Download 9 lessons learned as a National Park medic

9 lessons learned as a National Park medic
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 nonhypothermic 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 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.