Practice in Context
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Most wildland-fire agencies lack the organization and standards required to adequately address the host of emergency medical service issues they regularly confront. Incident management teams, medical unit leaders, emergency medical technicians, advanced emergency medical technicians, other intermediate-level EMS personnel, and Paramedics frequently are mobilized from one part of the country to another, causing inconsistent EMS delivery on wildland-fire incidents.
Part of this inconsistency comes from the differences in training between EMTs and wilderness first responders. The EMT curriculum doesn't spend much time on prevention, instead focusing on treatment. Wilderness medicine knows that it's much easier to stay warm than re-warm hypothermia and to stay hydrated than to treat dehydration and heat exhaustion in remote circumstances.
A Wilderness First Responder course covers much of the EMT curriculum and prepares people for managing medical problems in remote circumstances. The course runs between 70 and 80 hours and is less costly and time-consuming than EMT courses. In the outdoor industry, the standard training is as a WFR, not a Wilderness EMT. Conversely, WEMTs spend significant time practicing with oxygen, long and short boards, AEDs, quick patient contact times, and the like, so they are prepared to work in both worlds.
On the second day a fire in the Arizona desert in July, about half of a 20-person crew began to show varying degrees of heat exhaustion. The two wilderness EMTs on the crew requested that the worst cases be taken by vehicle to fire camp to receive IV fluids, the less afflicted be given time to cool down and rehydrate in the shade, and the remainder of the crew be encouraged to drink more and take more frequent breaks until acclimatized to the heat. Some fire crews are aware of potential for heat injuries, some not, but the WEMT certification gave enough credibility for the crew supervisor to take the suggestions seriously.
EMTs are trained to work where transport is prompt, the environment is controlled, equipment is readily available, and communications are reliable. EMTs make very few decisions on if and how soon someone needs to see a doctor.
WFRs are trained to work where transport may take hours or days. Carrying a patient is much more taxing than a ride in the back of an ambulance. The environment is out of WFRs' control, so they must manage the patient and each other though whatever is thrown at them. Equipment consists of little more than clothing, food, water, and survival and navigation tools, not dedicated medical equipment. WFRs have to make due with what is at hand to splint, dress wounds and build litters.
EMTs are prepared to work in a rural or urban context. WFRs are prepared to work outdoors. EMTs respond primarily to emergencies. WFRs spend more of their time managing blisters, rashes, sinus infections, ash or wood chips in the eye or gastrointestinal distress.
Hygiene, especially hand-washing, is a part of both curriculums; I speak to it in wilderness medicine in the context of the currently prominent MRSA infections, and the more subtle diarrhea and flu-like illness, which are common and preventable. It's not dramatic or heroic, but it keeps people healthy and in the field, and its day to day reality in the wilderness.
In the wilderness, unnecessary transport or unnecessarily urgent transport, strains resources and creates unnecessary risk. WFRs learn to make assessments. Decision protocols help them with the urgency questions and evidence-based protocols help them decide when to relocate a dislocation and when spine immobilization is not warranted. This is practice in context. The EMT solves these by driving the patient to the ER. In the wilderness we need more practical options.
Imagine a dead tree falls on a firefighter just before sunset. He sustained extensive lacerations to the face and particularly one eye. The patient's crew used a space-blanket to carry him a quarter-mile to a landing zone, and he was transported by the closest available helicopter to a local hospital roughly an hour-and-a-half after sustaining the injury. If standard EMS measures had been used, it would have taken many more hours to hike in a backboard, construct a larger landing zone for use after dark, and bring in an instrument-rated pilot and helicopter from much farther away.
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