By law, all EMS providers must operate under the medical oversight of a licensed physician. However, most physicians have little wilderness medical experience, and there hasn’t been specific training has been lacking for physicians in providing this type of oversight in a wilderness environment. Until now.
Michael Millin, MD, MPH, Seth Hawkins, MD, EMT-P, and Will Smith, MD, EMT-P, have developed a unique and innovative wilderness EMS medical director course that brings EMS medical education and awareness to physicians and other prehospital providers who might not otherwise have a chance to be exposed to such information.
The course is the brainchild of Millin, who lives and works in Baltimore, but finds himself in his off time hiking in a nearby rural area. On one such hike, he was reminded of an idea that he had been carrying around since his days of working as the medical director for the National Ski Patrol (NSP). The idea, that an urban EMS provider might not have the needed wilderness medical skills to attend to someone injured in such a rural area, stuck with him.
“You need someone with specialized skills and equipment to be able to get someone out of a place like that,” says Millin, who is an assistant professor of emergency medicine at Johns Hopkins University School of Medicine, the medical director for Johns Hopkins Critical Care Transport Program and the medical director for Baltimore Washington International Airport Fire & Rescue.
An Idea Spreads
The more he thought about it, the more intrigued he became with the idea. He wasn’t able to get the idea off the ground while at the NSP, but it seemed now, five years later, that the idea was ripe for fruition. He invited colleagues Hawkins and Smith and a few select others to join him in trying to bring the idea to light.
“EMS is anywhere patient care is delivered, and we recognized a disconnect in medical oversight, where wilderness medicine was concerned,” says Smith, who has had extensive prehospital EMS experience before going to medical school and is president and medical director of Wilderness and Emergency Medicine Consulting, based in Jackson, Wyo. “It’s becoming recognized that EMS starts when patient care starts, no matter where that is. And we need to make sure that all parts of the system work together, rural or urban.”
Millin now holds a leadership position with the National Association of EMS Physicians (NAEMSP), and brought his wilderness EMS training idea to the operations committee as an educational program. “They thought it was a great idea,” he says. “Eight people from the committee, who had interest in EMS, got together with me to form this program.”
Millin, Hawkins and Smith developed a curriculum together and presented it to NAEMSP and the Wilderness Medical Society (WMS) as a collaborative course, and the organizations enthusiastically embraced the idea. It’s the first such formal collaboration between the two organizations. All three are members of both organizations.
Forty-three students attended the first course, which was offered this past November in Tucson at the WMS desert medicine meeting. “We weren’t sure how many people we were going to have, or if it would even be feasible or doable,” says Smith. “We ended up with 43 students in the class, which blew us away.”
The 16-hour curriculum is intended to be a weekend course, but can be flexible, depending on the need of participants. “For now, we will be delivering the course in association with other conferences offered by NAEMSP or WMS,” says Millin. “It will be a shared program between the two associations, and the three of us will be course directors delivering the course.”
The course consists of historical development of EMS and wilderness medicine, logistical considerations in systematic EMS response in a wilderness environment, a review of field care for specific emergency medical conditions, legal issues, and the role a physician plays in wilderness EMS. The next course offerings are slated for January 2013 at the NAEMSP Conference in Florida and the summer 2013 WMS conference in Colorado.
In developing the course, the three took a collaborative approach—among themselves and among others who wanted to participate in the curriculum development: “Everyone submitted ideas for the curriculum, and everyone had an equal voice in debating what they thought was most important to include in the curriculum,” says Hawkins, medical director of the Burke EMS Special Operations Team. “The idea was to try to avoid loud voices or big names in steering where the curriculum went. This was a more scientific way of coming up with a curriculum.”
The core goal of the course is to bring training and knowledge of wilderness medicine to medical personnel who have had little or no exposure to such medicine. “The American Board of Medical Specialties recognizes that physician care and a hands-on understanding of what’s going on in the field of EMS can make a big difference to the overall medical oversight of any system, whether or not it’s wilderness or urban,” says Smith. “The more physicians are hands-on out of the field, the more they understand the constraints and the ways to improve the system.”
To make this goal a reality, and to bolster the success of the wilderness EMS medical director course, sharing is the centerpiece of the curriculum, particularly when it comes to cross training. “What we realized was a lot of physicians and EMS personnel had a lot of medical experience, but didn’t have a lot of experience working without traditional equipment,” says Hawkins. “Or, there’s great outdoors people, who have no clue about EMS.”
So the curriculum was designed specifically to bring these two factions together in a way that both could share and learn from other’s experience. “There’s EMS content for people who aren’t really familiar with field medical care, and there’s wilderness content and outdoor and equipment-based training for people who have great EMS backgrounds, but who are not as familiar with the outdoors,” Hawkins adds.
To give credibility to the course, Millin, Hawkins and Smith developed the curriculum with standardized elements drawn from the Delphi Methodology, which is a structured communication and scientific research tool developed by the RAND Corporation. Essentially, it takes the opinions of a panel of experts, who provide those opinions anonymously and without access to other opinions, to come to an expert consensus of opinion.
“We want EMS care to be equal throughout all care environments,” says Hawkins. “So we wanted to be sure that the paramedics providing care in the wilderness are following the same degree of quality management, quality assurance and medical oversight as they would in the city.”
The Delphi Methodology provided the opportunity for the curriculum to be both engaging and as scientifically rigorous as possible in terms of development. “We identified experts who gave me their thoughts on what should be in the curriculum,” says Millin. “From there we developed the core content, and then we all flushed out the full curriculum.”
The drive to develop the course comes from recognition for a need for consistency in the care of patients, says Millin. “Pathophysiology of disease is the same no matter where you are, so if you’re having a critical illness in the middle of the streets of Baltimore, or you’re having a critical illness on the top of Mt. Hood in Oregon, you should receive the same quality of care.” This means that all patients, regardless of where they are, should be managed by EMS providers who have been trained with a nationally recognized education and a defined scope of practice, are held to a standard of practice with a robust quality improvement program, and ultimately function under medical oversight, he adds. “It’s a concept that has been long in coming, and to see these two associations support it is really exciting.”
Collectively, Millin, Hawkins and Smith feel that the Wilderness EMS Medical Director course is about improving quality of care delivered to patients in the wilderness and the role that physicians play in that process. “Wilderness EMS is ‘real’ EMS, and as such, should have physician involvement,” says Millin. “Our course is really about training physicians to become active in medical direction for wilderness EMS programs, and we want the focus to be on the partnership, which has been formed between NAEMSP and WMS.”
The three course directors are passionate about EMS and passionate about wilderness medicine. These passions drive them, and will drive the course, to continue to be successful. Their ability to combine the transcendent beauty of the wilderness with the need for state-of-the-art medicine into a collaborative partnership with physicians and prehospital providers is unique, much needed, and will ultimately have a significant effect on many lives.