Lessons Learned from Wilderness Medicine for Civilian EMS

Abandoned limestone quarry with lake at the bottom. — Shutterstock/Vladimir Mulder

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By Mitch Newcomer

Emergency medical responses are, of course, calls for medical support. However, such medical support can only effectively apply to incidents with a foundation of leadership. Many responders unknowingly establish leadership on incidents but may not consider needs carefully.

This sense of leadership becomes increasingly necessary when we start applying our prehospital medicine to wilderness environments. Many lessons can be adapted from wilderness medicine to civilian EMS. Throughout this article, we will discuss one such wilderness case and lessons learned for responding to any incident.

Diver Adventure

For this case, we travel to an abandoned limestone quarry that has since flooded. This quarry has drawn self-contained underwater breathing apparatus (SCUBA) divers due to its clear water and depths exceeding 100 feet in certain areas. On the weekends, divers in the hundreds occupy the water from daybreak to late evening, where many of them enjoy night diving.

The quarry sits in central Pennsylvania, next to a large warehouse. There is little more in the area; therefore, when an incident takes place, the divers need to be reasonably self-reliant until definitive care arrives.

As we get started, it’s important to address the inherent risks of diving and the attempts at risk mitigation. Overall, when divers follow the established procedures, diving is a very safe sport. Recreational SCUBA divers descend to a maximum depth of 130 feet, generally using a standard air mixture or occasionally a gas mixture containing a slightly higher percentage of oxygen—the primary concern while at depth is the pressure added by the water.

Risk mitigation for diving primarily focuses on situational awareness and sticking within defined limits. A diver will only dive to a specified depth for a specified time, leaving a safety cushion. Divers do recognize that a multitude of factors can cause a plan to be derailed. However, all attempts are made to stay within the plan.

This case brings us back to the quarry for a weekend in mid-October. A group of experienced divers were looking to get the most out of the remainder of the dive seasons. They had spent the day in the water, and decided to wrap up the day with a night dive.

The divers waited for dusk to fall, and then they geared up. The divers walked to the banks while doing final gear checks. All the equipment seemed as it should be. The dive plan was discussed and agreed upon. The plan was fairly simple: maintain a bottom depth of no more than 80 feet and the first one to 1,500 PSI of air signal to turn around.

Signs of Trouble

The first anomaly of the dive was that the large spotlights shining from the warehouse onto a cliff over the quarry were not illuminated that evening. Even at night, these lights kept the quarry from ever hitting true darkness. No one on the team commented on this. They were all experienced divers and had all done this dive before.

The divers signaled to descend and dropped down to a platform in about 25 feet of water. The darkness from the lack of lights was noted but not overly concerning. The divers followed an old rope off the platform to an old motorboat wreck, taking them to a depth of about 65 feet.

This is where the following abnormality was noted. Due to it being late in the dive season, the water was on the cusp of turning cold. The water was frigid for all the divers due to the lack of sunlight. Cold water seeping through a wet suit can feel like needle pricks on the skin. Still, the divers pressed on. The dive took them down another line to an old crane at a depth of 75 feet.

This is where the next issue came up. A slow leak started dripping frigid water through the mask seal of one of the divers. This diver was now faced with a multitude of problems that, individually, would have been small and manageable. However, these problems set everything on edge as none were corrected.

The diver, already on edge and facing heavy anxiety, made the decision to call the dive and ascend. A signal went to the rest of the group, and the ascent began. However, problem-solving could have been more effectively applied throughout the ascent. The leak on the mask increased, causing difficulty seeing. As a diver ascends, the air volume in their buoyancy control device increases.

If the diver does not correctly vent this air, they become something like a balloon rocketing to the surface. Due to the lack of vision, this diver did not properly vent his air. He entered an uncontrolled ascent, which is a nightmare situation for divers. Knowing the dire straits of the problem, the diver entered a state of panic, further delaying sound problem-solving.

Luckily, one of the other divers could aid the panicked diver, and both were brought to the surface. They were transported to an emergency department and monitored for signs of decompression sickness. Both were discharged with no complications. Although this situation did not develop into a life-threatening event, it did develop into a lesson in risk management.

Lessons Learned

The first lesson learned was that experience does not mitigate risk. However, experience teaches you how to reduce risk better. The risk is only mitigated when you apply your experiences. All the divers that set off on this dive said they felt off about the darker conditions of the quarry and the frigid temperatures. However, everyone wrote off their feelings, citing experience as an excuse.

This practice is often not applied correctly in civilian EMS either. As EMS, we will arrive at a call in an environment that’s like one we have worked in countless times. There may only be one slight indicator that something is different. These indicators are easy to ignore. However, these are the times when we must explore that feeling and use our experience to figure out what is different and how we must mitigate that risk.

An example of this is operating an emergency vehicle. We often drive the vehicle and think we know how it handles. However, something may be off in its handling, and we ignore the problem. This problem could affect the safety of the vehicle and result in a collision. In this case, experience became a hindrance—rather than an asset—to risk mitigation.

The divers also identified that no one wanted to speak up. In diving, there is an adage that any diver can call any dive for any reason. This concept often gets eclipsed by the pressure to not be the one who “ruins” the dive for everyone else.

This lack of communication caused divers to enter into an environment where they were already unprepared for active risk mitigation. EMS often has the same communication barriers. Lower levels of care or inexperienced providers do not want to speak up.

They may believe a higher level of care must already be aware of the issue. Or maybe they think the issue is not actually that important given that a more experienced provider seems unconcerned.

Every team member must feel like an active part of the team and have the opportunity to speak. Two eyes alone cannot see everything on an emergency scene. This practice can be applied to something as simple as medication administration.

Suppose a paramedic makes a mistake and states they will administer an inappropriate medication dose. In that case, anyone on the scene is responsible for speaking up if the statement raises alarm.

This case is also a perfect example of minor problems becoming big problems. If we consider most poor adventure-sports cases, catastrophic failures are uncommon. Incidents are generally the result of several minor problems that are ignored until they pass the point of no return.

On this evening dive, the diver who suffered a panicked ascent ignored several minor problems. The darkness of the lake was tolerable alone; however, it put anxiety and tunnel vision into play. Then, the frigid water further diminished the diver’s problem-solving capabilities. This problem was also written off as not being a big deal. Then, when the leak started, it was too late to change course. A mask leak is generally a small deal for divers.

However, in conjunction with frigid water temperatures and dark water, the mask leak became a more significant issue. This issue did not fully capture the issues, but since the diver’s decision-making abilities were diminished, the situation was bleak.

Providers on EMS calls have likely found themselves in similar situations. The situation may arise as a patient with a minor complaint that gets minimal attention. For instance, a case of mild exertional dyspnea may not be considered urgent until the patient develops chest pain.

While the provider assesses the chest pain, the patient enters flash pulmonary edema, and the provider finds themselves in a game of catch-up. Because we are backtracking to fix an old problem, we cannot develop our fullest potential for continual problem-solving. This will cause future problems to be only partially corrected or to be worked through incorrectly.

If the initial problem had received more attention, we may have identified pulmonary edema in the first place and worked to fix it before further problems developed.

The beginning of this article may have implied that the similarities between wilderness medicine and civilian EMS are loose. However, EMS is, in essence, wilderness medicine. We work in out-of-clinic settings while utilizing the limited equipment we carry.

We often do this with limited staffing as well. Our response to medical emergencies is a constant risk mitigation and decision-making process. Every decision culminates in our experiences and ability to think through a problem and respond. Always be aware of the risk, be a team player, speak up, and address issues as they arise.