In 2009, the American Board of Medical Specialties (ABMS) recognized emergency medical services (EMS) as a board-certified subspecialty of emergency medicine.¹ This development is significant as it identifies that EMS is a practice of medicine, which, like all practices of medicine, is founded in science. Further, the creation of EMS as a boarded subspecialty affirms that physicians engaging in the practice require specialized training and expertise, and that the patients who are cared for in the EMS environment have better outcomes when EMS physicians are involved.

Historically, many programs that are in essence providing wilderness EMS (WEMS) services have functioned without physician medical director oversight. In fact, many of these programs have often argued that they are indeed not providing EMS care and, thus, should not be required to have physician oversight. Yet, if a formal response team is providing emergency medical care in the wilderness environment, they should be considered a WEMS program that structurally looks the same as their traditional counterpart in the health care system. For the sake of this chapter, we will consider within the definition of a WEMS program any response team or agency that is trained, equipped, and advertising itself to be able to provide patient care at any level in the wilderness including search and rescue (SAR) teams, ski patrols, wildland fire response units, lifeguards, swiftwater rescue units, and all programs that provide EMS care in the wilderness environment.

This chapter will focus on the role and relationship of a physician medical director to the leadership and providers with a WEMS program.

As one considers the role of physicians in providing medical oversight of WEMS programs, it is perhaps first necessary to provide a working definition of EMS. The medical directors council with 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 an appropriate response, pre-arrival instructions, direct patient care by trained personnel, and appropriate transport or disposition.”² Further, the council believes that “anyone participating in any component of this response system is practicing EMS.”³

The question of the boundary between first aid and EMS often arises with volunteer SAR programs as well as ski patrols and other wilderness rescue agencies. The leadership of many of these programs will consider that the care provided is considered first aid and not EMS and, thus, is not subject to state regulations. Yet, EMS is not defined by the actions performed, but more so by a duty to act by the providers involved and the level of assessment of the patient that is performed by the provider.

Further, the statement by NASEMSO identifies that the location of the incident is not relevant to the definition of EMS, and, thus, a program may be considered to be engaging in EMS services regardless of the austereness of the environment. Indeed, as pathophysiology of disease typically knows no boundaries, patients should receive similar standards of care regardless of the environment, understanding, and of course, the resource limitations that may be imposed by some environments.

Understanding that there are environmental differences between traditional EMS and WEMS, it is important to recognize that there may be a need for differences in system design and oversight. In recognition of this need, while also promoting the importance of the role of medical oversight in maintaining a high standard of care, the National Association of EMS Physicians (NAEMSP) in partnership with NASEMSO published a position statement on medical direction for operational EMS programs.³ This position addresses the role of physicians in all operational EMS environments, which includes WEMS, ski patrols, lifeguard programs, urban and wilderness SAR, and tactical law enforcement.

The NAEMSP/NASEMSO position on operational EMS programs identifies that the providers who work in these environments require specialized skills, and, thus, should also require specialized medical direction.³ Further, and most importantly, NAEMSP and NASEMSO state that these programs “should function within and not outside the mainstream healthcare system,” and that providers “regardless of the level of care provided or scope of practice [should] have a qualified medical director.”3

As health care is regulated at a state level, it is ultimately up to the appropriate regulatory authority for EMS within the state to determine the amount of oversight that is required for a WEMS program. Some regulatory authorities will identify the line of necessary regulation at anything above first aid. Unfortunately, however, there is no clear definition in the EMS literature defining the threshold at which medical care exceeds first aid. Note that the International Liaison Committee on Resuscitation did publish a consensus definition of first aid, along with care types defined as first aid for various conditions, in 2010 and revised it in 2015.¹³ This may begin to influence EMS definitions in the future. In the meantime, in alignment with the definition of EMS published by NASEMSO and the position on medical oversight published by NAEMSP/NASEMSO, it seems most appropriate to define EMS as anything that involves an organized response with providers who have a defined duty to act. This was also the conclusion of a Delphi-developed consensus position statement from WEMS educators, regulators, and clinicians, who concluded that WEMS providers having a defined duty to act should be functioning with medical oversight.¹⁴ Finally, since EMS is by definition a practice of medicine, as identified by ABMS, any provision of medical care provided in the EMS environment should involve the oversight of a physician medical director.

As physicians work toward integration of oversight into an existing team it seems relevant to explain the purpose. Physicians know too well that medicine is challenging and complex. The physician who believes that mistakes are not possible is dangerous, as all physicians make errors during medical decision-making. But quality and safely delivered patient care is founded on the principle that we should learn from mistakes. Continuous analysis and study of care provided is the cornerstone to safe patient care. The idea that we need to always be critical and reflect on our care so that we can learn from our triumphs and errors for the improvement of patient care is essential. Ultimately, this is the purpose for recognizing that WEMS is a practice of medicine that requires physician oversight. The ultimate purpose of the physician medical director for a WEMS program is to focus on patient care and provide the structure for continuous review and improvement of the care delivered by the team.

As medicine becomes increasingly complex with specialties and subspecialties, it is relevant to realize that WEMS is its own unique practice requiring specialized training. Ideally, medical directors of WEMS programs will be board certified in EMS, with additional training in the specific operational environment of the wilderness. However, it is important to recognize the reality that there are far fewer physicians with the ideal training background than the numbers of SAR teams, ski patrols, and other WEMS programs.

Regarding the medical component to the medical director’s qualifications, at a minimum the medical director should be licensed in the primary state of the team, maintain board certification in an ABMS specialty, have a working knowledge in the management of emergent diseases, and should complete EMS medical director training. More ideal is board certification in emergency medicine or another specialty that reflects the broad spectrum of EMS patients and their acute presentation. Furthermore, although fellowship or board certification in EMS is most ideal, many otherwise qualified physicians working with SAR teams and ski patrols will not have this background. As an alternative, NAEMSP and the Wilderness Medical Society (WMS) endorse a 16-hour course that covers the basics of medical oversight for WEMS programs.⁶ With a core content developed by a Delphi technique from WEMS experts,⁷ the curriculum is flexible to meet the backgrounds of the students for a given class. NAEMSP also offers a 3-day medical director’s course more focused on urban EMS, and an online version that covers the fundamentals of medical oversight.

Regarding the operational qualifications, EMS program medical directors need to be able to safely operate in the given environment so as to be an integrated member of the team with the providers under their supervision. For WEMS programs, this translates to the physician needing to complete SAR team qualifications, ski patrol training, or any other operational training requirements as all other members of the team. Working in the environment safely with the providers gives the physician perspective that is critical when hard decisions regarding patient care need to be made.

Ultimately, the physician and providers need to have a working relationship to accomplish the task of providing quality patient care. This relationship has formal structure that will often evolve into a less formal process. Formally, EMS providers, like
all health care providers, have a defined scope of practice, which defines the level of care that the provider is allowed to provide to the patient. As defined by the National EMS Scope of Practice document all EMS providers, regardless of the level of care or the operational environment, have a scope of practice that is defined by four intersecting pillars—Education, Certification, Licensure, and Credentialing.⁸

WEMS providers typically receive education in both wilderness medicine and traditional EMS. Although there is currently no national standard for WEMS training curriculum, there are programs that are nationally recognized. Further, the NAEMSP WEMS Committee is currently leading a project to develop Delphi-driven consensus regarding training for various levels of WMS providers. Similarly, proposed standards for some wilderness medical certifications have been published by subject matter experts in magazines,⁹ in the form of minimum curriculum standards rather than total operational scope of practice,¹⁰ and speculation as to whether an industry standard existed,¹¹ the answer to which, at least for WFA in this particular 2009 analysis, was “no.” The American Society for Testing and Materials (ASTM) published minimum training standards¹² and scope of practice standards¹³ for Wilderness First Responders (WFR) which have been updated as recently as 2013 and 2016, respectively. However, ASTM standards are rarely utilized in traditional medical care, and these standards have not seen widespread acceptance or use in the EMS or wilderness medicine community. An important new contribution to this question of standards is a recent consensus document describing “proposed scopes of practice of wilderness EMS providers”; however, it is so recent as of this chapter writing that its ultimate impact on WEMS remains to be seen.¹⁴ As there are currently no universally recognized national standards dictating full scope of practice, many states require, in addition to focused wilderness medical training, state-recognized training in one of the levels of EMS.