Flight Plan
When wildland firefighters request a helicopter for a critically injured patient at the scene of a motor vehicle crash on a rural highway, they rarely think about their own potential needs. But when the need for an air medical evacuation is requested on a wildfire incident, everyone near a radio seems to instantly increase their situational awareness — for themselves or their crew. The overhead staff also has to ensure that such resources are readily available as they hope the medical emergency is not as severe as it may sound.
Over the last several years, wildland fires have seen an increase in air ambulance requests, medical evacuations and short-haul rescue needs. The more well-known had tragic outcomes, such as the Dutch Creek Incident, or were more recent and complex, such as the 2010 Deer Park Fire in Fairfield, Idaho.
This increase in air ambulance requests and short-haul extraction demands has also caused an adamant stirring within the men and women who have boots on the ground, as demonstrated by the Cow Creek Fire in Colorado. The Type II incident management team assigned to that fire enlisted the help of the Grand Teton National Park Rangers to develop an extraction plan for those wildland firefighters serving in this high-altitude, remote fire setting. They now have a well-known, lessons-learned paper that shows their medical plan and decision-making process in the event of an emergency. Those lessons learned were in relation to the Dutch Creek Mitigation Measures developed in spring 2010. These measures are helpful in risk management, but many safety officers, medical unit leaders and others have never heard of them or seen a printed copy.
The lessons learned may also have considered Rob Palmer's The Palmer Perspective, which many wildland firefighters have seen on the Internet. A National Park Service employee, Palmer, documented the Golden Hour of advanced life support to the critically injured as well as some operational engagement practices involving wildland firefighters. His younger brother, Andy, died in the Dutch Creek Incident, and he witnessed the death of his Arrowhead Hotshot co-worker, Daniel Holmes, in a tree incident. His insight into these tragedies offers a valuable podium from which to provide information for those who are in the position to make changes.
Often, with tragedy comes change — not at the speed many of us demand of those above us or the rate we personally practice, but it does come. However, the Internet and social networking sources such as Facebook and Twitter are helping to immediately disseminate lessons learned and keep others safe. While this openness can be helpful to overhead, crews of all types and many others in the wildland fire environment during an immediate incident, it can also be detrimental to the confidentiality needed for tragic situations and subsequent investigations.
Recently, the Incident Emergency Medical Subcommittee, under the auspices of the Risk Management Committee and National Wildfire Coordinating Group, published the Emergency Helicopter Extraction List. The EHEL provides a list of potentially available helicopters that can provide hoist and short-haul rescue services, but it may pose several problems. To help mitigate this, it is the responsibility of wildland firefighters who have knowledge of other supportive aircraft to help keep the EHEL committee updated on those changes.
While a great deal of work was done to accomplish this by Les Herman, a private contractor paid by the U.S. government, it did leave out many private EMS or hospital-based air ambulances, which often are the listed resource on ICS Form 206. Typically, many of the air ambulances listed in the shift plan do not have the capability or operational understanding to support hoists and short-haul extraction. Unfortunately, in many wildfire-prone areas, especially in less-populated states, the closest air ambulance is called when a medical situation arises. Often, those listed for hoist and short-haul rescue are not in close proximity due to cost and non-compete clauses that have a provision of care for all citizens, not just a focused group.
A potential problem with using only EHEL aircraft on the ICS 206 Form is that many private or hospital-based air ambulances are often called to the wildland fire incident, instead of EHEL aircraft. Therefore, they may not have the radio frequencies, as in Deer Park and Dutch Creek; they may not have the hoist; and they may have no experience speaking with air attack, who may have additional insight to the airspace situation. In addition, private and hospital-based air ambulances often have policies and procedures that may make the medical mission difficult to accomplish.
The use of private and hospital-based air ambulances could be controlled even more tightly in the near future as hundreds of recent helicopter incidents have resulted in crashes with multiple fatalities, near-misses, accidents and other related situations involving helicopter EMS. Currently, the Federal Aviation Administration, National Transportation Safety Board and helicopter EMS are having serious air ambulance policy discussions. These include subjects such as medical protocols, flight weather standards, crew configuration, funding and dispatching of aircraft. Idaho alone has seven air ambulance providers, all hospital-based, with two services based in Boise ultimately competing for dollars. In 2008, the Idaho EMS Bureau established a rotation system and issued a directive stating that ground EMS agencies and hospitals could no longer helicopter-shop when a different service denied a flight.
Another problem is that incident commanders, safety officers, medical unit leaders and line EMTs have, at one time or another, placed all of their eggs in the one basket of military aircraft. Although this idea is counterproductive due to current military operation tempo and deployments, it is still being used in many situations. In addition, many assume that military aircraft always have a combat medic. However, this is not always the case, and if the aircraft does show up with a "medic," he or she may only be a NREMT-Basic, due to military exemptions from a state requirement to have a licensed provider on military air ambulances. They also may not have the necessary equipment to provide ALS for the patient you want them to pick up.
The other military aircraft factor is the National Guard. Many weekend warriors are just that — one weekend a month, two weeks a year. They may not be around when you need them for a variety of reasons, such as not coming in during the day because they are flying at night to maintain night-vision goggle flying skills. The time delay for a life-threatening injury should be considered when calling on a National Guard aircraft that is not staffed 24 hours or one that may have a hoist but no ALS or medical provider on board. If this situation arises, be prepared to send the highest level medical provider with that patient.
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