition of wilderness medicine: wilderness medicine is medical care and problem-solving in circumstances where the surrounding environment has more power over our well-being than does the infrastructure of our civilization. That definition is useful in the context of a more philosophical and anthropological discussion of wilderness medicine. But more specifically operational and clinical definitions have been proposed. In the context of WEMS care, Auerbach’s Wilderness Medicine defines wilderness in this way: wilderness is those areas where fixed or transient geographic challenges reduce availability of, or alter requirements for, medical or patient movement resources.¹ For us as health care providers, this definition of wilderness is more useful than more general dictionary-based definitions of “a tract or region uncultivated and uninhabited by human beings,” or “an area essentially undisturbed by human activity together with its naturally developed life community,” or “an empty or pathless region,” or other 21st-century generalized definitions.² Auerbach’s definition of wilderness is echoed by the National Association of EMS Physicians (NAEMSP), who further suggest that “wilderness” be defined locally.³

Other EMS textbooks have also proposed that “wilderness” must be contextual.⁴ The idea of a contextual definition in medical care reflects a broader reality about the wilderness. As discussed further in the Introduction chapter, all post-Industrial Revolution definitions of wilderness are contextual inventions. They say as much or more about the cultural use of the word as they do about any independently defined ecological reality. Consequently, with this word, specific context of use (in this case, a medical context) becomes even more relevant. Building on its contextual definition of “wilderness,” Auerbach’s Wilderness Medicine goes on to define “wilderness medicine” in this way: wilderness medicine is medical care delivered in those areas where fixed or transient geographic challenges reduce availability of, or alter requirements for, medical or patient movement resources.¹

In this text, we will follow the convention established by Auerbach for definitions of wilderness and wilderness medicine. Such a wilderness medicine definition also mirrors other similar definitions in the medical literature that emphasize austere environments, resource limitations, and impairment of timely access to more advanced care.⁵^,⁶^,⁷

This definition of wilderness medicine is both more comprehensive and more specific than definitions that are based exclusively on time, resources, or location.⁶ Each of these alternate definitions has critical failures in capturing wilderness medicine practice.³^,⁸ The time definition (usually more than 1 hour, or sometimes more than 2 hours, from “definitive care,” often citing the “Golden Hour”) is perhaps most common.⁹ But this time-based definition fails to define “definitive care,” as well as excludes care occurring within 1 to 2 hours of definitive care that still certainly qualifies as wilderness medicine.³ In addition, the significance of a “golden hour” in out-of-hospital emergency medical care is exceedingly controversial and increasingly felt to be mythical. Such challenges to the “golden hour” concept
make its use as the foundational definition of wilderness medicine problematic, especially if defined as a literal 60 minute window.¹⁰^,¹¹^,¹²^,¹³^,¹⁴^,¹⁵^,¹⁶^,¹⁷^,¹⁸^,¹⁹^,²⁰ The resource definition inappropriately excludes many WEMS operations from wilderness medicine, as WEMS operations frequently have access to resources not available to typical EMS systems (eg, the high altitude helicopters available in some national parks as discussed in Chapter 28). A definition based on location ignores the fact that even major urban centers can include features of wilderness medicine, both in terms of routine practice,²¹^,²² in geographic areas such as some of the huge American urban parks, or during disasters. This conviction that wilderness medicine can be anywhere is embodied in the Gusteau Principle: any location in America can include features of wilderness medicine and require WEMS management.⁸,^*

In 2012, Frank Hubbell published definitions of various stages of WEMS medical care that may be useful in further defining subtypes of wilderness medical care. Specifically, he defined extended care as care lasting from 1 hour to 24 hours. This matches well with an EMS perspective that an EMS activity lasting more than an hour is an extended medical operation, although some WEMS operations may be completed in less than an hour. He defined remote medicine as care in areas where no definitive care is available.²³ Indeed, these terms are so foundational that they became the basis of the cover art for his 2014 textbook WILDCARE.⁹

That definition of “remote” also matches a growing use of the term remote in the medical industry to mean an area where more formal medical care must be definitively inserted. This is similar to the meaning implied, for example, by Remote Medical International (RMI). RMI provides medical infrastructure for clients and industries working in “remote and challenging” environments, which they define as areas where traditional medical care is challenged or diminished by “geographic location, work conditions, environmental extremes, political instability, or regulatory environments.”²⁴ They provide an integrated medical support model providing continuity of care throughout the life cycle of a project, of which WEMS or WM training may only be a part, and which speaks to the need in a “remote” area to replicate an entire medical infrastructure.

Definition of EMS

Although EMS is taken for granted in contemporary society, it is a very recent innovation in the history of medicine; indeed, the formal existence of EMS is one of the most significant public health stories of the 20th century. Though the meaning of “EMS” is often taken for granted, debate has arisen regarding what is and is not considered EMS or part of an EMS system. A precise definition is needed to resolve such questions. Amazingly, it was not until 2012 that a consensus definition was published, when the National Association of State EMS Officials (NASEMSO) defined EMS as “the integrated system of medical response established and designed to respond, assess, treat, monitor, observe, and determine the disposition of patients with injury or illness and those in need of medically safe transportation.”²⁵ That definition has been widely adopted by EMS organizations, and is of great utility in navigating questions of “what is EMS” in terms of wilderness medicine. It will be the definition of EMS used throughout this textbook. Further clarifying that definition, NASEMSO emphasizes the primary health care focus of EMS, as well as its role as a vital component of emergency preparedness systems. We agree that EMS as applied in wilderness areas contains critically important elements of public health and emergency preparedness. NASEMSO also specifically notes the inclusion of multiple casualty incidents, mass gathering events (Chapter 9), medical oversight (Chapter 4), education (Chapter 2), and research (Chapter 8) as within the purview of EMS. They go on to clarify that “anyone participating in any component of this response system is practicing EMS… EMS is the practice of medicine and as such, any of the activities that constitute EMS require oversight by a physician.”²⁵ They specifically exclude the following from an EMS definition: Good Samaritan care (as they define such care); basic first aid, cardiopulmonary resuscitation (CPR), and public access defibrillator use available outside the established EMS system; care, unrelated to the EMS system, rendered by professionals within an established health care facility; public health programs and home health care programs unaffiliated with an established EMS system. These are also important modifiers of an EMS definition for wilderness applications.

However, as noted in the Introduction chapter and later in this chapter, EMS has long recognized the critical role of first aiders, bystanders, and community support in providing care prior to the arrival of EMS.²⁶ In many cases, from a public health and patient advocacy standpoint, EMS serves as the organization that promotes first aid and community health interventions. In wilderness areas, first aiders and ad hoc caregivers are often the primary care providers for extended periods—even hours or days—before EMS arrival, unlike many other EMS systems, and so a WEMS system must pay even more attention to the role and training of such first aiders. Because of this, our text includes extensive discussion of ways WEMS systems can promote quality care by such first aiders and Good Samaritans. At the same time, it is particularly important to acknowledge that, by definition, basic first aid and Good Samaritan care are not formally part of EMS. Therefore, formal definitions of “basic first aid” and “Good Samaritan care” become important, and are discussed later in this chapter.

Definition of Wilderness EMS

Building on the definitions of “wilderness” and “wilderness medicine” above, in this text we define “wilderness EMS” as follows: “wilderness EMS is the systematic and preplanned delivery of wilderness medicine by formal health care providers.”1 The scope of WEMS includes, but is not limited to, the topics represented by the various chapters of this book.

RELATIONSHIP BETWEEN EMS, WM, AND WEMS

Understanding the relationship between wilderness medicine and EMS—not just how they are defined, but how they intersect and operate in real-world activities—is crucial to understanding the unique role of WEMS in the medical world.

In 1990, Bowman attempted to define these operational categories in a landmark publication in the Journal of Wilderness Medicine.²⁷ He proposed two separate tracks for caring for the ill and injured: a “professional medical track” and a “prehospital emergency care track.” While these definitions reflected a status quo in the middle of the 20th century, they are no longer useful in defining out-of-hospital care. Even when applying his own definitions, Bowman described overlaps, and those overlaps now eclipse any benefit from these definitions. As noted in our introductory chapter, the term “professional” now encompasses volunteers, and out-of-hospital providers (as well as emergency care providers of all sorts) are now all considered professionals. In addition, the modern concept of EMS as mobile integrated health care argues for its inclusion within the overall health care system rather than preceding it. The model of integrated care makes distinctions between “hospital” and “non-hospital” less meaningful, as care that was once considered exclusively “hospital” is more and more integrated into out-of-hospital operations. Put most simply, “prehospital emergency care” is now a common “professional medical track” delivering treatments that were once exclusively “hospital-based,” rendering such distinctions largely meaningless. We will discuss this more in Chapter 2 as we explore educational frameworks and the modern credentialing process for WEMS providers.

However, Bowman was pointing to an important distinction that still exists: ad hoc wilderness care delivered by recreationalists who do not have a duty to act, versus formal wilderness care delivered by system-based credentialed providers who do have a formal duty to act. This credentialing and duty to act, more so than professionalism or where the care is delivered, is the meaningful distinction in 21st-century medical care in the wilderness.

In Chapter 26 we propose the distinction between a “recreational rescuer” and a “professional rescuer.” It must be made clear that “professional” in this term does not necessarily mean “paid,” and that “recreational” refers to the primary activities of the caregiver in the wilderness and not their relationship to the rescue (no rescue is recreational!). With such caveats, these terms may be the best current way to understand the distinction between ad hoc care and formal care, and the caregivers who deliver it.

The transition zone is in those providers who do prepare to deliver care via formal certifications. Examples would be wilderness guides and experiential education leaders for organizations such as Outward Bound and NOLS. As discussed further in Chapter 2, a standard has evolved in this outdoor industry that such professionals should be trained in wilderness medical care, usually to the Wilderness First Aid (WFA) or, more often, the Wilderness First Responder (WFR) level. These are undoubtedly formal medical certifications that involve a scope of practice and a set of standards. In addition, these providers may have established a duty to act through any implied contractual obligations in the literature they share with clients describing the requisite medical qualifications of themselves or their staff.

However, within a medicolegal context, while wilderness guides and experiential education leaders may carry medical certification and may have a limited duty to act, their medical certifications and duty to act fit most closely within the definition of first aid. As shown elsewhere—including our Introduction, Education (Chapter 2), and Legal (Chapter 5) chapters—“first aid” is an extremely contested term whose meaning may be contextual. The International Liaison Committee on Resuscitation (ILCOR) published a 2015 international consensus definition of first aid as “the helping behaviors and initial care provided for an acute illness or injury.”²⁸ ILCOR clarifies that “first aid can be initiated by anyone in any situation,” and that its goals are “to preserve life, alleviate suffering, prevent further illness or injury, and promote recovery.” Somewhat less usefully, they define a first aid provider as “someone trained in first aid who should recognize, assess, and prioritize the need for first aid; provide care by using appropriate competencies; and recognize limitation, and see seek additional care when needed.”²⁸ This nearly tautological definition of first aid provider could be applied to any health care provider type, replacing the word “first aid” with that other care type, and begs the question of how much training is needed to perform tasks that can by definition be done by anyone at any time. However, the underlying definition of first aid, tied to the concept that it can be initiated by anyone in any situation, is functional, and is the definition that will be used throughout this textbook when “first aid” is discussed, with the additional modifier that such care should be unanticipated, uncontracted, and ad hoc—in other words, applied without a duty to treat. This distinguishes it from EMS, where the delivery of care is anticipated and planned, and this ad hoc nature is also sometimes referred to as “Good Samaritan Care.”

Importantly, the ILCOR definition also confirms that first aid is the unregulated practice of medicine. The concept of
first aid as a form of medical care, and should be applied using universal modern medical care principles, is further confirmed by ILCOR, who state that “first aid assessments and interventions should be medically sound and based on evidence-based medicine (EBM) or, in the absence of such evidence, on expert medical consensus.”²⁸

While some WEMS systems do employ WFA as a minimum standard, in general, wilderness activities that are not operating within the EMS system will certify staff at the levels of WFA or WFR. In general, skills and scopes of practice within these certifications do not require medical oversight and are not regulated by state EMS organizations. Most often, EMS systems—wilderness or otherwise—will certify staff at the levels of emergency medical dispatcher (EMD), wilderness emergency medical technician (WEMT), wilderness paramedic, or wilderness clinician. The medical oversight point is also helpful in understanding the distinction between WEMS and wilderness medicine. While there is not an exclusive distinction here, in general, activities for which state regulatory bodies require medical oversight are more consistent with WEMS. Activities considered to be simply first aid and not requiring oversight (although we feel clinician input is always a benefit) are more consistent with recreational wilderness medicine. The differences in medical oversight/direction versus medical advising are discussed in more detail later in this chapter, and medical oversight in general is the entire topic of Chapter 4.

In addition, remember that first aid does interface with EMS and plays an important role within its operations as care delivered before formal providers arrive. Such citizen-based care has been crucial to many of the successes of EMS in the 21st century and is well recognized as an important element of the out-of-hospital chain of survival. Therefore, a recognized interface between these two types of care (formal “professional” EMS care and informal “recreational” first aid care) already exists within the standard out-of-hospital care model in the United States.

Finally, there is an element of intent, which gets back to Bowman’s original framework. The actual care delivered by professional EMS providers or by recreational first aid providers may be identical. In fact, most experts feel the fundamental principles of basic life support (BLS) interventions are likely more important to effective wilderness and emergency medical care than more advanced (ALS) interventions, and this is a pervasive theme of this textbook.²⁹^,³⁰^,³¹ For example, given a patient in cardiac arrest, high quality CPR is the most important intervention, which should be the same regardless of the credential of the provider delivering it. If the actual care is the same, then the final distinction is the intent of the caregiver in delivering that care.

The primary intent of professional EMS personnel dispatched to a medical care operation is health care. The primary intent of recreational rescuers who find themselves involved in a medical care operation is not health care, even if it is planned for by developing protocols, carrying medical kits, and training. Another important use of this concept of “intent” is for providers with autonomous medical licenses, such as physicians, who find themselves in a health care role in the wilderness. An example would be physicians delivering medical care on an expedition. The care such physicians deliver would be the same whether they are expedition clients or expedition physicians. However, clearly the medicolegal expectations and their role within the health care continuum are different. Once again, it is the intent that clarifies this. If they are a team physician, and their primary role and purpose on the expedition is to deliver medical care, this is a WEMS role. If they are a team member who happens to be a physician, and their primary role is not to deliver health care to others, then any role they do take on is more general wilderness medicine. This also explains the role of a clinician who unexpectedly comes upon an incident. Such a case might be a broken leg on a ski slope. Two people ski up to help—an orthopedic surgeon skiing for recreation and an on-duty ski patroller. The orthopedic surgeon would be practicing general wilderness medicine, while the ski patroller would be practicing WEMS, even if the precise care they both deliver is identical. This example also shows the scope of practice of general wilderness medical care, depending on the certification/licensure level of the provider, may actually exceed that of WEMS care.

In summary, there are many ways that WEMS and general wilderness medicine intersect. However, the most helpful ways to distinguish them are certification type, duty to act, presence of medical oversight, and intent of care. Characteristics more consistent with WEMS care are non-first aid certification types (EMD, EMR, EMT, clinician), a demonstrable duty to act which is a primary intent, and the presence of medical oversight for non-independent certifications.

Medical Advisors and Medical Directors

The Difference Between a Medical Advisor and a Medical Director

The difference between a “medical advisor” and a “medical director” is contested, in many of the same ways as the distinction between general wilderness medicine and WEMS.¹ However, the distinction outlined in that discussion can also serve to clarify the difference between advisors and directors. In general, medical advisors serve organizations whose primary purpose is recreational (meaning it primarily fields “recreational rescuers”) and who plan to provide general wilderness medicine, while medical directors serve organizations whose primary purpose is medical and who plan to provide WEMS services.

More specifically, the difference between medical advisors and medical directors is contextual and functional. To understand this, it is helpful to imagine a single WEMT serving as a member of both an Outward Bound school and a Mountain
Rescue Association team, both of which also have the same physician as medical advisor (Outward Bound) or medical director (Mountain Rescue Association team). In each case, the EMT and the physician are both the same person, with the same certifications and the same training. It is the context and the role they take that define the difference between their activities, not any objective definitional line or difference in them, their training, or for the most part their practice. Nothing encapsulates this blurring better than the historical fact that Outward Bound’s foundational origins—even its name—are intrinsically connected to marine rescue services.³²

However, there are still critical differences.

Traditionally, the term “medical advisor” indicates a consultative role in which a health care provider advises an organization regarding their medical and risk management activities. The title implies no specific authority, would appear to have more limited medicolegal risk, and is most appropriate for those cases where no specific scopes of practice beyond first aid are being activated by the provider.

In contrast, the term “medical director” indicates a degree of authority beyond that of an advisor. A medical director is necessary if the services offered by the provider include the activation of EMS-specific scopes of practice, which is of importance for providers at multiple levels, including the BLS level. It is our conviction that BLS EMS services benefit from qualified medical oversight as much as ALS services do. We recognize some other authors and institutions argue that organizations preparing for first aid-only or BLS-only care may use medical advisors, and that anything above this level requires medical direction. However, this argument suffers from a significant flaw: namely, that “first aid” and “BLS” themselves are contested terms with multiple meanings. It is unclear whether a WFR, for example, is operating as a first aid level practitioner within their scope of practice and does not require medical oversight, or is acting as an EMS provider via a state-recognized First Responder certification which requires medical direction. It is for reasons such as this that the EMS transition to “Emergency Medical Responder” rather than “First Responder” will likely bring clarity to this situation. Some states permit BLS providers—generally considered to be providers operating at the EMT-Basic, first responder, or medical responder level—to provide care without formal medical oversight, although this action is not supported by NASEMSO.¹^,³³ Again, however, this regulatory reality begs the question whether BLS care without medical oversight is appropriate. Our position is that the salient distinction as to whether medical direction (versus oversight) is needed is whether the system is EMS or not, rather than whether the care delivered is BLS or ALS.

Based on NASEMSO position statements,³⁴ consensus position papers,³⁵ and medical standards, all EMS systems, including those operating in the wilderness, should strive to establish physician-led medical oversight.

Our contention would be that the term medical advisor should be confined to those situations where health care provider input is purely advisory and is not being used legally or operationally to activate or support any certification levels or EMS-grade protocols (ie, protocols beyond what would typically be considered first aid).

The title and role of such advisors highlight two of the most important issues sometimes missing from these debates: the existence of real out-of-hospital patients and the importance of increased physician involvement in their care. Whether we call someone a medical advisor or medical director, or whether we call the system they work within WM or WEMS, may be less material than recognizing that there is a patient in need and a critical role for a physician to perform. In that sense, a more important concept than choosing a precisely correct term is acknowledging the reality that an individual in duress is a legitimate patient, despite circumstantial location in the wilderness, and deserves care directed by a physician.

The Role of PAs and APRNs in Medical Direction and Medical Advising

One of the most contentious topics in WEMS today is whether nonphysicians can serve as medical advisors or medical directors. Nonphysician clinicians in WEMS operations include PAs (formerly known as physician assistants)^* and advanced practice registered nurses (APRNs). Here, careful parsing of the two terms may again be helpful. As we have insisted, words matter, and terminology for nonphysician clinicians represents a rapidly developing nomenclature amid a dynamic health care culture.

PAs became active in American health care following the reintroduction of military medics into civilian practice. Civilian medical systems recognized their advanced training and practice skills, and in the absence of a clear niche in which they could insert those skills into civilian practice, a category of “physician assistant” was pioneered at Duke University and soon implemented elsewhere. It is ironic that, while their historical heritage sprang from austere and battlefield medical care, the modern PA is more often utilized in clinicand hospital-based medicine, and EMS is a more unusual application for this credential.

While most American providers and patients are familiar with the nurse practitioner (NP) credential, in fact, four separate nursing licenses exist permitting autonomous or advanced
practice for registered nurses (RNs) of which NP is only one,^* making advanced practice RN (APRN) the more comprehensive name for this type of provider.

When considering a medical advisor, clearly a candidate should have a background that matches the operational needs of the institution. In that sense, precise medical credentialing may be less important than an individual’s other qualifications to function as a “medical advisor” for a wilderness-based organization. Nevertheless, we continue to think that clinician-level providers in general provide the most appropriate and comprehensive medical advisor services. In most cases nonphysician clinicians work in collaboration with a physician to provide this type of service, bringing a physician to the equation as well.

On the other hand, “medical director” implies a specific EMS, regulatory, and legal role, the requirements for which are often dictated by state rules or practice. So, for example, in some states nonphysician clinicians can serve as medical directors, while in others their role is confined to assistant medical directors, and in still others they cannot have any medical director role whatsoever. At this time, it does appear the most consistent practice across the country is to confine primary medical director roles to physicians. However, the underlying point and purpose is that the system have physician-level medical oversight, rather than that the individual position be held by a physician. So, for example, physician assistants must always have physician-level collaboration.³⁶ Therefore, a PA serving as a program’s medical director will still have physician collaboration, even if the titular role of director is held by a PA. This becomes more complicated in the case of APRNs, who are capable of autonomous medical practice, and whose medical practice is often dictated by a separate regulatory body—a state board of nursing, whereas EMS is most often regulated by a state medical board. Since nursing has a much smaller footprint in EMS, largely confined to air medical transport units, the role of autonomous nurse practitioners is an extremely esoteric issue best addressed by analyzing local and state circumstances and regulations. The overall principle is this: the ideal and most common arrangement for a WEMS system is the provision of immediate physician-level medical oversight, but other frameworks utilizing delegated, collaborative PA oversight or APRN involvement may be necessary and appropriate in certain systems.

Regulation and Accreditation

The question of medical advisors versus medical directors, as well as the overarching dialogue in wilderness medicine and WEMS about standardization, is intrinsically connected with the issue of regulation. Regulation has been an increasingly pressing and contentious issue in wilderness medicine and WEMS over the past few decades, and it is likely to increase in importance. As early as 1996, the Wilderness Medicine Newsletter noted, “Standardization, accreditation, risk management—these are the buzz words of the 90s when it comes to outdoor education and adventure programming.”³⁷ A classic case study is the issue of ski patrols, which fall into very different regulatory categories in different states, ranging from nonregulated first aid providers outside the EMS system in some states to formally regulated providers within the EMS system in other states.³⁸

The problem of regulation is particularly difficult for WEMS, which represents a merger of what has historically been one of the least regulated types of medicine (wilderness medicine) with one of the most regulated types (EMS). A clean distinction from a regulatory perspective would be to declare that wilderness medicine does not require regulation and WEMS does. Despite its appealing simplicity, deeper scrutiny blurs the crispness of this dividing line. Some issues have been discussed earlier, such as the line between first aid and formal medical care, or the question of whether teams of providers such as lifeguards and ski patrollers are practicing wilderness medicine or WEMS.

Not only is there a conceptual difficulty in terms of the degree to which WEMS should be regulated, there is also simply a numerical and cultural evolution in regulation in our society. In the years from 1970 (the beginning of the WEMS Golden Age of Growth as described below) to 2015, total pages of federal regulations have increased nearly fourfold, from 20,000 to over 80,000.39 While EMS is largely regulated at the state level, EMS educational organizations have cited similar growth patterns with relevance in out-of-hospital medicine, noting that being aware of regulations and working to comply with them can be burdensome and occupy significant staff time and resources.⁴⁰ Another element of regulation is requisite licensure^†. In the 1950s, less than 5% of overall American workers were required to have licensure; by 2008, that percentage was estimated to be almost 29%.⁴¹ Currently all states and the District of Columbia require licensure of EMTs, which has been cited in the labor literature as one of the occupations with the highest number of states requiring licensure.⁴² This makes EMS in general one of the most highly regulated industries in terms of licensure; extending such regulation to WEMS could be an expected future evolution for cultural reasons, as well as for legal reasons as an instance of the practice of medicine, historically a heavily regulated industry itself.

In the sense of the ILCOR definition of first aid cited earlier, many elements of wilderness medicine are similar to first aid and may be seen in a Good Samaritan context, at least insofar as they are differentiated from WEMS. One helpful way to think of the
regulatory difference between first aid and EMS would be not definitional but rather functional and contextual. In other words, the difference cannot depend on either individual people or their defined credential, but rather the role they are serving and the context in which they are delivering care. Consider for example that, as discussed further in Chapter 31, in Utah a ski patroller is (by legislated definition) providing first aid, while in Maryland that same ski patroller is (by legislated definition) providing EMS care. Or that in North Carolina and the majority of other American states, an American Red Cross-credentialed First Aider—or a layperson reading the Outward Bound Wilderness First-Aid Handbook and applying its teachings as unregulated “first aid”—has a wider scope of practice to treat dislocations than a credentialed paramedic.⁴⁴^,⁴⁵^,⁴⁶

This functional distinction between WM and WEMS fits a more expansive definition of wilderness medicine. The actual practice of WM is extremely broad, including space medicine, marine medicine, elements of tactical and disaster medicine, and many others beyond the original conception of care delivered on an outdoor trip or other, more dated definitions discussed earlier. The expedition physician or the medically credentialed astronaut or the remote jungle clinic medical APRN are legitimate wilderness medicine practitioners, not EMS practitioners; they are certainly not practicing first aid in its ad hoc sense, but they also likely do not need to be particularly regulated beyond the regulations already attached to their respective credential. On the other hand, those functional attributes of wilderness medical care that fall within the NASEMSO definition of EMS ²⁵—generally speaking, multicredentialed teams, often working from delegated practice models, preassembled to provide care in a specific jurisdiction using preset protocols or medical oversight—would deserve regulatory attention.

A flip side to the involuntary nature of regulation is accreditation. According to the Business Dictionary, accreditation is “certification of competence in a specific subject or areas of expertise, and of the integrity of an agency, firm, group, or person, awarded by a duly recognized and respected accrediting organization.”47 Examples of this can already be seen of this in the credentialing of individuals discussed earlier from a regulatory standpoint. In this educational and organizational context (and the American Heritage Dictionary affirms that this term is especially used in the context of educational institutions),⁴⁸ accreditation is a voluntary process by which organizations are recognized to meet certain standards; although as accreditation becomes more powerful, its voluntary nature becomes increasingly theoretical, as market or regulatory forces compel organizations to comply with accreditation. An important component of the definition cited here of accreditation is the qualification and authority of the agency granting accreditation. A critical question to ask is where the accrediting agency itself is recognized and qualified to serve as a credentialing body for the industry or organization it is ostensibly accrediting.

Given that standardization is one of the defining problems of the consolidation era of the 1980s to early 2010s described later, accreditation represents a potential solution and possible direction for WEMS educators and practitioners, and has in fact been cited as a form of “self-regulation” (discussed later in this section) and an alternative to external, likely governmental, regulation.⁴⁹^,⁵⁰ It may play a supportive role for prospective students navigating multiple educational opportunities in wilderness medical and WEMS training, by setting a baseline expectation of their experiences and allowing them to compare programs. Historically and currently, there has been a caveat emptor (“buyer beware”) model often attributed to the industry of wilderness medicine and WEMS education⁵¹^,⁵²^,⁵³^,⁵⁴ and this could help improve that situation. In addition, accreditation or other forms of regulated standardization can be helpful for organizational leaders such as rescue teams hiring or accepting personnel; famously, a group of concerned leaders of outdoor organizations at the 1994 Wilderness Risk Managers Conference noted that the “tremendous proliferation” of wilderness medicine certifying schools meant that they “didn’t know whose certifications to accept.”⁵³ And as an example from elsewhere in the house of medicine, accreditation plays a critical role in the functionality and professional standing of physician-level fellowships, as noted elsewhere in this chapter and in Chapter 2. It may come to play a more significant role in non-clinician (BLS and ALS) training and practice as well, and eventually represent an industry standard that, while ostensibly voluntary, comes to take on more of a regulatory feel if accreditation becomes critically important to credibility and industry positioning for education and regulated practice for clinical care. Currently, a primary EMS accrediting body is the Commission on Accreditation for Pre-Hospital Continuing Education (CAPCE), formerly the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS). One area of growth in regulation and accreditation would be the recognition of outdoor schools and wilderness medicine schools as accredited institutions of higher learning. In 2013, Landmark Learning became the first outdoor school to be accredited as an institution of higher learning by the U.S. Department of Education via the Accrediting Council for Continuing Education and Training (ACCET) (see Figure 1.1). Such accreditation will likely continue to expand in the industry, both for educational institutions and clinical patient care organizations, and will likely form another element to the standardization and regulation debate and evolution in this field. Some argue that minimum competencies and accreditation standards only encourage educational organizations to meet the minimum. However, the capitalist nature of the education at this time suggests that “meeting and exceeding” standards is often a goal in itself, and it is unlikely that establishing minimum standards would meaningfully prevent high-performing schools from exceeding them.

The potential benefits of such accreditation and regulation to the consumer must be balanced against the potential costs to the educational institution or the agency delivering care. For example, in the federalist model by which most EMS education and practice is regulated in the United States, the actual details of regulation are deferred to the states. This means that a school seeking to train individuals in all 50 states and the District of Columbia must navigate up to 51 different sets of regulations and approval processes. This administrative task can, paradoxically, hamper the preparation and delivery of excellent field medical education. Similarly, from an agency standpoint, some states divide their EMS regulatory authority into regions or counties. Such division can create challenges for WEMS teams, like mountain rescue and cave rescue teams, that by necessity operate in multiple regions/counties, or even multiple states in a region. Again, significant time can be spent navigating these regulatory and approval processes, which are often simply artifacts of regulatory and political construct and don’t necessarily represent differences in environment, terrain, provider skills, or patient needs. As an example, a mountain rescue team in one county may not be credentialed to provide care in an adjacent county without formal regulatory approval, despite the fact that a climbing site might straddle two counties and climbers might freely travel back and forth between them.

Some would argue that the wilderness medicine educational community does not need external regulation because it successfully “self-regulates.” From a words matter perspective, this term is interesting. Taken literally, it means that regulation still occurs, just within the internal industry rather than externally. This by necessity means that some corporation, or conglomerate of corporations, is establishing a regulatory framework by which it is qualified to regulate others in that industry. This harkens back a bit to the definition cited earlier of an accrediting agency; an important element to that definition is that the agency is qualified and credentialed itself to regulate and accredit. Building a formal regulatory or accrediting infrastructure, even an internal one, means setting up a formal set of regulations and a formal pathway to accreditation, along with an explanation of the credentials that justify that organization as a legitimate accrediting body. Formal internal regulatory structures have potential limitations, including bypass of the checks, balances, and external validation offered by external regulatory patterns; potential elitism (one portion of an industry dictates the regulatory standards for an entire industry) or even antitrust risk; potential conflict of interest for those empowered to regulate in terms of balancing industry and society-wide needs with individual corporate needs; and evidence that some of the most significant industry crises of our era may have been precipitated by deregulation and self-regulation.⁵⁵^,⁵⁶^,⁵⁷^,⁵⁸ Some have explicitly argued that external regulation is preferable for most industries: for example, a Harvard researcher convening a conference at Harvard Business School on self-regulations has concluded that third-party verification, accreditation, and regulation are increasingly important to deliver on the promise of quality standards.⁵⁹ If the term is not meant literally, in the sense of setting up a formal regulatory system, and is meant casually, such as “self-regulation” as a cultural standard, there are limitations to quality parameters of this as well. An often-cited medical example is the relationship between physicians and pharmaceutical companies, which was historically “self-regulated” but increasingly criticized for demonstrable unreconciled conflicts of interest and changes in physician practices based more on industry interests than patient-centered concerns.⁶⁰ Perhaps most importantly, without external regulation, ownership of quality becomes the responsibility of the industry itself; leaders cannot complain about quality deviations in supposedly marginal or low-performing vendors because they themselves are actually responsible for maintaining that quality industry-wide.

Regulation is likely to be a defining debate—perhaps the most critical debate—during the next few decades of growth in wilderness medicine and WEMS.⁶¹ Getting it right is critical to avoid, on the one hand, unnecessary bureaucracy and impedance of creativity and industry growth and, on the other hand, unregulated medical practice that violates state law and results in loss of the standardization and safety benefits of regulated medical care, or educational practices that don’t maintain minimum or comprehensible standards.

HISTORY

A Living Timeline of Wilderness EMS History

Numerous perspectives on the history of both wilderness medicine and WEMS can be found in the medical literature. However, as Quinn and Rodway point out in Auerbach’s Wilderness Medicine 7e, “the history of wilderness medicine could be a textbook unto itself ”⁶²; that book has not yet been written, nor has the corresponding textbook on the history of EMS. Figure 1.1 is the most comprehensive timeline constructed to date in this endeavor. Nowhere are the principles of precision, accuracy, and truthfulness cited in our Introduction chapter more important than they are here. Since much of this history is previously unpublished, some of the work is that of a historian.

Happily, the role of the historian in this project is significantly facilitated by two factors. First, many of the historical founders of the field are still in active practice and available for interview and review of data. Second, the digital and social media opportunities for evidence-building described in the Introduction are phenomenally powerful for this type of work. In reviewing the data here, much of which relies on memory, shared confirmation, and review of primary historical materials such as printed

curricula and photographs, we ended up forming a specific group of collaborators to crowd-source and informally peer review the information we found. This dialogue group consisted of more than sixty leaders in the fields of EMS, wilderness medicine, and WEMS. It is important to emphasize that this was not a consensus group in the sense of endorsement. All individuals had the opportunity to review and critique, but no endorsement phase was included or should be implied. This arrangement resembles other peer review processes, where reviewers have input but an editor has the final say regarding content. This method may lack the anonymity and scientific rigor of formal peer review, but its defects are counterbalanced by the fact that it is far more inclusive of many voices—a balance that is characteristic of the new era of digital and social information discussed in the Introduction.

FIGURE 1.1. Wilderness EMS Historical Timeline

FIGURE 1.1. (continued)

For this timeline project, our role as authors of a textbook is to serve as gardeners. More than one of the contributors questioned if we were getting into the weeds in some of the entries. In that sense, the garden analogy is helpful. This is not a meticulously pruned and landscaped garden. It’s a wilderness garden. It is full of intentionally planted species, but has also produced some surprising volunteers. The degree to which anything turns out to be a weed will only become apparent when the garden is seen as a whole. In our experience some of the most beautiful blossoms first emerge as weeds. Our strategy has been to open up a broad opportunity for planting and growth, see what appears, and then start trimming and weeding. In the process, we’ve been surprised at some things that have grown and have been retained; we are humble enough to know we’re just volunteer gardeners, not professional landscape architects, in the building of this timeline. We expect the timeline will continue to develop and be refined, both retrospectively and prospectively, as our historical understanding of WEMS evolves. It also should be noted that, while nearly one hundred people ultimately contributed to the design and review of the timeline, any errors and misunderstandings within it are my own.

Wilderness EMS History

The Premodern Era: WEMS in Prehistory Through the 19th Century

As we noted in our introductory chapter, wilderness medicine dates back to the first attempts of one hominid to care for another. Similarly, WEMS could date back to the first time such attempts were formed into systems, or even just applied in teams. In that sense, the origins of WEMS are probably prehistorical. However, as Figure 1.1 suggests, numerous publications have suggested origins of wilderness medical care that could also be considered markers for the initiation or formalization of WEMS. These include events in ancient history, such as the development of “recognizable” wilderness medicine by Greek naval surgeons, or much more recent developments, such as the naval medicine systems established by the British at the onset of the 19th century. One important point emerges in reviewing these historical markers: the important role marine and naval medicine have played in the growth of wilderness medicine and WEMS. As we will show, modern wilderness medicine and WEMS took on a much more mountain- and alpine-oriented emphasis in the United States when they flourished in the golden era of growth in the mid-20th century. Hence, it can be forgotten that many of the origins of wilderness medical care come from open water and oceanic wildernesses rather than the mountain wildernesses many associate it with today. In addition, the American experience exploring what was for Europeans a New World without the urban medical resources of their day, along with the incorporation of Native medical practices, lead to a particular generalist medical practice in North America that could be considered a form of austere medicine. In this context, Bill Forgey, often considered the “father of wilderness medicine” himself,²⁴⁰^,²⁴⁸^,²⁴⁹^,²⁵⁰^,²⁵¹^,²⁵²^,²⁵³ has written that John Wesley’s Primitive Physic may represent one of the first American wilderness medicine texts when it was published in 1740 by this founder of the Methodist and Wesleyan Christian movements in the United States. Many writers have cited Napoleon’s chief medical advisor, Baron Jean Dominique Larrey, as the historical originator of an EMS system, with the ambulance volante system he implemented during the Napoleonic Wars in Europe.⁶⁴^,⁶⁵ While this has achieved de facto status as the prevailing EMS origin narrative, surely some systematic means of caring for and removing soldiers and warriors must have emerged before the Napoleonic Wars of the turn of the 19th century.

The Early Modern Era: WEMS in the First Half of the 20th Century

The early 20th century saw the introduction of many precursors to what are now familiar WEMS systems. From a maritime standpoint, the U.S. Coast Guard was formed in 1915 by the merger of multiple 19th-century marine rescue services.⁷⁰ From a ski rescue standpoint, the interwar period saw the founding of multiple ski medicine organizations, culminating in the formation of the National Ski Patrol in Stowe, Vermont in 1938 as a committee of the National Ski Association.⁷⁵^,⁷⁶^,⁷⁷ And from a mountaineering and mountain rescue standpoint, the oldest continuously operating mountain rescue team in the United States—the Crag Rats of the Mt. Hood area in Portland, Oregon—was founded in 1926.⁷¹ The Crag Rats and other such teams would go on to become founding members of the Mountain Rescue Association in 1959.⁸³ From an EMS standpoint, the first volunteer rescue squad in the United States was founded in the 1920s in Roanoke, Virginia,⁶⁵ a precursor to the currently most common WEMS provider model, the modern volunteer rescue squad or fire department.

The World War II (WWII) period did not slow down WEMS advances. Like many military conflicts, it in fact spurred civilian innovation. Many date the beginning of WEMS systems in the United States to the formation of the Department of Defense’s 10th Mountain Division in a unique collaboration of the U.S. Army, the National Ski Patrol, and the American Alpine Club.¹^,³^,²⁵⁴ More important than the establishment of the 10th Mountain Division was the role these soldiers played upon return to civilian life and their contributions to ski-based WEMS operations in American ski areas, especially in the western United States. Also during the WWII period, Outward Bound was founded in Aberdovey, Wales. This famous organization was influenced by the wartime pressures upon Great Britain at that time, contributing to its initial maritime rescue identity and activities²⁵⁵—one example being their role reactivating the Gordonstoun Cliff Watchers, an auxiliary of His Majesty’s Coastguard watching for ships in distress and enemy submarine activity.²⁵⁶ Indeed, the name Outward Bound derives from the nautical term for a boat leaving harbor, further reinforced by Outward Bound’s use of the nautical flag indicating imminent harbor departure, the “Blue Peter” (a white square inside a blue square).

Outward Bound schools and philosophies would go on to have a massive impact on the development of WEMS in the United States, from the establishment of the first American schools in Colorado (1962), Minnesota (1964), and North Carolina (1966), all the way to the present day.⁷⁸ About the same time, in 1965, the National Outdoor Leadership School was founded.⁸⁵^,⁸⁶ After retiring the official full name in 2016 and now known simply by the independonym “NOLS,”⁸⁶^,²²⁸^,²²⁹ this organization, like the Outward Bound schools, has had a massive impact on the growth of WEMS practices and culture in this country.

The post-WWII era up to the 1960s witnessed the growth and dominance of civic and recreationalist groups over wilderness medical programs. These include the Sierra Club, the Mountaineers, local ski patrols, the Boy Scouts, local rescue squads, local marine rescue services, and local lifeguard agencies and providers, as well as community-based ad hoc or formal climbing rescue and water rescue teams generally built from groups of recreationalists. Formal services were also provided by the Coast Guard and rare government-sponsored rescue services. Organizations combined and formalized, such as the establishment of the National Ski Patrol in 1953 as a freestanding organization⁷⁷—rather than a subsidiary of the National Ski Association as it had existed previously⁷⁵^,⁷⁶^,⁷⁷—and the consolidation during this era of multiple mountain rescue teams into the nationwide Mountain Rescue Association in 1959.⁸³ The Boy Scouts, founded in 1910, were major drivers of publications and standards in wilderness medical care during this era.⁶⁸

However, neither “wilderness medicine” nor “EMS” would have been fully recognizable terms to anyone prior to the turn of the decade at the end of the 1960s. Most authorities mark the beginning of both modern EMS and modern wilderness medicine during the late 1960s and early 1970s, and that is where we can thus also mark the birth of modern WEMS.

The Golden Era of Growth: WEMS in the Late 1960s to Early 1980s

Most EMS authorities mark the modern era of EMS as beginning in 1966, a year marked by the release of the landmark EMS publication Accidental Death & Disability,¹ the formation of mobile “coronary care units” (modern ambulances) in Belfast—an innovation which heavily influenced North American thinking about ambulance capabilities—and the passage of the Highway Safety Act of 1966, which established cabinet-level oversight of a new public health innovation known as “EMS.”⁶⁵

Modern WEMS and wilderness medicine as we know them today began at the same time. In this era, specific existing outdoor schools (such as NOLS and Outward Bound described earlier) and new wilderness medicine schools (described below) played a unique role in the development of wilderness medicine and WEMS. In perhaps no other medical discipline have nonacademic private corporations played the leading role in the development of a modern medical specialty. This situation speaks to WEMS and WM‘s unique practice environment and their unique historical origins in sources generally outside traditional medical educational institutions.

Wilderness Medicine Outfitters, established in 1967 by Carl Weil, was the first wilderness medicine school.⁸⁸ It was followed by Stonehearth Outdoor Learning Opportunities (SOLO), whose founders, Lee Frizzell and Frank Hubbell, taught their first classes in the early 1970s.⁹ Frizzell and Hubbell established the country’s first fixed wilderness medicine campus in 1976.⁹ Emergency physician Peter Goth was extremely active in wilderness medicine during this era as well, working extensively with Outward Bound schools and with NAEMSP, and founded Wilderness Medical Associates (now known as Wilderness Medical Associates International) in 1984.¹¹⁵^,²³⁶ During this time NOLS and Outward Bound Schools were also active in wilderness medical training and practice in their own right (Figure 1.1).⁸⁵^,⁸⁶^,⁹⁹^,⁹⁸^,¹⁰³^,¹²¹^,¹²²^,¹⁴¹ As discussed further in Chapter 2, these various schools, their leaders, and the other institutions they incubated produced the vast bulk of WEMS curricula and operational standards in the second half of the 20th century and into the 21st. The impact of these organizations, from their establishment and development in the 1970s and 1980s on through their role today, on the formalization, development, and dissemination of wilderness medicine and WEMS as a discrete medical specialty cannot be overstated. In particular, many of the formal medical certification courses now traditionally associated with modern wilderness medicine were formalized or invented by these schools. WFA, as a general
term, was being taught by the Boy Scouts and many other groups before 1967.^* WMO developed an advanced version of this coursework and refined it to a particular curriculum in the late 1960s.^† In 1974, SOLO was teaching a Mountain Rescue Seminar, a precursor to their own unique curricula.^‡ NOLS developed a Backcountry Emergency Care curriculum in 1979, a precursor to the modern, industry-standard WFR curriculum.⁸⁶^,¹⁰³ Some authorities state the first formal wilderness-oriented emergency medical technician (EMT) class was taught by the Appalachian Search & Rescue Conference at the University of Virginia in 1977.¹¹¹^,²⁵⁷ But in fact the first such EMT certification course our working group could identify was taught by Minnesota Outward Bound School (now Voyageur Outward Bound) years earlier, in 1974, followed by a similar course taught at North Carolina Outward Bound School’s Table Rock base camp in 1976.²³⁹,^§ In 1981, SOLO established the first formal Wilderness EMT (WEMT) course in the country, along with the concept of initial and recurring WEMT certification.¹¹³,^¶ One year later, in 1985, Frank Hubbell of SOLO and Peter Goth of WMA taught the first formal WFR course at the North Carolina Outward Bound School base camp in the Florida Everglades.¹²¹^,¹²² Since their first introduction in the mid-1980s, WFR and WEMT certifications have been standard parts of both risk management for outdoor organizations and response certifications for rescue organizations. These certifications are both described in much more detail in their current form in Chapter 2.

Other notable programs were introduced during this golden era of wilderness medical development. Such programs include the first National Park Service (NPS) WEMS class, which was held in North Carolina in 1972,⁹³^,⁹⁴ as well as the establishment of the NPS ParkMedic program in Fresno, California in 1978 (Figure 1.1).⁹⁴^,¹⁰²

Also of critical importance during this era was the formation of the Wilderness Medical Society in 1983 by Drs. Paul Auerbach, Ed Geehr, and Ken Kizer.⁸⁵^,¹¹² The establishment of this professional society was a key step in the later growth of wilderness medicine from a largely “first aid” activity existing outside traditional concepts of medical practice to a legitimate medical specialty. The Wilderness Medical Society eventually developed its own magazine (first published in 1984 with Ed Geehr as its first editor),⁹⁹,^** scientific journal (first published in 1990 with Paul Auerbach and Oswald Oelz as coeditors),⁵^,¹³⁶,^†† medical meetings (first held in Yosemite National Park in 1984),116 and ultimately world conferences on wilderness medicine (first held in 1991).⁸⁵

Numerous wilderness medical texts now considered standard resources in wilderness medicine education were first published during this golden era as well. These include Wilkerson’s Medicine for Mountaineering in 1967 (now known in its current 6th edition as Medicine for Mountaineering and Other Wilderness Activities),⁸⁷ Werner’s Where There Is No Doctor in 1977 (now available in a 2015 revised and updated version),¹⁰⁰ Forgey’s Wilderness Medicine: Beyond First Aid in 1979 (now in its 7th edition),⁸⁵ and Auerbach and Geehr’s Management of Wilderness & Environmental Emergencies in 1983 (now in its 7th edition and known as Auerbach’s Wilderness Medicine).¹¹⁴ Auerbach’s text is particularly notable for its encyclopedic treatment of wilderness medicine topics. While the first edition (1983) consisted of 646 pages, its current seventh edition (2017) now includes 2,848 pages in two volumes, and Dr. Auerbach has become the Redlich Family Professor in the Department of Emergency Medicine at Stanford University. The experience of this one book and author alone is a marker of the movement of wilderness medicine from its beginnings outside traditional academia to its current position of medical authority. Numerous other texts were first published during this era as well, some of which are listed in Figure 1.1.

On the EMS and emergency medicine side, the era from the late 1960s to the early 1980s saw the rapid establishment, proliferation, and refinement of EMS operations and the specialty of emergency medicine.

Emergency medicine was not a recognized medical specialty prior to the 1960s. In fact, emergency medical care was generally a poorly respected medical practice often delegated to those trying to build a practice in another specialty, those in some other form of transition or partial practice, or in many cases, to a nurse, who would call a physician (not obligated to respond) for any physician-level care needed—all questionable practices for patients who were often, perversely, the sickest and most emergent.⁸² This all began to change in the late 1960s as emergency medicine pioneers worked to forge a specialty out of this niche hospital-based medical practice. In 1968, the American College of Emergency Physicians (ACEP) was established, and also quickly developed its own publications, scientific journal, and annual and specialty medical meetings. In 1970, the first emergency medicine residency was established at the University of Cincinnati, and the first academic department of emergency medicine was introduced at the University of Southern California in either 1970⁶⁵ or 1971.⁸² In 1976, the American Board of Emergency Medicine was founded to administer an annual board examination, and in 1979, emergency medicine was formally recognized as a board-certified medical specialty by the American Board of Medical Specialties (ABMS).⁶⁵ Despite its strong positioning in the house of medicine now, many are not aware that emergency medicine has only been a formal specialty for less than 40 years.

While EMS also did not exist as a standardized national program of any sort prior to the end of the 1960s, by the early 1970s it was already a well-recognized and assumed component of American popular culture and medical care. The National Registry of EMTs was founded in 1970 after the American Academy of Orthopedic Surgeons published the first EMT curriculum in 1969.⁶⁵ This curriculum and its corresponding certification were quickly identified by the wilderness medicine community as ideal paradigms for fundamental out-of-hospital medical knowledge to which wilderness modulations could be added. As noted above, wilderness-influenced EMT classes began appearing only a few years later in places like Minnesota, North Carolina, and Virginia, followed by the formal establishment of a WEMT curriculum by SOLO about a decade later. In 1973, the Emergency Medical Services Act was passed and 911 universal emergency access was established. Many Americans are not aware that 911 services, now taken for granted, were not universally or even commonly in place prior to the mid-1970s. Emergency Care in the Streets, the first EMS textbook in the country and built around Nancy Caroline’s experiences on the streets of Pittsburgh, was published in 1979, and is still available now in its 9th edition.¹⁰⁴ As with Auerbach’s Wilderness Medicine, the appearance and multiplication of textbooks was a key marker to the growth and sophistication of this new medical specialty. Numerous EMS textbooks of varying degrees of specialization now exist, this itself being one. All these types of books owe a significant debt to pioneers such as Nancy Caroline, Paul Auerbach, Edward Geehr, and Bill Forgey, who carved a path in the wilderness of the publishing world for descriptions of atypical, field-based medical practices.

The National Association of State EMS Directors (now the National Association of State EMS Officers) was founded in 1980.⁶⁵^,¹⁰⁸ The first full-time EMS medical director was not appointed until 1981, when that role was created in New York.⁶⁵ In 1984, the NAEMSP was founded; like WMS and ACEP, it would go on to create its own scientific journal, communication publications, and professional meetings.¹¹⁹ In that same year, the National Disaster Medical System (NDMS), an important parallel system to EMS for disaster response, was founded by the United States Public Health Service.¹²⁰ That year the American Society for Testing and Materials (ASTM) also formed its EMS Committee (F-30) for setting standards for this new medical specialty.⁶⁵ In 1985, Warren Bowman wrote Winter Emergency Care (now Outdoor Emergency Care) for the National Ski Patrol, who also issued the first Winter Emergency Care certificates (now Outdoor Emergency Care or OEC, discussed in more detail in Chapter 2).⁷⁷,^*

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