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EMS challenges in the wildland setting

A new group has formed to determine the best way to provide consistent medical direction on wildland incidents


Ambulances arrive at Sutter Santa Rosa Regional Hospital to evacuate patients in Santa Rosa, Calif., on Saturday, Oct. 26, 2019.

AP Photo/Ethan Swope

By Michael Rains, NRP

Andy Palmer never made it to the hospital. The 18-year-old died in California’s Shasta-Trinity National Forest after a tree-falling incident during the Eagle Fire response in 2008.

According to the National Park Service (NPS), the incident was a “jarring wake-up call” for many in the wildland firefighting community, as emergency medical efforts were not as robust as other facets of interagency fire response.

There are numerous challenges facing the delivery of emergency medical care to the firefighters within a wildfire setting. Consistent equipment, medical direction, protocols, quality and affordable education to front-line crews, and delivery of service in a consistent and organized manner are vital during large wildland incidents.

All this needs to be addressed in a time of a changing culture, not unlike the culture shift that occurred in the structure arena approximately 30 years ago, with the integration of EMS services. Some progress has been made to bringing medical resources to the wildland setting, but it is an uphill battle in some areas.

Multi-agency involvement

One part of the challenge is the numerous players that are involved in a fire incident. There are the many federal agencies, like the U.S. Forest Service, National Park Service and the Department of the Interior’s Bureau of Land Management and Bureau of Indian Affairs, just to name a few. Numerous state agencies become involved in the ordering of resources to fight the fire, and local agencies that are often situated in a rural setting can be overwhelmed by the extent of the incident, requiring assistance from outside groups.

As resources arrive on the scene, most of the incident command structure, suppression components, logistics, safety officers and communications teams have been well established and work together to contain and control the incident to its resolve.

Some individuals within interagency Incident Command System realize the importance of having a detailed and effective emergency medical response within the incident, but there is little consistency among agencies.

For years when a medical staff was needed, a Medical Unit Leader (MED-L) was ordered and assigned to supervise the medical care for the responders on the incident. In most cases, they were given a limited number of personnel to assist them. But without enough personnel and resources, particularly for a large incident with sprawling geographical layout, this is almost an impossible task. Even in the cases where a high priority is placed on EMS coverage for an incident, there are numerous challenges associated with setting up an effective response.

Changes rooted in tragedy

It has been well documented over the years that good prehospital care is time-related. The “Golden Hour” has been a standard of care for years, and research done during our military time in the Middle East has substantiated these findings. Our troops have the benefit of rapid effective care. Why shouldn’t our men and women putting themselves in harm’s way to protect our wilderness areas and, more frequently, our towns and cities located in the wildland/urban interface receive expedited medical care?

The aforementioned incident involving Andy Palmer is a perfect example. Our wildland firefighters should not be dying in the field from a broken leg. Fortunately, there has been some progress since this incident.

According to the NPS, following Palmer’s death, the National Wildfire Coordinating Group (NWCG) issued the Dutch Creek Protocols, highlighting the need for standardized communication protocols. The Wildland Fire Lessons Learned Center shared information outlining the communication protocol in the event of a medical emergency to add to Incident Response Pocket Guide (IRPG). This ultimately became the Medical Incident Report in the 2014 IRPG. The Medical Incident Report was updated in the 2018 IRPG.

The Wildland Fire Lessons Learned Center also produced a video about Palmer’s death, focusing on guidelines for emergency medical response and extractions. The video’s conclusion stresses the importance of agencies being able answer three questions:

  1. What will we do if someone gets hurt?
  2. How will we get them out of here?
  3. How long will it take to get them to the hospital?

According to the NPS, since Palmer’s death, three new positions have been made available in the Incident Qualification and Certification System (IQCS): arduous duty EMT, Advanced EMT and paramedic. The standard requirements for these three positions ensure a minimum level of fire behavior knowledge and fitness level for EMTs working on the fireline and that a person with the proper qualification can be ordered by an incident management team for a fire assignment. Further, the ICS-206 WF, Medical Plan, is more robust and includes the Medical Incident Report.

The issue of medical direction

One would think that if we had the available and appropriate resources on scene, most of the problems would be solved; however, the complexity of the issue is much greater than that.

Up to this point, when outside resources are needed and called, they come from a variety of areas. We have contributors (city fire departments and fire district units), contractors (private sector resources), federal agencies (most of which do not have Medical Direction or ALS), and local agencies that are trying to take care of business in their backyards.

Many of these responding units could be arriving from multiple states, creating its own set of challenges. EMS personnel are licensed in their individual states, and unless an agreement of has been made between state EMS agencies, they are not licensed to practice out of their local area. The medical unit leader assigned to the fire will contact the state EMS authority to get a temporary reciprocity granted for the duration of the fire.

Several states have signed on to the Recognition of EMS Personnel Licensure Interstate CompAct (REPLICA), which has eased the burden; however, medics still face other issues crossing state lines to care for patients outside their area.

There are state and federal regulations that complicate an ALS practitioner’s ability to utilize narcotics for pain relief unless they have medical direction from a physician licensed in that state. To date, as paramedics show up on an incident, they have been taking their ALS kit from whatever agency they are responding from and utilizing their local medical direction if needed. This results in inconsistency in protocols, medical direction and equipment that arrives on an incident. And some of the contributors are sending out an ALS team with no pain management capabilities. Some of the larger contractors have obtained medical direction in numerous states, but they are in place only for the utilization of the members who are obtained by a specific contractor.

Arizona Wildland Medical Advisory Group

In late 2018, myself and a group of individuals came together to address some of the issues facing the Wildland EMS response issues. The Arizona Wildland Medical Advisory Group (AWMAG) started meeting in November 2018 with about 15 people, and by the second meeting in February 2019, there was representation from five states across the Western United States. The group has grown to about 100 people from several different disciplines and has representation from local, state, Native American Tribal and federal agencies.

The group has been working on some of the above challenges to provide consistent medical direction that apply to the fire incident itself, not just individual agencies. There are currently 11 states where medical direction is available. It is our hope that with some education and consistency, we can make a difference in the care provided – and save lives.

About the Author

Michael H. Rains, NRP, is a firefighter/paramedic with the Scottsdale (Arizona) Fire Department. He has over 38 years of experience in emergency medicine and as an EMS educator. In 2018, he and a few Wildland Medical Unit Leaders started a grassroots organization called the Arizona Wildland Medical Advisory Group, which includes numerous members from states across the Western United States. The group has been addressing areas of consistency in protocols, education, resources, equipment and consistency in Medical Direction for EMS personnel responding to wildfire incidents. He has been working with the U.S. Forest Service to educate their members in EMT training as well as an advanced scope of practice for front-line hand crews.