Download Reversing the Trend: Taking Medical Care to the Firefighter

Reversing the Trend: Taking Medical Care to the Firefighter
Medical Care at the Fireline
Thomas F. Pedigo, PA-C, NREMT-P, MEDL
Pridemark Wildfire/Medical Support Team
6425 W. 52nd Ave, Unit 9
Arvada, CO 80002, USA
303-432-0100 office
303-432-1928 fax
[email protected]
Abstract
Wildland fire incidents are among the most hazardous in the world. Personnel work in extreme conditions,
requiring aggressive physical rehabilitation and medical care. To truly address all pertinent aspects of the
medical care of these personnel, increased efforts need to be made before, during and after incidents to
ensure they are appropriately cared for. Prior to the incident, preventative measures and screening can be
enforced that will decrease the probability of long-term medical conditions provoking acute episodes on the
fireline. At the incident, advanced medical providers and well-trained emergency medical providers can
serve to recognize and intervene in order to rapidly and efficiently treat firefighters and minimize financial
components of hospital transport of ill parties. Emergency medical care currently does not meet a
consistent standard, particularly with respect to knowledge of fireline injuries and needs. This paper
utilizes anecdotal cases and supporting research to highlight the current lack of appropriate medical care
present on the wildland fire incident. It also provides recommendations for further study and
implementation of improved standards that will benefit the ill or injured firefighter and ensure the safety of
on-scene emergency medical providers.
Keywords- emergency medical care, occupational health, preventive medicine, EMT, paramedic, physician
assistant, nurse practitioner, physician, heart attacks, advanced clinical practitioner, medical unit leader
It almost goes without saying that with wildfire incidents come injuries. Tragedies such as the
Mann Gulch of ’49 or the more recent Storm King loss have focused the spotlight on safety issues, helping
the wildfire management community to reorganize its thoughts and priorities. But when our safety plans
fail, or unpreventable accidents occur, it begs the question: ‘Safety first, but what comes second?’ Safety is
but one slice of the pie known throughout industrial and hazardous occupations as ‘occupational health.’
Other key components include prevention, health promotion, and emergency medical care. To provide for
the occupational health of the wildland firefighter- one of the most dangerous and most taxing jobs in the
world- all of these components must be addressed.
Occupational health may first be addressed at the level of prevention. The red card Pack Test
provides for a certain amount of prevention by ensuring a minimum level of physical fitness. While
increasing physical testing requirements adds another element of safety, the focus of safety has primarily
remained aimed at the fireline. An excellent example of this is a direct comparison of the number and type
of wildfire fatalities. In the past fifteen years, the PRIMARY cause of death of a firefighter was not due to
fire activity (ie. burnover, snags, or aircraft accidents) but in fact due to heart attacks, a medical problem.
Since 1985, 28% of all deaths were heart attacks, with the next highest being vehicle accidents (22.5%),
aircraft accidents (12.6%) and burnover events (11.4%) (NIFC 2001). Compared with the initial fatalities
in the early or middle 1900s, this represents a tremendous accomplishment in the area of fire safety. It
results, however in the glaring reality that medical problems are neither being monitored nor treated. While
other medical problems have resulted in some wildfire fatalities, none stand out so clearly as the heart
attack. This is a condition not brought on by a single stressful incident or by a long, wearing season, but
indeed as an acute syndrome encountered only after years of neglect of such preventable factors such as
cholesterol, high blood pressure, atherosclerosis, etc. A true preventive model of care needs to be
established to ensure that physical exams are completed, that routine laboratory tests are made for those
with risk factors, and that all personnel, including incident management personnel, are physically fit to
endure prolonged situations of stress and fatigue. Multiple papers in recent wildland fire safety council
conferences (Sharkey 1999) have addressed the dietary needs, immunological responses, and susceptibility
of the wildland firefighter to additional medical problems as a result of sustained fireline activity. Turning
these factors into tangibly enforced guidelines for the prevention of disease is the next vital step in
protecting our firefighters from further harm, and to protecting the governing agencies from further
liability. Prevention takes place prior to the fire season, prior to the incident, and prior to the heart attack.
Prevention can then be extended into the fire camp, with the assistance of educated medical personnel
trained to provide interventional medicine.
Interventional medicine is a concept of treating medical conditions before they take a firefighter
out of duty for a prolonged time. One example of this occurred on the Greasewood Fire Complex in
Colorado earlier this year. A firefighter was assessed by a paramedic to be moderately dehydrated.
Subsequently, the firefighter was pulled off the line, placed in a cool area, given two liters of intravenous
solution, and then allowed to continue work after an afternoon of rest and oral fluid rehydration (Halford
2001). The same individual may have met a different fate if either he had been assessed by an untrained
firefighter, an inexperienced EMT, or had continued unchecked. On the other hand, had the same
individual been sent to the hospital emergency room, the incident would have lost money, paying for the
ER visit, the return trip, and the extra hospital fees associated with intravenous fluids. By applying the
concept of interventional medicine, this individual was given the necessary treatment for no additional cost,
and was allowed to return to the fireline after a thorough physical assessment. This example demonstrates
an enhanced level of immediate care, earlier intervention, and cost-effectiveness of providing the
necessary, trained medical personnel.
The key to providing the necessary medical care lies in the level of care present in camp as well as
on the line. In order to make the appropriate determination, several factors need to be examined. First and
foremost, members of the incident management team who are responsible for the ordering and supervision
of medical units and their personnel must ensure they are familiar with the various levels of training and
skill ability with respect to EMTs, paramedics, and advanced practitioners. Medical Unit Leaders must be
medically trained and experienced in order to ensure sound decision-making and appropriate ordering of
additional personnel. Finally, it is imperative that the lack of fireline experience and knowledge be
addressed. These are key components to enhancing the medical care in a manner that takes improved
medical care to the firefighter.
One of the questions posed to the medical unit at the 2001 Colorado Wildfire Academy was,
“What is the difference between an EMT and a Paramedic?” (Christopolous 2001). This question was
repeated by fireline and incident management personnel alike. There is a lack of uniform knowledge and
understanding of the training differences. The crux of the situation lies in that these may well be the same
individuals who are hiring medical personnel. One can liken it to an inexperienced firefighter ordering air
attack apparatus- they simply do not have the knowledge basis to know what they are ordering or the
capabilities of those individuals. To add to the problem, there is no one uniform standard of certification
utilized to ensure competency of EMTs, paramedics and other health care providers. The core training of
these individuals is almost entirely urban-based, meaning its focus is providing basic or advanced life
support from an ambulance to a local hospital. There is absolutely no focus on wildland fire, and very little
direct information in the basic level with respect to the types of injuries seen on wildland fire incidents. In
order to provide some insight to the various levels and their abilities, let us examine one of the more
uniform national standards for EMS. The National Registry of Emergency Medical Technicians has an
established, national curriculum for both EMTs and paramedics which remains the sole consistent standard
from state to state. Even so, it warrants mentioning that this standard has not been adopted by any formal
policy by NWCG, the USFS or other institutions involved in the training of wildland firefighters.
Number of didactic hours, total
National Registry EMT
120
National Registry Paramedic
100-1200
Clinical Hours
10 observational
250+ clinical
250+ internship
Field Preceptorship
no
yes
Airway, Breathing, Circulation
basic airway protection, CPR
advanced airways, cardiac meds,
Defibrillation, chest decompression
Medication
only assist with patient’s meds
may administer multiple meds
Pain Management
splinting only
splinting, pain medication
Burn Treatment
3 hours
3 hours
As noted above, the paramedic curriculum is much more comprehensive, includes more
interventional skills and medications, and has a competency-based clinical component which holds
certifying agencies responsible to ensure continuous quality assurance (US DOT 1998).
Further examination of the core curricula of the above positions illuminates the lack of medical
training pertinent to the wildland environment, especially the EMT. Assuming this national standard was
to be used, the paramedic receives an appropriate background in a multitude of advanced and basic
anatomy, physiology, and emergency treatment, with some additional education in the area of primary care.
The EMT receives very little education with respect to fireline injuries and, in fact, receives over three
times more training in urban-based ambulance and hospital operations than in environmental or burn
treatment. They receive no formal training with respect to primary care complaints such as colds, coughs,
and blisters (US DOT 1994). So, if the current levels of emergency medical care are not sufficient to deal
with the type of number of injuries on a particular wildfire incident, where can we turn?
The answer is the advanced clinical practitioner. A physician, nurse practitioner, or physician
assistant holds the training, the education, the experience, and the medical authority to address all types of
emergency and primary care issues on the wildfire incident. With the latter two having a minimum of 4-6
years of medical experience and a clinical competency-based curriculum, they are among the higher level
of care referred to by the wildland incident management team as APMC or agency provided medical care.
Cost does become a factor when considering APMC providers but may serve as a necessary tool on larger,
prolonged incidents where multiple emergency and primary care injuries and illnesses arise. The ability to
write a prescription, suture a laceration, treat an allergic reaction, assess the physical and mental well-being
of fireline personnel, and provide more invasive procedural care for trauma patients makes them an
invaluable resource in the base camp. Unfortunately, the availability of quality health care remains limited
when the unit leaders and incident management personnel are either unable or unwilling to recognize the
true lack of medical care currently available on the wildfire incident.
Retreating back to the incident of the heart attack, early intervention of advanced cardiac life
support with a heart attack victim is a prime example of necessary medical care. Once a person loses their
pulse and stops breathing, they are considered to be in cardiac arrest. Immediately, cardiopulmonary
resuscitation is imperative. In less than 4-6 minutes, the individual with a ‘shockable’ heart rhythm
necessitates defibrillation (a.k.a. ‘shocking’). Within 10 minutes, advanced cardiac medication is
warranted. According to the American Heart Association, the likelihood of survival without the
appropriate treatment at the appropriate time decreases the outcome from up to a 30% survival rate to a 08% survival rate (and that is provided that defibrillation still occurs within 10 minutes) (AHA 1994). These
established survival rates necessitate that at a minimum an EMT should be within almost immediate reach
of most if not all firefighters. As many are not trained in defibrillation or carry that equipment, a paramedic
on the division is the next appropriate level of intervention with medication and ‘shocking.’ This is the
only way to increase the survival rate of a firefighter once the heart attack has ensued. The medical unit
leader can be of invaluable assistance in coordinating this approach to the wildfire incident.
The Medical unit leader (MEDL) often becomes the focal point for the administration of medical
care, both emergent and primary care, on the incident. The importance of this position dictates that those
who fill it not only be trained in the paperwork and intricate nature of the Incident Command System, but
that they also hold a certain amount of advanced medical training and experience. No IC would place a
‘green’ firefighter in charge of a division- it’s a safety and operational issue. Yet there are neither medical
training nor medical experience requirements for the position that often is left to provide medical care at the
base camp, direction to fireline EMTs, and medical administrative responsibilities. The very same ‘green’
firefighter currently may operate as the MEDL, administer the incorrect over-the-counter medications,
order the wrong equipment and personnel, and invariably be left to determine the extrication method of a
patient. This last component leads to delayed care and unnecessary helicopter evacuations. Such was the
case in August of 2000 near Encampment, Wyoming when a firefighter suffered severe second and third
degree burns to the thigh, hands, and abdominal flank when his fusee was mistakenly ignited in his pocket
(Colson 2000). His definitive care was delayed as he was transported to a nearby clinic that was not
prepared to handle burn trauma. While he eventually made it to the burn unit at University Hospital in
Denver, Colorado, his transport may well have been expedited in the event the personnel in place were
well-trained and experienced in providing emergency trauma care and determining appropriate transport.
Such knowledge is not a luxury but a necessity when considered as a component of the Medical unit
leader’s training and expertise.
As if safety and quality of medical care were not enough to warrant a revision of current medical
provisions, cost needs to be assessed as well. Assuming a transporting fee of $300-$400, a base rate for the
ER visit of between $500 and $1100, and cost of loss of time of that particular individual, each single event
that is transported to the hospital unnecessarily is costing the incident somewhere between $1000 to $2000
per person. Add in cost of any suture procedures, medication administration, and delays in return to the
incident and that cost escalates. While a solitary transport off the line of a small incident may not be
enough to justify providing APMC coverage for the fire, the case can be made that a type I fire with
multiple injuries, illnesses and transports to the hospital may well be costing more in transportation costs
than by providing a clinician on site. In order to determine this cost, it will be necessary to take a
retrospective look at past incidents, medical costs and the likelihood of potential treatment on site by a
clinician. The same clinician may also serve to provide quality care and monitoring of dispensed over-thecounter medications by EMTs not currently trained to provide such medications. Finally, the chance of
liability from lawsuits may be lowered by assuring a higher standard of care with personnel who are
medically licensed to provide primary care.
Recommendations
After exploring the apparent lack of medical care available to the fireline firefighter, the following
recommendations can be made:
1) A comprehensive retrospective study of medical records from several active regions to determine the
cost of treatment on site versus transport to the local hospital. This study should have a large enough
sample population of small, medium, and large/prolonged fire incidents to explore the need for APMC
on larger incidents. Additionally, the study could explore the time of year, type of crew (federal,
volunteer, etc.), and type of injuries and illnesses that are definitively treatable on the fireline or at the
base camp.
2) Development of a Fireline EMT curriculum designed to ensure the EMTs knowledge and ability to
treat injuries pertinent to the wildland’s extreme conditions to which they have not been exposed.
3) Development of a higher standard for the Fireline EMT. Documented, competency-based training and
experience is a necessary component in order to allow for the EMT to be prepared for the roving
fireline positions or the base camp operations.
4) Adopt a single national curriculum for the Fireline EMT/Fireline Paramedic. Instead of avoiding the
uncertain field of state vs. national certifications, it is incumbent upon the existing fire agencies to
adopt the National Registry curriculum as the minimum acceptable level of certification and by doing
so establish a uniform requirement.
5) Education of the appropriate IMT personnel on the level of medical providers available. Logistics,
Safety, Finance, Operations, Supply, Planning, ICs, and Medical Unit Leaders are the core of the target
population that need to recognize the importance of not just the limits but also the abilities of various
medical care providers.
6) Increased medical care on the fireline. An incident with multiple divisions should at a minimum
include an EMT on the fireline per crew, a paramedic per division capable of responding to an
emergency scene, a paramedic at any tanker or helicopter base, and a medical unit consisting of a
medically knowledgeable MEDL, an EMT and Paramedic with an ambulance, and one additional
medical provider. Include advanced clinical practitioners where there are enough injuries and illnesses
to justify on-site diagnostic care. Finally, any crews that are airlifted to a distance away from the
division line need to include an experienced fireline Paramedic.
Conclusions
This paper utilizes many anecdotal incidents to illustrate a much broader theme of lack of
appropriate medical care. This anecdotal evidence is not sufficient alone to warrant a broad change on the
fire incident. However, it suffices to highlight the need for further study and concentration on health care
issues. The multiple wildland fire agencies involved in safety have shown a dramatic ability to address and
focus on safety issues with very positive results in recent years. However, if heart attacks are the number
one cause of firefighter death on the wildfire incident over the past 15 years, why do we neglect to either
enforce earlier interventional screening or ensure higher on-site standards of care? Additional resources
can and should be applied for further analysis of the evolving awareness of medical issues. A stronger
emphasis needs to be placed on ensuring that EMTs and paramedics have applicable experience. Incident
management teams will need to refocus efforts to answer the one final question that plagues the medical
delivery system of wildfire incidents- safety comes first, but when safety fails what comes second?