Abstract
In this issue of Wilderness & Environmental Medicine, an article by Warden et al 1 provides a timely overview of various specialized operational emergency medical service (EMS) programs that serve in either tactical, hazardous, or austere environments as part of the entry level medical care in the US health care system. These specialized EMS programs function in unique environments and provide, in most cases, point of injury medical care beyond what can be provided by traditional EMS agencies. These programs include classic programs in rural and wilderness settings, for example, ski patrol, water rescue, and wilderness search and rescue (SAR). More contemporary operational EMS programs that have evolved significantly in the past 10 to 20 years are tactical emergency medical services, military tactical combat casualty care (TCCC), urban search and rescue, and aviation medical support. As with all traditional EMS programs within the United States, these unique operational EMS programs should be held to the same rigorous or continuous quality improvement programs that are designed to ensure standardization of medical care. Unfortunately, not all operational EMS fall within any medical jurisdiction at the city, county, state, or national level. The point of the article by Warden et al 1 is that the role for a medical director is lacking for wilderness and operational EMS programs; and that these programs, where lacking, should have a formal role in emergency response and be formally integrated into the local and state EMS system so that training and certification standards are met and all patients receive safe, quality health care, whether it be in remote and austere settings or as it is now within our cities and communities in the United States.
A classic example of this of gap of medical oversight among personnel and medical care of victims in austere settings is within SAR programs across the United States. In each state, SAR activities are conducted by individual agencies, for example, law enforcement, fire and rescue personnel, state-recognized SAR teams, or organized solely by community volunteers or by a combination of these resources. In other states, there is a state SAR coordinator within the government that oversees policies that mandate education, training, and administration of all SAR-related activities. However, many SAR programs at the state or local level are not governed by any formal medical direction oversight by a physician or medical designee. Thus, any medical care rendered at the point of injury to a rescue victim during a search by a SAR team member or a community volunteer is consider solely first aid until the victim is transferred from the location found by a litter team to the closest location available to the regional EMS flight evacuation or EMS ground agency. Knowing the occurrence of trauma (eg, falls from heights) or illness (eg, cardiac arrest) in the wilderness, establishing a mandate for only community-based first aid sets an inferior standard of preparation for medical care in these remote environments. In this example, it is easy to argue that not only is there a lack of any formal medical direction, but also there is a persistent lack of robust medical preparation of SAR personnel beyond cardiopulmonary resuscitation and first aid in many teams that are assigned to regional or statewide recognized SAR teams. There should be no lack of mandate or continuity of medical care whether it is provided by an urban EMS agency under a medical director or an operational EMS team responding to a victim 24 hours away in the wilderness.
Recently, a position statement by the National Association of EMS Physicians (NAEMSP) and the National Association of State EMS Officials stated that operational EMS programs often fall outside the normal health care delivery systems because they function in remote settings. 2 However, these specialized operational EMS services should function closely and within the mainstream health care system. These programs should be composed of an appropriately trained medical director who will develop and maintain standards of medical care among the operational EMS membership. In many cases, the medical director would be enhancing the entry level of medical standards beyond urban first aid training to more appropriate wilderness medical training, for example, wilderness first aid, advanced wilderness first aid, or wilderness first responder and certification. Many operational EMS teams already meet this standard of medical preparation and beyond.
Just as stated within the position statement of the NAEMSP and the National Association of State EMS Officials, an operational EMS medical director should have appropriate training, certification, and licensure, expertise in EMS systems, and expertise in the operational specialty, for example, tactical EMS. Ideally, the medical director should be a fully qualified member of the operational EMS team. Now, EMS is the newest medical subspecialty recognized by the American Board of Medical Specialties, and increasingly, many physicians have extensive EMS training but little wilderness medical experience or training. Similarly, many physicians have deep wilderness or wilderness medical training but have little exposure to the EMS operational environmental or EMS oversight. In some areas, physicians are asked to serve as Wilderness EMS (WEMS) medical directors and have neither specific wilderness nor EMS training.
In effort to address this gap, the WEMS Medical Director Course was recently developed to support health care providers asked to provide medical oversight to EMS systems operating in wilderness environments. The course is specifically engineered to benefit all physicians and levels of preparation. The course includes current content addressing online medical direction; offline medical direction; the historical development of both wilderness medicine and WEMS; updates to the current standard of care in EMS management of specific medical conditions; design and maintenance of a WEMS system; logistics of EMS care and operations; legal issues in WEMS oversight and practice; exercises on protocol development and medical oversight; and extensive discussion of specific WEMS environments and operations.
The concept for the course was originally conceived by Michael Millin, MD. He developed a core curriculum among a group of WEMS specialists in the NAESP community using Delphi methodology for scientific rigor. That curriculum was converted into an actual course by the 3 course directors: Michael Millin, MD (immediate past medical director for National Ski Patrol), Seth Hawkins, MD (medical director for Linville Gorge, the deepest gorge in the eastern United States), and Will Smith, MD (medical director for Grand Teton National Park, Teton County Search and Rescue, and National Park Service–Southeast Arizona Group). Each instructor is a current and active medical director for a WEMS system.
November 2011, the first WEMS Medical Director course was rolled out at the Wilderness Medical Society (WMS) Desert Medicine Conference held in Tucson, Arizona. Each instructor of the WEMS Medical Director Course is currently active in WEMS system oversight and design. Each instructor is also a dual member of both the NAEMSP and the WMS, and both organizations agreed to institutionally support this course. These recent graduates of the WEMS Medical Director Course are well prepared to begin service as medical directors for WEMS systems of all types. In 2012, this course is anticipated to be offered at upcoming NAEMSP and WMS conferences.