Wilderness emergency medical services (WEMS) are designed to provide high quality health care in wilderness environments. A WEMS program should have oversight by a qualified physician responsible for protocol development, education, and quality improvement. The director is also ideally fully trained as a member of that wilderness rescue program, supporting the team with real-time patient care. WEMS providers function with scopes of practice approved by the local medical director and regulatory authority. With a focus on providing quality patient care, it is time for the evolution of WEMS as an integrated element of a local emergency response system.
Wilderness emergency medical services (EMS) programs should be integrated with local emergency response programs.
Wilderness EMS programs should function with the oversight of a qualified physician medical director.
Wilderness EMS providers should function with defined scopes of practice as determined by their education, certification of that education, licensure, and local medical director credentialing. These scopes of practice should include provisions to use operationally specific protocols that are approved by the local medical director and the appropriate EMS regulatory authority.
Although one could argue that the history of emergency medical services (EMS) dates back to the Napoleonic Wars or perhaps the US Civil War, when organized systems were developed to move injured soldiers off the battle field, formal wilderness EMS (WEMS) programs in the United States can be traced to 1938 with the work of Charles Minot Dole and the formation of a ski rescue committee with the National Ski Association.
Over the past 75 years, wilderness medicine and EMS have both evolved greatly in their own rights. With the development of the Wilderness Medical Society (WMS), the National Association of EMS Physicians (NAEMSP), and their respective scientific journals, these 2 disciplines have established themselves as bona fide practices of medicine. This is an exciting time as the practice of WEMS is in evolution, combining the creativity of wilderness medicine with the structure of formal EMS systems.
Definition of Emergency Medical Services
The National Association of State EMS Officials (NASEMSO) defines EMS as an “Integrated system of medical response… that includes the full spectrum of response from recognition of the emergency to access of the healthcare system, dispatch of appropriate response, pre-arrival instructions, direct patient care by trained personnel, and appropriate transport or disposition.”
Further, in their statement defining EMS, the NASEMSO medical directors council states that anyone participating in any of the activities of EMS, regardless of the environment, is by definition engaging in the practice of EMS medicine, which requires the oversight of a qualified physician.
To those who are not directly involved in their operations, EMS systems may look very different throughout the United States and even the world. These differences become quite pronounced when comparing traditional frontcountry EMS programs to backcountry WEMS programs. Yet, despite these differences, the fundamental elements of EMS systems remain the same.
With the 1964 publication of Accidental Death and Disability: The Neglected Disease of Modern Society , the public and Congress began to take notice of the importance of improving the system of emergency care in the United States. This publication identified a fractured emergency care system, beginning with poor quality care provided to patients in the out-of-hospital milieu and a disorganized system of getting patients to acute care hospitals.
In 1973, Congress passed the EMS Act, appropriating federal resources to the development of regional EMS systems. The EMS Act of 1973 identified 15 essential components to an EMS system: personnel, training, communications, transportation, facilities, critical care units, public safety agencies, consumer participation, access to care, patient transfer, coordinated patient record-keeping, public information and education, review and evaluation, disaster planning, and mutual aid. Interestingly, the original development of EMS systems did not stipulate physician involvement, an oversight that would be corrected in future years.
Given the essential components of an EMS system as identified by the 1973 EMS Act and the more recently published definition of EMS by NASEMSO, perhaps the following scenario will clarify the general structure and purpose of an EMS system:
It’s a bright sunny day and Mr Jones is out for a bike ride with a bunch of friends. Without notice or a precipitating event, Mr Jones falls off his bike and lies on the ground unresponsive. One of Mr Jones’ fellow bike riders recently completed a bystander hands-only cardiopulmonary resuscitation (CPR) course offered by the local fire department and recognized that Mr Jones was having agonal respirations. He quickly began chest compressions and another friend called 9-1-1. The dispatcher mobilized appropriate resources and continued to assist the friends on the telephone. Within minutes the fire department arrived with an automated external defibrillator. Mr Jones was shocked out of ventricular fibrillation, transferred to a hospital where he had emergent percutaneous coronary intervention showing a 100% left anterior descending artery lesion. He was discharged from the hospital 2 days later, neurologically intact, to follow-up with cardiac rehab.
This scenario highlights many important components to an EMS system. Through community engagement, the EMS system was able to educate Mr Jones’ friends in the technique of hands-only CPR and how to access the emergency care system. The firefighters that arrived acted on protocols that were developed by an EMS medical director who ultimately provides oversight and responsibility for the care of Mr Jones. Mr Jones was then safely transferred to an acute care hospital that initiated definitive care and follow-up.
Without the essential components of an EMS system previously outlined, Mr Jones would likely have died for lack of community engagement and appropriately trained resources arriving to his side. Analogous medical and traumatic emergencies are seen in wilderness areas as those seen in areas covered by more traditional EMS agencies. It is the challenge and priority of WEMS system medical directors and administrators to develop programs that provide, with reasonable consideration to logistical and environmental factors, similarly high quality of care to patients in the wilderness as is delivered in urban areas.
Definition of Wilderness Emergency Medical Services
The NASEMSO definition of EMS states that anyone engaging in the activities of EMS is practicing EMS medicine, regardless of the environmental constraints. Further, the 1973 EMS Act does not describe specific environments for the development of an EMS system, thereby implying that the requirements to create an EMS system apply for all environments. It follows that the care of patients in a wilderness environment should be supported by a similar organizational structure as care of patients in traditional frontcountry environments.
Considering the scenario with Mr Jones, this patient’s greatest chance for neurologically intact survival lies in a system that is able to initiate early CPR, mobilize trained resources, and transport him to an acute care hospital capable of performing cardiac intervention. EMS is this system and in the wilderness such a system is called WEMS.
Defining wilderness, and those circumstances in which WEMS providers are operational and protocols are activated, is critical. In some systems, the same provider might be operating within a specific scope of practice in a traditional system but another when he or she is in a wilderness setting. Many authors have proposed criteria to define wilderness in the sense of a different type of medical care needed. These definitions include distance to definitive care (variably defined but usually somewhere between 1 to 2 hours), the presence of environmental considerations, or austerity (lack of traditional resources). Yet all these definitions have significant barriers to being applied universally and so it must be understood that definitions in WEMS must be contextual. A more compelling definition encompassing multiple situational factors is “medical management in situations where care and prevention are limited by environmental considerations, prolonged extrication, and/or resource availability.” A more recent definition, higher in complexity but more specific to EMS care, is the systematic and preplanned delivery of medical care in those areas where fixed or transient geographic challenges reduce availability or alter requirements for medical or patient movement resources.
Clearly, the constraints of the wilderness environment necessitate a different structure compared with traditional frontcountry EMS. Most obviously, EMS providers responding to WEMS events need to be trained and prepared to operate in the extremes of environmental conditions and carry into those environments the equipment needed for their own self-preservation and the care of their patients.
Noting that WEMS systems evolved from volunteers in the skiing and climbing community desiring to help their fellow outdoor enthusiasts, a prevailing attitude has been that something is better than nothing, regardless of the quality of the intervention. This has led to the development of a system of wilderness response agencies that often were not integrated into the emergency care system, that often functioned without physician oversight, and that lacked the essential components to an EMS system.
In an effort to address the lack of integration of wilderness medical response with the rest of the emergency care system, NAEMSP and NASEMSO published a position statement on medical oversight of operational EMS programs, which includes ski patrols, wilderness search and rescue (SAR) teams, urban SAR teams, fast or open water rescue teams, and wildland fire crews. This statement points out that these programs should function within and not outside the health care system and have a qualified medical director that ensures established patient care standards are met.
There is no doubt that it can be logistically and even financially constraining for a volunteer wilderness SAR team or ski patrol to meet all the requirements of an EMS system. However, assuming the ultimate purpose is provision of quality patient care, this goal is quite appropriate. Regardless of the environment, the pathophysiology of acute coronary syndrome, major trauma, or the myriad of emergent conditions is generally the same. Further, the environmental factors of temperature extremes and prolonged extrication that are specific to WEMS response may exacerbate or even accelerate underlying pathophysiology, making patient care management more complex. From a patient care perspective, it makes sense that the health care system designed to manage emergent conditions in the wilderness should also be designed to provide quality and expeditious patient care, physician oversight, and processes for review and continuous improvement.