It’s 5:30 a.m. Some have already begun their morning, but most are still asleep. The National Weather Service has been closely monitoring a storm that’s been brewing all night. Suddenly, seven large tornadoes develop within the supercell that stretches for more than 100 miles across the state. More than 30 communities will be affected.
Local governments are notified, and tornado sirens sound. A severe tornado breaks the silence of the pre-dawn morning in one rural community. Residents rush to the safest spot. Most make it; some don’t. Early reports indicate that more than 100,000 people have been affected, with about 1,500 injured.
The incident’s magnitude and significant damage to roadways, bridges and other infrastructure mean local fire, law enforcement and EMS agencies will be strapped, and treatment and transportation of the injured will be delayed. The Federal Emergency Management Agency (FEMA) is unable to send early resources due to the severity of damage and rural location.
The past few years, we’ve seen a change in emergency services. More departments have emphasized mass casualty and disaster management training. EMS agencies around the world have spent countless dollars on mass casualty incident (MCI) and disaster kits to handle any large-scale incident. In the event of one, first responders are confident they’ll be able to meet the challenges presented by these incidents with extra resources.
But what happens when your resources run out? What do you do when federal agencies can’t get to your area for hours, if at all, because the affected area is so immense? What happens when you can’t get your patients to a hospital only 15 minutes away because of access issues?
For more than two decades, specialized rescue teams have dealt with the delivery of care in remote locations, delayed access to patients and transportation problems. Wilderness first responders (WFRs), urban search-and-rescue (USAR) teams, ski patrols, backcountry guides and wilderness medicine providers are specially trained and use a specific set of protocols that allow them to manage patients when faced with limited resources and extended transport times. These providers can be a vital resource to your region during extensive or protracted MCIs or disaster situations.
Let’s examine the capabilities of WFRs and how they can be of assistance during major incidents. Regarded as the medics of the deep woods, WFRs range from basic first aid providers to backcountry physicians. They’re trained to function independently under the most remote and adverse conditions. These providers are employed by national parks, summer camps and USAR groups, and they’re utilized for their specialized approach to emergency medical care.
Wilderness medicine is found in locations where the delay in treatment could cause significant harm to the patient. It applies the standard and universal principles of medical care to a specialized working context, similar to MCI or disaster operations. Wilderness medicine providers act under the same standards as urban providers, except that they operate with an expanded scope of practice required by the challenges in their normal work environment. During incidents that occur in what’s defined as “wilderness context,” WFRs can:
1. Terminate CPR in the field;
2. Administer medications for anaphylaxis and severe asthma;
3. Reduce simple dislocations;
4. Manage wounds and remove impaled objects; and
5. Perform advanced spinal assessment.
Several of the protocols listed above may look familiar, because they pertain to a standard paramedic protocol. Some might feel that others, such as numbers three and four, exceed acceptable parameters or scope of practice. But these rescuers operate in the wilderness context, where they have to preserve tissue and support perfusion for extended periods of time without the support of a hospital and advanced care.
So how would wilderness medicine be beneficial in the urban context? Let’s revisit the aforementioned scenario. Fire and EMS are only able to come within two blocks of the largest accumulation of wounded patients. Although three hospitals are within 20 minutes of the scene, the last patient won’t get there for 26 hours. Now, let’s look at how the WFR’s expanded protocols assist with field treatment and how these capabilities can be used during this disaster scenario.
Termination of CPR in the Field
You arrive at your assigned area to find about 100 residents sorting through the chaos. From afar, you see several residents waving to you excitedly. Upon arrival at their location, you learn they just discovered a family of five trapped in the remains of their house. As the roof collapsed, it fell on the family as they were sheltered in the bathroom.
The mother and three children have sustained multiple cuts, some serious, and multiple fractures. The father is found apneic and pulseless. You open his airway without spontaneous breathing. This is a bad situation. It’s just you, your partner and the equipment on your back to care for multiple patients, some of whom have serious injuries that require your attention. In an MCI setting, you must do the “greatest good for the greatest number.” You and your partner choose not to start CPR, because you have four patients you must attend to immediately and the arrest was caused by a traumatic event.
This protocol has two parts: when to stop, and when it’s OK not to start. CPR can be withheld if the patient is obviously dead from lethal injuries, is in cardiac arrest resultant from trauma or has been underwater for more than one hour, or if the scene isn’t safe. If you choose to start, CPR can be terminated if the pulse returns, someone takes over, or they’ve been in sustained cardiac arrest for more than 30 minutes. Physiologically, we know that cardiac arrest caused by trauma has a poor prognosis, and 30 minutes without perfusion to the major organs cannot sustain viability.
Epinephrine for Anaphylaxis
From behind you, someone yells out that her daughter can’t breathe. You arrive at the mother’s side to find a 12-year-old girl who was stung multiple times on her legs after wandering into a nest of fire ants.
She has a history of anaphylaxis from bee stings but has never been stung by fire ants. She presents with generalized urticaria, edema in her legs up to the knees and respiratory distress. You recognize anaphylaxis, which requires immediate treatment, but transport time is delayed and ALS may not be available in this scenario.
You immediately administer 0.3 mg of epinephrine 1:1,000 intramuscularly (IM). You notice some immediate relief of respiratory symptoms. However, the patient may not arrive at a hospital for several hours, and epinephrine’s short metabolic life (about 15 minutes) means anaphylaxis will continue to be a problem without administration of an antihistamine, such as Benadryl. You follow up with 50 mg of Benadryl by mouth and 60 mg of prednisone, a corticosteroid that helps to stave off edema in the tissue and prevents further rebound reactions. She states relief of symptoms and continued pain in her legs secondary to the ant bites.
Most services carry epinephrine and recognize its need in an anaphylactic patient, but few BLS protocols allow for administration of Benadryl. WFRs, who are trained to recognize the signs and symptoms of anaphylaxis, as well as the pathophysiology of its different reactions, carry Benadryl, epinephrine 1:1,000 and PO prednisone to treat it.
Epinephrine for Severe Asthma
You’re searching a home and find a 36-year-old male patient trapped by a roof truss that collapsed on him. Although not critically injured, the chaos of the situation, compounded by the dust from the roof insulation, has triggered an asthma attack.
The patient says he doesn’t know what happened to his inhaler, has an extensive history of asthma and has been intubated before due to a severe attack. He’s anxious and in apparent respiratory distress. You try to calm him down, but it doesn’t work.
You call your partner on the radio, and she brings you an oxygen kit with a nebulizer and albuterol. You apply the mask to your patient and deliver 2.5 mg of albuterol without relief. The patient has degraded into respiratory failure and slipped to “V” on the alert, voice, pain, unresponsive (APVU) scale. You administer 0.3 mg epinephrine 1:1,000 IM with improvement in the patient’s mental status and respiratory effort. A second nebulizer is administered with albuterol, followed with prednisone. He remains stable throughout the extrication and transport to the hospital.
Asthma has many triggers, which include such stress-inducing situations as a disaster. The main concern with asthma patients is bronchoconstriction with secondary swelling. An asthma attack can be effectively controlled with inhaled beta agonists. A severe asthma attack needs a more aggressive treatment regimen. In the event that the patient doesn’t have their personal inhaler or the inhaler isn’t effective enough, the standard urban BLS treatment regimen is to administer oxygen and be prepared to give positive pressure ventilations. Some agencies have protocols for nebulized albuterol. If the airways are too constricted for the medication to enter the bronchioles, WFRs have other options.
Epinephrine, which is already being carried for anaphylactic reactions, can be beneficial in a severely asthmatic patient. It can be administered IM with resultant bronchodilation, which allows air to access the alveolar sacs and provides an opportunity to get the patient’s medication where it needs to be–in the lungs. The second problem is swelling. If the patient has the ability to swallow, the WFR can administer oral corticosteroids to reduce swelling and prevent further complications. Now the severe asthmatic who won’t be seen in the emergency department for 10 more hours has a better chance of survival.
Simple Dislocation Reduction
The next patient you find is outside his house, holding his shoulder. He says he was descending the stairs in his house as the wind started to rip off the roof. He was knocked from his feet but tried to break the fall by grabbing onto the handrail, which resulted in an anterior shoulder dislocation. Upon examination, you note that distal CSM (circulation, sensation and motor) is impaired, and the patient can’t feel his hand.
You determine that he dislocated his shoulder by an indirect mechanism of injury (MOI). The MOI, history of the incident and physical exam will allow the rescuer to differentiate between a dislocation, fracture and shoulder separation. WFRs can reduce simple joints–shoulders, fingers, toes and patella–that are dislocated from an indirect force, because they have a lower likelihood of fracture than those from a direct force. You safely reduce his dislocated shoulder on site, re-establishing perfusion to his extremity, and the patient is seen the next day at a hospital.
This expanded-scope protocol allows for reduction of dislocations of “simple joints” as a result of indirect forces, either with or without compromised circulation. The purpose is to prevent permanent tissue and/or nerve damage, because dislocated joints can impede circulation and cause significant nerve damage. The longer a joint is “out of socket,” the harder it is to reduce and the more likely there will be permanent damage due to ischemia. Shoulders, fingers, toes and patella qualify because they’re relatively easy to reduce with less danger of nerve damage (as compared to an elbow).
WFRs may be with this patient for an extended period of time, so they not only have to find the problem, but also anticipate what will happen in the future if it’s left untreated. In this scenario, because damaged tissue leads to swelling; swelling leads to pressure and pressure leads to distal ischemia, it’s better to reduce the joint to avoid later ischemia.
The next patient you come across has a two-foot steel rod protruding from her lower leg. You consider whether it interferes with transport and if it’s safe and easy to remove. Leaving the object in place makes the injury more difficult to manage and provides a medium for infection and causes undue anxiety. Removal may cause heavy bleeding, but you’re trained to control bleeding.
You decide that the risk of infection and difficulty in handling this patient outweigh the risk of removal. You remove the rod, find the wound has started to bleed excessively and apply a tourniquet. The bleeding stops. You clean the wound thoroughly with copious amounts of clean water and a 1% povidone-iodine solution. You then add packing to keep the wound open and facilitate drainage and cleaning, and wrap it with bandages and apply a pressure dressing. The tourniquet is released slowly after about 20 minutes without further bleeding, and perfusion is restored to the extremity.
Wounds will be a common complaint at major incidents and disaster scenes. The goal is to treat each patient to the best of the rescuer’s ability and prevent further harm. The major concern in the backcountry is the onset of infection. Typically, EMS agencies control bleeding, dress and bandage the wound, and transport to the hospital. High-risk wounds (i.e., deep punctures and open fractures) have a higher risk of infection. With urban transport times typically ranging from one minute to one hour, infection isn’t a major concern. In a wilderness context, transport times often exceed two hours, making it important to clean high-risk wounds to prevent infection that compounds the patient’s condition.
Cleaning a wound decreases the patient’s chance of infection and shortens their recovery time. Wounds are cleaned just as they would be in the hospital setting, making the obvious allowance for less-than-sterile conditions. This simple procedure reduces the risk of infection setting in.
For removal of impaled objects, some patients can’t wait for extrication or transport. If an impaled object impairs the patient’s removal, or extrication tools won’t be available for an extended time period, the WFR can remove the impaled object. This procedure is performed only when the object will interfere with safe transport of the patient and only if it can be removed without causing excessive damage or uncontrollable bleeding.
The obvious objects that can be removed are those that interfere with the patient’s airway or prevent effective CPR. However, even if your protocol allows you to remove an object from a patient at the scene of a disaster, remember, it’s often best to secure an object in place if it’s protruding from the abdomen, impaled close to a large vessel or positioned in another dangerous location. Be sure the object is easy to remove and in a safe location before attempting this procedure.
The final patient you’re called on to assist is a 45-year-old male who’s been trapped in his basement for 20 hours. He weighs 250 lbs. and fell into the basement as his house was ripped apart. He apparently hit his head and had a period of unconsciousness.
The nearest ambulance is four blocks away. Although there’s a mechanism for spine injury, there’s a debate about whether a backboard is indicated. When there’s a positive MOI for spinal injury, careful evaluation is always necessary. More importantly, the patient must be absolutely reliable, with no acute stress reaction and no distracting injuries.
Upon further examination, you determine this patient presents with normal function and sensation in his extremities, doesn’t complain of any spine pain and doesn’t have neurological deficits, which allows you to rule out spinal injury. If this were his only injury, he could be tagged as a green priority, or “walking wounded.” Since he also has a traumatic brain injury (period of unconsciousness), he remains a yellow tag but can evacuate on his own power.
By using a spinal clearance protocol properly and consistently, on scene providers can detect obvious and occult injuries, or the lack thereof. Having the ability to “clear” a spine can have a positive impact on the incident, further reducing the demand for equipment and manpower.
During a disaster, “the plan” isn’t always followed exactly as it was initially adopted. There are often too many variables to take into consideration or circumstances that exceed the standard plan’s resources or capabilities. Disaster medical courses and the National Incident Management System (NIMS) focus on operations where many different resources are available or en route. But, before the cavalry arrives, first responders are often on their own. It’s during these instances, which are far from standard, that standard medicine shouldn’t be the last line of defense.
Wilderness medicine allows for these variables and welcomes the challenge. With the ever-increasing threat of large-scale incidents and disaster situations, there’s a need for resources and modified protocols that allow for greater patient care.
The wilderness medicine expanded protocols are just one example of what’s possible when the two worlds collide. Improvisation is often the key to patient survival when you’re hours or days from the closest medical facility. WFRs are trained to function with minimal equipment and are accustomed to working in adverse conditions.
WFRs and specialized medical responders, such as search and rescue, USAR and ski patrol personnel, can be valuable on-scene resources when multiple patients are trapped under rubble and crews are limited. Build them into your service’s major incident plans, and tap their expertise when needed. JEMS
This article originally appeared in May 2010 JEMS as The Urban Jungle: Wilderness medicine meets non-rural EMS.