Disaster Preparedness and Mass Casualty Management in Washington State

Staff from Aerie and the Student Conservation Association recently provided disaster preparedness and MCI training to 170 employees of the Washington Conservation Corps in Lacey and Mount Vernon, WA. WCC is an incredibly skilled and experienced group with a long and inspiring history of providing disaster relief throughout the US. These trainings occurred over three days, using 3, 20-patient simulated mass-casualty events as the focal points for teaching and review. Events such as these are perfect opportunities for an organization to review its risk management and training policies, and provide participants with an awareness of what to expect from such an event and how they can better prepare if they are confronted with such a difficult scenario. In 2009, Aerie has trained over 300 WCC staff in wilderness medicine and MCI/ disaster preparedness. We are honored to work with such an amazing group.

Cooperation in the Wilderness Medicine Industry

Aerie was very happy to cooperate with other wilderness medicine training providers to put together a Scope of Practice (SoP)suggested guideline for Wilderness First Aid training. Dr. David Johnson of WMA and Tod Schimelpfenig of WMI took a leadership role and put a tremendous amount of effort into crafting and then seeking our feedback on this document. A copy will be placed on this Blog for others to look at and comment upon. This SoP will be discussed at some length next week at the AORE conference in Minneapolis, MN. From there, Tod and David will submit the document to the Wilderness Medical Society for further review. The goal will be in part to provide more consistency and transparency within the industry. Next on the curriculum list is the Wilderness First Responder program.

Competition in the Wilderness Medicine Industry

This year's Wilderness Risk Management conference, held in Raleigh-Durham, NC, was a productive event for Aerie. Each year, we use the conference as an opportunity to meet with leaders of other wilderness medicine training providers, most notably WMI and WMA . After speaking at length with Tod Schimelpfenig, Curriculum Director of WMI, and Dr. David Johnson, President and Medical Director of WMA, about a wide range of issues, from industry standardization to curriculum decisions, I am again convinced of their organizations' outstanding quality. It is petty, disingenuous and self-defeating to suggest otherwise. Although some dangerous outliers exist, the defacto wilderness medicine industry standards are extremely high. This fact alone inspires Aerie to maintain our excellence. All organizations benefit from industry quality, and will suffer from its lack. While WMA and WMI are our competitors, they also help define our industry, which is equally if not more important than the challenge of competition. Wilderness medicine students are looking for quality education, and the industry needs to provide a product that serves their needs and represents the industry well. Our students move between organizations to certify and recertify, and then they represent the industry by taking their education out into the field and practicing their skills. We are happy that many of our competitors provide such outstanding courses, benefiting our common students and the industry as a whole.

Wilderness Risk Management Conference

Aerie is at the annual Wilderness Risk Management Conference in Raleigh-Durham, North Carolina. This is the industry's premier event. Our Board member, Bob Birkby, is the conference keynote speaker. We will be bring home to our classes more of the latest information on industry standards in wilderness risk management, wilderness medicine and outdoor leadership.

Dislocation Reduction Instruction in Wilderness Medicine Courses

From Aerie's Wilderness Medicine Manual, 10th Edition.

Reduction of a dislocation is not without controversy. A provider may cause further harm if they act hastily. However, leaving a joint dislocated for many hours will also cause damage. This decision should be influenced by your relationship with the patient, distance from definitive medical care, your comfort with the assessment and the procedure, local regulations, and your institutional protocols, if any. Anyone who informs you that at the introductory wilderness medicine level the assessment of dislocations is straightforward, that the treatment is without risk, or that the skill is easy to retain, is, in our opinion, completely misinformed.
Always have a dislocated joint evaluated by qualified medical personnel upon return to the frontcountry.

Epinephrine Administration Instruction in Wilderness Medicine Courses

Considerable debate and misinformation surround the administration of epinephrine at the WFR/ WFA level. Some regard adrenalin as the most important item in their first aid kits. Others do not even consider carrying it out of fear of litigation. The DEA is not (yet) hovering above your campsite, waiting for you to give epinephrine to yourself or your family and friends. However, administering your epinephrine to your patient, without lawful protocols signed by an authorized medical provider licensed in your state, is considered by many legal professionals to be an illegal act. This presents an employing agency with a nearly impossible dilemma: can they mandate their employees to break the law? Similarly, it is entirely conceivable that withholding epinephrine or not having epinephrine on an outdoor trip could be considered as acts of omission, which are serious allegations. Many large outdoor organizations, such as the Student Conservation Association, NOLS and Outward Bound have considered the same legal arguments and made very different decisions about whether to carry epinephrine in the field. These are very complex issues. They are debated each year at the Wilderness Risk Management conference. 2009 was no exception. At this year's conference, outdoor law specialist Frances Turner-Mock stated that she found this to be one of the most complicated legal issues she has ever encountered in law. It is no surprise that so many organizations find it so difficult to make a decision.

Understand that having a certificate that testifies to your competence in the management of anaphylaxis, including the administration of epinephrine, is no substitute for signed physician protocols that are in accordance with local laws and regulations. To date, we know of no lawsuits brought against an individual that administered epinephrine in an outdoor setting.

A number of employing agencies do not have a medical director or the medical director is not licensed in the state that the employee is working; however, many expect their employees to carry and administer adrenalin if needed. This is a potential set-up for litigation. As with so many medical/legal issues, protect yourself by making informed decisions based on thorough assessments; few lawsuits arise from positive patient outcomes.

Further mitigate your risk by considering your relationship to your potential patient and the presence of physician protocols in accordance with the law. Anaphylactic reactions evolve very rapidly, so the best time to weigh the risk is before the trip begins.

It is our hope that adrenaline will be available by auto injector without prescription. At that point, organizations and individuals can make medical decisions based more on medical criteria than legal concerns.

Standards in Wilderness Medicine Education

Recently, the Wilderness Medical Society published the latest edition of Wilderness and Environmental Medicine (Vol. 20, No. 2,). This publication contains two articles, one by Dr. William Forgey, the second by Dr. Thomas Welch et. al., both critical of current wilderness medical training offered for the laypublic. We strongly enourage you to read these postings.



A Message from Aerie's Director
What should we teach and what should we omit?
At Aerie, we are constantly reviewing and revising our curriculum. This is our ethical and legal responsibility, and for this task we rely on our Medical Director, our Board of Advisors, our instructors, current industry standards, and, to a large extent, our students. We watch our students, paying attention to what they learn, how they learn, and what they retain. In this way, our students give us constant feedback on the efficacy of our instruction. This feedback educates our curriculum decision-making and encourages us to distinguish what we can teach from what we should teach. Our instructors are experienced enough and the wilderness medicine industry is sufficiently unregulated that we can teach many advanced skills that we chose to exclude from our introductory courses. Instead, Aerie classes are defined by our emphasis on decision-making and patient assessment, which we most effectively convey through challenging and in-depth, intense scenarios.
In both the medical and outdoor fields, judgment, gained from experience, is the most valuable and difficult skill to either learn or teach. Sound judgment is nearly impossible to package into a cohesive “teaching unit,” and it is difficult to market. The latter point is important to state, because as Aerie’s Director, I am sometimes tempted to make our classes appear as if they will teach everything a perspective student wants and needs to know, providing them skills that look good on paper or in pictures. In my opinion, the wilderness medicine industry falls prey to these temptations too often, giving students the impression that any particular physical skill set, usually the one being offered, will set their students apart in the field and provide the life-saving intervention that their patients might require. As a result, wilderness medicine is often defined by what we do, construct, or administer, rather than by the more crucial skills involved in critical thinking and decision-making. Examples of this include the teaching of certain medication administrations and instruction in advanced skills in introductory courses.
As a critical care paramedic, paramedic instructor and ambulance preceptor, I regularly observe the complications and potential dangers inherent in teaching advanced skill sets to people with little patient-care experience. Often, priorities are lost or at least confused under the stress of a true emergency. For example, after over 1,000 hours of instruction and two years of training, paramedic students will often reach for a medication to administer before fully assessing their patient; they start an IV before checking for a pulse. In large part they do this because they have more trust in doing than in observing. These mistakes are not isolated events but are instead the norm, a part of the learning process. Fortunately, in an urban setting, preceptors are able to step in and redirect. However, by definition, wilderness environments usually preclude such intervention. Aerie students take our classes precisely because they venture into areas where such recourse is not available. It is a wilderness medicine educator’s responsibility to understand this dynamic and provide training that not only increases our students’ potential to help but also minimizes their potential to harm. This issue has significant legal as well as educational implications. For example, the Montana Board of Medical Examiners recently published a Position Paper on wilderness medicine in Montana, warning EMTs that acting outside of current state EMT protocol (which most of these advanced techniques clearly do) is not permitted under state law and may subject the EMT to reproach. We have always taught exactly this at Aerie. While state protocols may not have been written with wilderness care as a consideration, acting outside of the protocols has inherent risk and should only be considered in an educated manner. The more we teach our students that strays from standard protocol, the more risk they may face. Personally, I believe it is extremely difficult for a newly trained student to balance the legal and medical risks and benefits of many of these advanced procedures and that, as educators, we need to understand this challenge and adjust our curricula appropriately.
In addition, I believe that, particularly in the absence of experience, the more physical skills you have at your disposal, the more appealing these skills become and the more likely is their misapplication. This is far more likely when we teach fairly advanced skills to students in 16 or 80-hour classes, or even in a longer Wilderness EMT courses. It is not a matter of whether an individual is capable of learning and performing the skills; my nine year-old daughter is capable of performing almost any advanced physical skill taught in these classes. However, she has yet to develop the judgment necessary to decide when to apply the skills appropriately.
There is little doubt in my mind that certain levels of wilderness medicine training should instruct students in relatively advanced techniques, including medication administration and certain orthopedic procedures such as dislocation reductions. However, these procedures are fairly few and do not define the tenor of Aerie classes. We do not, for example, believe that EMT students, most of whom initially struggle remembering to observe a scene for hazards or clear an airway, should confound their understanding of appropriate medical care with IV insertion, urinary catheter placement or wound suturing.
Although it may be tempting to move in other directions, our collective outdoor, medical and teaching experience always reminds us to focus on priorities, and in wilderness medicine these are the less-than-sexy goals of situational awareness, prevention and patient assessment, all of which form the basis for good decision making. While we teach in some of the most beautiful settings in the world, this is truly what makes an Aerie class unique. Through interactive discussions and challenging scenarios, we try to impart our experience to our students, enabling them to make sound judgments in the most difficult circumstances. Medicine itself is a difficult enough subject to teach and learn. Add to this the complexities inherent in providing care in extended, challenging environments, and there is, in my opinion, no question that wilderness medicine classes need to promote sound decision making, which is infinitely adaptable, over any particular physical skill sets, which are inherently limited, largely impractical, potentially harmful and often distracting to the tasks at hand.
David McEvoy, MS, Critical Care Paramedic
Director
March 1, 2008