Cardiac & Resuscitation, Patient Care, Training, Trauma

Wilderness EMS Has Special Considerations

Issue 4 and Volume 37.

After weeks of seemingly endless shifts working as an EMT in your suburban ambulance service, you’ve finally escaped for a week-long vacation in the mountains. On the second day of your vacation, you decide to hike one of the steep, granite-lined trails in the nearby national park.

As you begin to traverse the saddle between two high peaks, you suddenly see the unmistakable shape of an almost motionless human body approximately 100 yards below you down the steep slope.
Instinctively, you start down the slope to try to assist the injured hiker. You find him awake but confused, with external signs of head trauma and an obvious leg deformity. After you pull out your cell phone to call for help and see that you have no reception signal, you realize that you and the patient are on a ledge covered with small, unstable, bowling-ball sized boulders. You also realize you’re very much outside your normal element as an EMS provider.

A backcountry situation has been defined as any context in which there’s little to no communication with medical centers, a limited number of available resources, susceptibility to severe environmental conditions and the possibility for prolonged evacuations. These factors can present many logistical and patient care dilemmas and often require significant modifications to traditional urban EMS standards. This article highlights the differences and similarities between urban/suburban (“traditional”) EMS and backcountry EMS responses, as well as outlines the differences in protocols.

Patient Assessment & Setting Priorities
Scene size-up is critical when first encountering a patient, whether an urban or wilderness context. An essential element of EMS response is considering the safety of the patient and the rescuers. All responders must assume certain risks just to arrive at the patient—risks that must carefully be considered. Urban and suburban teams must consider such risks as downed power lines, hostile individuals, conflagrations and motor vehicle accidents (MVA). Outdoor rescuers must consider a different set of hazards, including challenging or dangerous terrain, dangerous animals, long-term exposure to severe weather and potential long-term care of the patient.

Patient assessment in the outdoors can also present other distinct challenges because of the skewed patient population and extremes of the environments encountered in wilderness settings. Wilderness rescuers will encounter more musculoskeletal injuries and trauma due to the active nature of outdoor enthusiasts, compared with less-remote, traditional EMS contexts in which chronic and acute illnesses tend to prevail.

Some prevalent outdoor afflictions include hypothermia, frostbite, heatstroke, bites/stings/rashes, altitude illness and seasickness. Several of these concerns (especially hypothermia and heat exhaustion) make patient assessment more challenging because they can distract the rescuer from other underlying, and often more severe, issues (e.g., alcohol, drug-use and shock) would in urban EMS.

Similarly, climbing gear or heavy winter clothing can also hide hematomas, hemorrhage or fractured bones. The need to expose these injuries during assessment must be balanced against efforts not to lose the insulation that clothing provides in the prevention of hypothermia. These concerns further reinforce why conducting a complete and thorough initial assessment, and frequent reassessments, is as important in the backcountry as it is in the front country.

Determining the cause of injury in the wild can also be difficult because rescuers may arrive on the scene hours after the incident occurred, and there may be no witnesses. Much like surveying the scene of an MVA in an urban/suburban environment, the outdoor rescuer must closely inspect the surrounding area and look for context clues, such as over-turned rocks, damaged equipment and blood on various surfaces. However, limited diagnostic tools and information don’t equate to an inability to properly assess, treat or rescue a patient.

Lack of traditional ambulance diagnostic and communication equipment will also make assessing injuries and illnesses more challenging in an austere environment. Communication with hospital staff and medical direction will likely be unavailable. Many of the vital signs taken in routine emergencies (e.g., heart rate, pupil size, temperature, capillary refill and mental status) will be just as important to note in wilderness rescues. However, ECG monitoring, pulse oximetry and end-tidal CO2 are diagnostic supports that are rarely deployed in most wilderness EMS situations. Traditional blood pressure monitoring with a cuff may not be feasible in the wilderness setting due to inability or limited ability to expose the patient. Therefore it’s important to use other markers, such as mental status, skin temperature, capillary refill and pulse strength to determine perfusion.

Limited Resources
An almost universal challenge in the wilderness setting is the limited amount of resources that will be available, coupled with the length of time to get the patient to definitive care. With some ingenuity and resourcefulness, however, many treatments and rescue techniques can be innovated from available equipment.

Although the possibilities are limited to the rescuers’ creativity and the contents of their pack, certain key items have often proven useful. These items include safety pins, triangle bandages, duct-tape, ace-bandages, SAM splints and plastic bags. Inflatable or foam sleeping pads are also valuable in that they can serve as splints, C-collars and protection from wet or cold ground. Backpack supports, skis, hiking poles and branches can also be used as splinting and traction-in-line devices.

All outdoor first aid kits should contain protective gloves, but proper body substance isolation is often compromised in wilderness contexts. This need not be the case with some improvisation. Bandanas, sunglasses, rain gear, long-sleeve shirts and pants, plastic bags and clear plastic-wrap are all acceptable forms of body substance isolation protection in outdoor situations.

Proper disposal of contaminated dressings, gloves and other equipment must also be done in a manner so as not to put the rescuers at risk, but also to adhere to wilderness Leave-No-Trace principles as much as possible. Hand washing, whether it’s with hand-sanitizers or biodegradable soaps, shouldn’t be overlooked. It’s important to use clean, decontaminated/treated water when cleaning wounds or hydrating a patient.

Many commercial products and common techniques are available to treat water obtained from natural sources for drinking or wound cleaning. Some of these include boiling, iodine/chlorine tablets, carbon-filters and steripens. However, outdoor rescuers must check for iodine/chlorine allergies when applicable. Additionally, halogens (iodine/chlorine) and steripens don’t work well with turbid water.
EMS providers must take care to improve the clarity of water prior to using this method. Purifying water is not only a good way to prevent infection when cleaning wounds, but it should also be a common backcountry practice to prevent such serious issues as diarrhea, giardia and other gastrointestinal problems.

What a wilderness expedition or rescue team may be limited to in terms of resources can often be compensated with manpower. More people not only means more available resources and equipment, but it also means more available hands. Many effective lifting, moving and transporting techniques can be executed by fellow able-body rescuers or friends when stretchers, spinal immobilization gear and other ambulance-based devices aren’t available or viable. Evacuation in the wilderness requires a large amount of manpower.

With some innovation, working with limited resources need not hamper or prevent treatment and rescue efforts in backcountry situations. Often a resourceful and creative rescuer can be more effective and successful than one who’s over-prepared or over-packed.

Evacuation Considerations
Wilderness rescuers must sometimes decide whether to evacuate a patient. Backcountry evacuations are time-consuming ventures and often put the rescuers at risk. Particularly, helicopter evacuations can be extremely difficult to execute.

Transporting a litter is exhausting work; in ideal conditions, it moves about one mile per hour with a team of 15–20 people. Similar to urban or suburban emergencies, a thorough yet efficient assessment of the patient and careful evaluation of scene logistics and weather are essential before ordering any type of evacuation. Sloppy assessments may lead to an unnecessary complex evacuation for a minor condition. Conversely, delayed evacuation for a patient with a missed life-threatening condition that requires immediate transport can lead to an otherwise potentially avoidable death.

Limited communication, distance from definitive healthcare, variable weather, terrain conditions and nature of injury must all be factors in the decision to evacuate vs. bivouac in the current location or moving to a safer spot. 

Exposure to severe weather conditions can leave the patient and rescue team at risk for hypothermia, frostbite, dehydration and/or heat-exhaustion. Long distances, steep or unstable snow terrain, impending weather, high or rapid-moving water or rapidly deteriorating patient status are situations that would make a ground rescue much more difficult.

There’s no exhaustive list of situations that require evacuation by air vs. walking the patient out, but the rescuer’s ability to judge and evaluate various situations will be essential in determining when rapid removal would be appropriate. Loss of life or limb, deteriorating vital signs, decreasing mental status, severe blood loss and spinal injury are all considered circumstances for which immediate evacuation is ideal.

Just as in ambulance-based EMS care, the rescuer’s judgment and ability to assess a situation will define the proper response and rescue to a wilderness emergency.

Extended-Care Principles
The extended-care principles employed by outdoor rescuers are one of the primary differences between wilderness EMS and traditional urban/suburban EMS. The necessity for extended patient care often dictates the expanded scope of practice of wilderness EMS providers.

In most circumstances, EMS-providers will secure dislocated bones in place and transport. In remote situations, however, it’s in the patient and rescuer’s interests to reduce dislocations in situ. This will prevent distal limb ischemia and the damage associated from prolonged dislocations.

Reducing dislocations may also help lessen pain for the patient and make evacuations easier for the patient and rescuer because the patient may be able to participate in their own rescue. It’s also important to keep in mind that some of the more complex joint and long-bone dislocations may be too difficult or complex to accomplish in the field.

It’s up the to the wilderness EMS provider’s judgment to determine whether reducing a dislocation would be appropriate in each situation. For example, patellar (knee cap) dislocations that are particularly common in hiking are one of the easiest dislocations to reduce and can transform an immobile patient into a potentially ambulatory patient with a rapid wilderness reduction.

Shoulder dislocations are another common wilderness injury that can be reduced with simple techniques and can transform an ailing patient into an active participant in their own rescue. If a reduction is attempted in the wilderness, it’s important to check pulses and sensation both before and after the reduction.

Treating and managing open wounds and other injuries also requires different treatment guidelines in the wilderness. Because evacuations may take hours—and sometimes even days—wounds must be properly cleaned and monitored for infections. Thorough scrubbing, irrigating and cleaning of wound sites, as well as consistent monitoring, are important in preventing infections. The severity of infections largely depends on the nature of the wound but can become evident within hours of the injury.

Wounds in humid environments, and those resulting from animal bites and stings, can be especially prone to infection. Rescuers may be tempted to waterproof some dressings, especially in aquatic or wet environments. However, this is ill-advised because preventing air circulation may increase the likelihood of an aerobic infection. Instead, the rescuer should clean the site with clean water and soap, or another antimicrobial, and replace the bandages often.

During evacuations, bandages and dressings may need to be replaced several times. Each time the dressing and bandages are changed, distal circulation, sensation and movement must be checked to ensure that dressings don’t interrupt blood flow. Splints and bandages applied in the wilderness may need to be modified from transitional splints that immobilize the joint above and below the injury to allow for limited movement if the patient is able to assist in a walking- out evacuation. Similar to traditional EMS, frequent reassessment of circulation, sensation and movement is needed when splints are in place. Additionally, extra padding between the splint and skin may be needed to prevent pressure sores from developing if definitive care is far away.

When definitive care is several hours away, some open wounds may need to be closed on site to allow proper healing and to prevent infection. Although rudimentary stitching techniques can be used, other less-invasive and more sterile options are available. Butterfly bandages or steristrips with tincture of benzoin can all be used as effective forms of wound-closures.

Wound closure staples are also useful in the wilderness and provide fast closure and bleeding control, especially of head wounds. Regardless of what techniques are used, proper cleaning and disinfection with clean water must be done prior to closing the wound. Continuous monitoring after wound closure is important.

An impaled object is an additional soft-tissue injury situation that may be frequently encountered in wilderness EMS. In general, removing impaled objects is discouraged in wilderness settings as much as it is in traditional EMS settings. An object shouldn’t be removed if it will cause further damage or severe bleeding, and objects lodged near major arteries or organs should be secured in place rather than removed.

However, wilderness rescuers sometimes remove an object if it prevents or hampers evacuation efforts, or blocks an airway or CPR attempts. Wilderness guidelines for spinal immobilization differ from most traditional urban/suburban trauma protocols. As mentioned earlier, the evacuation of a fully immobilized patient requires a lot of manpower and usually slows over-land evacuations significantly. Wilderness rescuers must carefully weigh the risks of potential C-spine injury against the logistical benefits on a case-by-case basis. Selective C-spine immobilization is a fundamental part of wilderness trauma care.

Patients with intact mental status, no midline neck tenderness, no focal neurological complaints and no major painful injuries that limit the neck assessment may not be immobilized simply because mechanism of injury or injuries above the level of the clavicles. C-spines are never “cleared” by providers and are always reassessed during evacuation and on arrival at definitive care.

CPR in the wilderness is difficult. First, as in all incidents, scene safety is paramount. If the scene isn’t safe for rescuers, CPR shouldn’t be initiated. If the patient has obvious rigor or the down time is unknown, CPR is unlikely to result in the successful resuscitation of a person with good mental outcome, and it can endanger rescuers. Further, the amount of time to definitive care must also be considered.

If the patient is hours from a hospital, the utility of CPR must be considered carefully. A trial of CPR may be indicated; however, if after 30 minutes there’s no return of spontaneous circulation, efforts may be stopped. Additionally, if the scene becomes unsafe to continue resuscitation efforts at any time, then CPR should be stopped.

Oral administration in wilderness rescue differs from ambulance based-EMS protocols. Ambulance-based EMS protocols rarely allow patients to be given anything orally because transport time can be prolonged in remote settings. Patients need to stay adequately hydrated and fed. Rescuers need to ensure the patients drink fluids if they’re able to and may need to assist with voiding. Certain oral medications, such as antihistamines and analgesics, can be given to patients during long evacuations.

A final clinical concern is the development of hypothermia in the wilderness setting. The prevention of hypothermia has already been discussed in the context of limiting unnecessary exposure of the patient to the environment by removing too much of their clothing. Additional simple interventions, such as placing an insulating pad under the patient and placing a hat on the patient’s head, can further reduce the risk of heat loss by conduction and radiation. All patients who are already hypothermic should be treated with passive re-warming measures, such as removing wet clothing. More active re-warming interventions may be logistically difficult during evaluations, but they should be considered on a case-by-case basis.

Proper documentation of the initial assessment, vital signs, important changes over time and treatments administered (and their effectiveness) is as important in the backcountry as it is in traditional EMS. This is especially true because the rescuer will be spending long periods of time with the patient. A well­-documented report will be essential for continuing care and further diagnosis when the patient finally arrives in a hospital setting.

Even in ideal conditions, most evacuations take many hours to successfully complete. Such long ordeals can lead to stress and emotional responses from both the patient and rescue team.
It’s important for rescuers to try and remain calm and collected and keep a positive outlook for the patient without making inconclusive promises. Rescuers must also pace themselves and prepare for long hours of walking, carrying, waiting and monitoring the patient. It’s important for rescuers to also effectively share the burden with the rest of the team and recognize when they’re putting themselves or their team further at risk. The well being of the team, patient and providers is paramount.

Working collaboratively with a group of rescuers and delegating tasks are essential to a successful and efficient backcountry rescue. Urban EMS providers face similar situations when working with fire and police departments and different medical teams in the field.

Patient care and the extended-care principles associated with outdoor medicine present an important break from standard EMS practice. Patient rescue, assessment and evacuation will often be complicated due to the variability of terrain, environmental conditions and limited resources in the backcountry. Wilderness rescuers must be respectful of their environment, safety conscious, resourceful and able to apply a modified scope of practice from traditional EMS to ensure success in outdoor medical emergencies. JEMS

> Auerbach P: Wilderness Medicine, Fifth Edition. Mosby: St. Louis, 2007.
> Bowman W, Leff L, National Ski Patrol: Outdoor Emergency Care, Third Edition. National Ski Patrol: Denver, 533, 1998.
> Stonehearth Open Learning Opportunities: Wilderness Emergency Medical Technician Handbook. Stonehearth Open Learning Opportunities: Conway, N.H., 2009.
> Ramsey D. The urban jungle: Wilderness medicine meets non-rural EMS. JEMS. 2010;35(5):48–55.
> Londson, Susan. Using pins and pens for wilderness care. ACEP. 2010;29(12):1–5.

This article originally appeared in April 2012 JEMS as “Far from Care: EMS in the wilderness requires special considerations.”