Seth C. Hawkins

Effects of ground EMS and ED personnel on air medical trauma on-site times.

INTRODUCTION On-site times for helicopter EMS (HEMS) providers are hypothesized to increase when procedures indicated by national standards of care and local HEMS are not consistently completed by ground EMS (GEMS) or ED providers before HEMS arrival in trauma cases. METHODS In this prospective study, we divided all trauma missions (120) flown by a university-based HEMS during a 3-month period into interfacility missions (between hospitals, ground providers are ED personnel) and scene missions (between scenes and hospitals, ground providers are GEMS). HEMS completed forms identifying which procedures were completed and omitted by GEMS or ED providers. We collected relevant times from county dispatchers and HEMS flight control. RESULTS Ground providers frequently did not complete indicated basic and advanced procedures. A relationship existed between scene GEMS omissions and HEMS on-site times. If no procedures were omitted, average HEMS time on-site was 13 minutes, increasing to 17 minutes for one procedure omitted and 20 minutes for two or more. No relationship was found on interfacility missions between ED provider omissions and HEMS on-site times. However, any existing effect may have been eclipsed by external factors significantly extending HEMS on-site times (mean 43 minutes). An average of 93 minutes elapsed between the request for HEMS transport and patient arrival at the transferring hospital. CONCLUSION GEMS frequently omit indicated procedures. For scene missions, reducing the number of indicated procedures omitted by scene GEMS providers could reduce on-site HEMS times. For interfacility missions, further study is indicated to determine what occurs before HEMS is contacted and while HEMS is on-site.

Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Drowning

The Wilderness Medical Society convened a panel to review available evidence supporting practices for the prevention and acute management of drowning in out-of-hospital and emergency medical care settings. Literature about definition and terminology, epidemiology, rescue, resuscitation, acute clinical management, disposition, and drowning prevention was reviewed. The panel graded evidence supporting practices according to the American College of Chest Physicians criteria, then made recommendations based on that evidence. Recommendations were based on the panels collective clinical experience and judgment when published evidence was lacking.

Retrieval of Additional Epinephrine From Auto-Injectors

Anaphylaxis is a challenging condition for any austere environment. It is unpredictable, has sudden onset and a high fatality rate, and is responsive only to epinephrine, a prescription medication. The Wilderness Medical Society has formally recommended that non-medical providers working in austere environments be trained to administer epinephrine. Medical providers frequently prescribe auto-injectors for this purpose due to their ease of use by nonmedical providers. However, auto-injectors have limitations in the wilderness environment, particularly due to their single-dose (or at most 2-dose) design. This paper describes an austere environment technique for obtaining multiple additional doses of epinephrine from auto-injectors that have already been used as designed.

Participation of iatrogenically coagulopathic patients in wilderness activities.

An increasing number of patients routinely undergo long-term anticoagulation with warfarin or other pharmacological agents. There is little evidence and no consensus documents in the literature regarding the appropriateness and relative risk of their participation in wilderness activities. We present a case report, conduct an analysis of the limited literature that is available, and make recommendations for wilderness medicine practitioners and screening personnel.

Extreme event medicine: considerations for the organisation of out-of-hospital care during obstacle, adventure and endurance competitions

Obstacle, adventure and endurance competitions in challenging or remote settings are increasing in popularity. A literature search indicates a dearth of evidence-based research on the organisation of medical care for wilderness competitions. The organisation of medical care for each event is best tailored to specific race components, participant characteristics, geography, risk assessments, legal requirements, and the availability of both local and outside resources. Considering the health risks and logistical complexities inherent in these events, there is a compelling need for guiding principles that bridge the fields of wilderness medicine and sports medicine in providing a framework for the organisation of medical care delivery during wilderness and remote obstacle, adventure and endurance competitions. This narrative review, authored by experts in wilderness and operational medicine, provides such a framework. The primary goal is to assist organisers and medical providers in planning for sporting events in which participants are in situations or locations that exceed the capacity of local emergency medical services resources.

Large Posterior Communicating Artery Aneurysm: Initial Presentation with Reproducible Facial Pain Without Cranial Nerve Deficit

Unruptured posterior communicating artery (PCOM) aneurysms can be difficult to diagnose and, when large (≥ 7mm), represent a substantial risk to the patient. While most unruptured PCOM aneurysms are asymptomatic, when symptoms do occur, clinical manifestations typically include severe headache (HA), visual acuity loss, and cranial nerve deficit. This case report describes an atypical initial presentation of a large unruptured PCOM aneurysm with symptoms mimicking trigeminal neuralgia, without other associated cranial nerve palsies or neurologic deficits. The patient returned to the emergency department four days later with a HA, trigeminal neuralgia, and a new cranial nerve III palsy. After appropriate imaging, she was found to have a large PCOM aneurysm, which was treated with surgical clipping with significant improvement in patient’s symptoms.

Medical Oversight, Educational Core Content, and Proposed Scopes of Practice of Wilderness EMS Providers: A Joint Project Developed by Wilderness EMS Educators, Medical Directors, and Regulators Using a Delphi Approach

Abstract Introduction: A disparity exists between the skills needed to manage patients in wilderness EMS environments and the scopes of practice that are traditionally approved by state EMS regulators. In response, the National Association of EMS Physicians Wilderness EMS Committee led a project to define the educational core content supporting scopes of practice of wilderness EMS providers and the conditions when wilderness EMS providers should be required to have medical oversight. Methods: Using a Delphi process, a group of experts in wilderness EMS, representing educators, medical directors, and regulators, developed model educational core content. This core content is a foundation for wilderness EMS provider scopes of practice and builds on both the National EMS Education Standards and the National EMS Scope of Practice Model. These experts also identified the conditions when oversight is needed for wilderness EMS providers. Results: By consensus, this group of experts identified the educational core content for four unique levels of wilderness EMS providers: Wilderness Emergency Medical Responder (WEMR), Wilderness Emergency Medical Technician (WEMT), Wilderness Advanced Emergency Medical Technician (WAEMT), and Wilderness Paramedic (WParamedic). These levels include specialized skills and techniques pertinent to the operational environment. The skills and techniques increase in complexity with more advanced certification levels, and address the unique circumstances of providing care to patients in the wilderness environment. Furthermore, this group identified that providers having a defined duty to act should be functioning with medical oversight. Conclusion: This group of experts defined the educational core content supporting the specific scopes of practice that each certification level of wilderness EMS provider should have when providing patient care in the wilderness setting. Wilderness EMS providers are, indeed, providing health care and should thus function within defined scopes of practice and with physician medical director oversight.

Wilderness Emergency Medical Services Systems

Wilderness emergency medical services (WEMS) are designed to provide high quality health care in wilderness environments. A WEMS program should have oversight by a qualified physician responsible for protocol development, education, and quality improvement. The director is also ideally fully trained as a member of that wilderness rescue program, supporting the team with real-time patient care. WEMS providers function with scopes of practice approved by the local medical director and regulatory authority. With a focus on providing quality patient care, it is time for the evolution of WEMS as an integrated element of a local emergency response system.

General Medical Considerations for the Wilderness Adventurer: Medical Conditions That May Worsen With or Present Challenges to Coping With Wilderness Exposure

Participation in wilderness and adventure sports is on the rise, and as such, practitioners will see more athletes seeking clearance to participate in these events. The purpose of this article is to describe specific medical conditions that may worsen or present challenges to the athlete in a wilderness environment.

General Medical Considerations for the Wilderness Adventurer: Medical Conditions That May Worsen with or Present Challenges to Coping with Wilderness Exposure

Participation in wilderness and adventure sports is on the rise, and as such, practitioners will see more athletes seeking clearance to participate in these events. The purpose of this article is to describe specific medical conditions that may worsen or present challenges to the athlete in a wilderness environment.