In 2014, I left my job as a paramedic in Los Angeles to work as a medic at Yellowstone National Park and transitioned from running calls in America’s second largest city to responding to emergencies in a remote national park with a service area of over 3,468 square miles, more than six times the size of Los Angeles.
Whether you work in urban or rural EMS, thinking like a remote-area EMS provider can improve your health and well-being, patient care, and scene management. Here are my lessons learned from practicing frontier medicine:
1. Pack the essentials
The exciting thing about working in EMS is that every day is different and unpredictable. When you leave the station, you might return in 10 minutes … or 10 hours. Due to this uncertainty, it’s essential to keep a jump kit with you on the ambulance or the engine to keep you performing at your best. I’ve found packing some of the same essentials needed for a long hike in the wilderness is equally helpful for a day of running calls:
- Nutrition (extra healthy food and snacks)
- Hydration (extra water)
- Sun protection (sunglasses and sunscreen)
- Insulation (extra clothing)
- Illumination (headlamp and/or flashlight)
- Repair tool (Leatherman)
- Navigation (local map)
- iPhone to contact medical control or calculate medication doses
2. Order additional resources early
This past summer, I was responding to a motorcycling accident and, when I heard the driver was unconscious and his 13-year-old passenger had also been thrown from the bike, I launched two Medevac helicopters before I stepped on scene. Working in remote EMS has reminded me that additional resources always take time to assemble, additional time to reach the scene, or they may not be available at all. Due to this, I always follow the maxim of “Order additional resources big, order them early and don’t be afraid to stand units down.” It is better to have additional resources en route and not need them versus the stressful alternative.
3. Beware of environmental hazards
Prior to working in remote EMS, I often thought of guns, knives and combative patients when pondering scene safety, but working in a wilderness setting has reminded me of the tremendous danger the environment can pose. At Yellowstone, the environmental hazards might be thunderheads massing overhead; rushing rivers; steep, rocky trails or an angry bison or bear that has just attacked a visitor and is protecting its prey. In addition, rain, extreme heat, sleet and snow can also affect the well-being of EMS providers. Scene safety is everyone’s responsibility, but don’t be afraid to delegate one person to always be scanning up, down and all around for threats.
4. Establish incident command
In Los Angeles, I often ran calls with the same crew and we quickly grew to know each other’s way of working. However, in remote EMS, it’s not uncommon to run calls with different agencies and with a new crew on each and every call. Due to this, it’s essential that providers don’t freelance by assigning themselves tasks and working independently of the team. Instead, it’s imperative to follow an incident command structure by establishing a unity of command, using common terminology, and agreeing upon a clear objective that answers basic questions such as:
- What do we want to do?
- Who is responsible for doing it?
- How do we communicate?
- What is the procedure if a responder is injured?
Lastly, don’t be afraid to improvise and be flexible when the patient’s presentation or the environment changes.
5. Have a backup plan
Early in my career I got this advice: “Whenever you’re attempting something in EMS, always have a backup plan of what you’re going to do when it doesn’t work.”
Given the inclement weather, uncertainty about the arrival of additional resources and long transport times to the hospital, this advice is especially important when you work in a remote setting. When you go to start an IV on a critical patient, have it in the back of your mind that you’ll jump to an IO if you’re can’t find a vein; be considering using CPAP on an asthma patient if they don’t respond to the non-rebreather oxygen mask you’re placing on them and have a hasty rescue team hiking to your patient with a wheeled litter in case the helicopter about to attempt a short-haul, is unsuccessful. This way, if there is any obstacle, you’re ready.
6. Know your treatment protocols
Working in remote EMS means long transport times to the hospital and, as an EMS provider, the unique opportunity to use your full range of treatments and medications. In addition, you may find your patient ten miles up the trail, far away from the thick binder of treatment protocols you keep in the ambulance. Due to this, it’s imperative to have an expert knowledge of your treatment protocols. Make flashcards, writing a complaint (such as abdominal pain) on one side and your treatment protocols on the reverse (vitals, oxygen, ECG monitor, IV, and consider Zofran for nausea, Fentanyl for pain and a 500 mL fluid bolus if hypotensive) and review them weekly so the treatment algorithms remain fresh in your mind.
7. Use medical control
The opportunity to speak with medical control during a call is one of the greatest — and least appreciated — aspects of our job. The chance to discuss your patient’s condition and the treatments you’re providing with a doctor, or nurse, at the hospital not only ensures better patient care and protects you from liability but is also a great learning opportunity. In remote EMS, where it’s not uncommon to have transport times between 45 minutes to three hours, I contact medical control on almost every call, via cell phone or a radio patch, and my patient care is always better for it.
8. Beware of the after-drop phenomenon
The “after-drop phenomenon” typically occurs in the context of hypothermia when a patient’s core temperature continues to drop, even after they have been removed from the cold environment. I’ve also seen similar deteriorations in non-hypothermic patients in remote settings who are involved in extended search and rescue operations. These patients are compensating in regards to their vital signs, mental status and pain level by themselves, only to have them suddenly deteriorate when rescuers arrive. Why is this? My guess is the relief that the patient experiences from seeing EMS causes them to relax which, in turn, shuts down their sympathetic nervous system which has been compensating to keep them alive. Due to this, whenever I respond to a critical patient, I tell them that the worst is over; we’re there to help, but remind them that they can’t give up now and need to keep working with us. It is important to keep the patient involved in their own self-care.
9. Talking is always the best treatment
Whether working in urban or rural EMS, the majority of our interventions and life-stabilizing treatments are finished within the first 10-15 minutes which means the rest of the call is really about monitoring the patient and delivering great customer service. Instead of mentally checking out once you’ve got the patient stabilized, use this time to connect with your patient. Engaging your patient in conversation will reduce their anxiety level, decrease the workload on their heart and lower their oxygen demand. You will not only save a life but you might also make a friend for life.
Did you know? Most of the large national parks like Yosemite, Yellowstone, Grand Teton, Grand Canyon and Lake Mead hire paramedics for the busy summer seasons. To find job postings, check USAJOBS website.
This article, originally published on January 04, 2016, has been updated.
