Download PMR Treatment Guidelines For Wilderness Providers

Treatment Guidelines for Wilderness Medical Providers
Portland Mountain Rescue
Portland Mountain Rescue has two classes of medical providers: state-certified EMS
providers and those with wilderness training. Those in the first group possess a current certification
from the Oregon Department of Human Services as a First Responder, EMT-Basic, EMTIntermediate, or EMT-Paramedic. For these providers, PMR is a state-recognized emergency
medical services (EMS) agency. These providers work under the supervision of our physician
advisor, the scope of practice dictated by the Oregon Board of Medical Examiners, state law
regarding the practice of EMT's, and PMR's formal medical protocols. PMR also has members
who are trained in wilderness medicine through other programs but do not possess a staterecognized certification. As these training programs are not recognized by the State of Oregon,
these providers do not operate directly under protocols for our state-certified providers or under
state statutes governing EMS providers. The purpose of these guidelines is to guide the care
provided by these wilderness providers.
There is precedent for this provision of basic medical care by trained persons who are not
state certified EMT's in the examples of lifeguards (trained according to an American Red Cross
curriculum), ski patrollers (trained using the National Ski Patrol's Outdoor Emergency Care
Curriculum), and guides (trained as Wilderness First Responders through organizations such as the
Wilderness Medical Institute and SOLO). Courses such as the Wilderness First Responder have
been taught to thousands of individuals over many years.
The hazardous and time-critical nature of mountain rescue requires that all of our medically
trained personnel be able to use their skills to treat our patients according to their level of training.
Keeping a patient immobilized over a concern for a spinal injury when personnel are present who
have been trained to provide that assessment subjects the patient and rescuers to other risks such as
rock fall, hypothermia, and unnecessary immobilization and carry-out. Studies have shown that
basic assessment skills including spinal assessment can be effectively taught to lay providers with
minimal training.
These guidelines are not substantially different from the urban EMS protocols governing
our state-certified providers. However, they have been written to address more specifically the
situations encountered by our wilderness providers and to be appropriate for their level of training.
They are based on the best evidence and expert consensus for wilderness care.
Treatment Guidelines for Wilderness Providers
General principles:
-These guidelines apply to members who have been trained according to accepted wilderness
medical curricula such as Wilderness First Aid, Wilderness Advanced First Aid, or Wilderness
First Responder through a recognized training entity such as the Wilderness Medical Institute or
SOLO and hold a current certification from that organization. These guidelines do not apply to
state-certified providers (First Responders, EMT-Basics, EMT-Intermediates, EMT-Paramedics).
Those individuals should refer to PMR’s medical protocols section.
-Care should be provided only up to the level taught in each individual’s training program. Certain
skills are not taught at all levels and should not be practiced by those not trained in them.
-Wilderness providers may not exceed the scope of practice for state-certified providers with a
similar level of training (ie a WFR may not do something a state-certified First Responder may
not). There are some slight differences between how some procedures should be performed (eg
selective spinal immobilization), which are described below.
Specific guidelines:
-Airways: Wilderness providers may not use invasive airways including oropharyngeal or
nasopharyngeal airways.
-Bleeding: Bleeding should be treated with direct pressure. Life-threatening bleeding not stopping
with direct pressure may be treated with a tourniquet applied just above the injury, although this is
rarely necessary. If the tourniquet is applied after a complete amputation, it should be left in place.
If not the limb is not amputated, the tourniquet should be loosened every 30 minutes to assess
whether it is still necessary for bleeding control.
-Defibrillation: Any provider may use an automated external defibrillator (AED): turn on the unit
and follow the directions.
-Selective Spinal Immobilization: Any patient with a potential mechanism of injury for spinal
injury or complaint of neck pain should have a focused spinal assessment by a provider trained to
do so. If the patient has a potential mechanism for spinal injury or neck pain and no provider is
present to assess the spine, the patient should be placed in full spinal immobilization. In cases of
extreme danger to patient and rescuer (e.g. active rockfall), the risks versus benefits of moving the
patient without optimal assessment or immobilization must be weighed by the most qualified
person available. See the medical chapter of the PMR training manual for our preferred methods of
spinal immobilization.
-Perform a separate spinal assessment after completing the primary and secondary surveys
-The procedure described here is different from that for state-certified medics.
-The patient may be cleared from spinal immobilization if ALL of the following are present:
-Fully awake and alert, with normal mental status
-No alcohol or medications that might alter his or her level of consciousness.
-No distracting injuries.
-Normal movement and feeling in arms and legs.
-No pain or tenderness when pushing on the bones of the entire spine.
-No pain with neck movement.
Medications: Wilderness providers trained to do so may administer epinephrine by auto-injector for
anaphylaxis or oxygen. No other drugs may be administered, including over the counter drugs.
Providing sugary food, liquids, or oral glucose for suspected hypoglycemia is allowed by any
provider.
-Extremity injuries: Extremity injuries should be splinted in a normal anatomic position. Axial (inline) traction may be applied to return a deformed extremity to the anatomical position. More
vigorous attempts to reduce a suspected dislocation should not be attempted unless the extremity
has no pulse or feeling.
-Wound Care: Most clean wounds can simply be bandaged if expected transport time is short.
Consider irrigating wounds with clean water if dirty or if evacuation will be delayed. Wounds
should not be closed with sutures, glue, or steri-strips.
-Hypoglycemia: All providers may give oral glucose or sugary foods for suspected hypoglycemia.
This would almost always occur in the case of a diabetic patient who took insulin or oral diabetes
medicines and then did not eat or overexerted him or herself. Glucose or dextrose (in some
packaged cake frostings) are the agents of choice and can be rubbed on the gums of a semiconscious patient. The amount of carbohydrates in a tube of glucose (96 calories in a 31 gram
tube) is inadequate to prevent the blood sugar from dropping again, and should be followed by a
more substantial meal if the patient improves with the smaller dose and has no contraindication to
eating.
-Hypothermia:
Mild hypothermia: (alert, vigorous shivering, good vital signs)
If patient is otherwise healthy and shivering well, he/she should be:
- DRY (remove any wet layers)
- INSULATED (i.e. clothes, sleeping bag, blanket or hypowrap)
- FED (high-calorie food/drink, if patient is not at risk of choking)
- OBSERVED (45-60 minutes, unless immediate threats present)
- WALKED OUT (carefully, if physical/mental status gets worse with exercise, STOP immediately
& reinsulate the patient)
The purpose of rewarming the patient for 45-60 minutes in a hypowrap before walking them
out is to decrease core temperature after drop and to mitigate the poor judgment and lack of
dexterity that might lead to a further injury.
Moderate / Severe Hypothermia: (altered mental status/unconscious, decreased/absent shivering,
decreased/absent vital signs)
Keep these patients lying flat and move them carefully. Gently place the patient in an insulated
“hypo-wrap.” Carefully check vital signs over 60 seconds. Evacuate the patient ASAP to an
advanced medical facility for rewarming.
• do NOT attempt aggressive rewarming in the field. Heating blankets may be placed on
the torso but should not touch bare skin.
• do NOT give fluids/food to patient with altered mental status
• do NOT rub extremities (no frictional heat, only skin/tissue damage).
In severely hypothermic patients with NO DETECTABLE PULSE (as assessed over 60
seconds by the clock), clinical decisions should be based on ability to transport and transport time:
• If transport time out of the field will be less than 3 hours, begin rescue breathing, protect patient
from further heat loss and DO NOT start chest compressions. While rescue breathing using a BagValve-Mask, aim for a respiratory rate of 6 breaths/minute. If using Mouth-to-Mask, give 12
breaths/minute. Carefully transport the patient to definitive medical care. Performing chest
compressions while transporting a patient in a litter is not effective.
• If transport time out of the field will be more than 3 hours, begin rescue breathing. Continue
rescue breathing for 3 minutes (by the clock) as improved oxygenation may improve cardiac
function and make it detectable. If patient still does not have a pulse (as assessed over 60 seconds
by the clock), start chest compressions and continue for up to 30 minutes while attempting to
rewarm the patient. If these efforts are unsuccessful in restoring spontaneous circulation,
discontinue chest compressions and consider subject deceased.
• Do not start rescue breathing or chest compressions in a patient who: 1) has obvious fatal injuries
(dead), 2) has ice formation in the airway (frozen/dead), 3) has a chest wall that is too stiff for
chest compressions (frozen/dead), or 4) if the rescuers are too exhausted or in danger.
-Avalanche: Treat patients with a pulse according to your training for trauma and hypothermia.
Assess for spinal injury according to the guideline above.
IF PATIENT HAS NO PULSE:
1. If burial is < thirty minutes, begin chest compressions and rescue breathing for twenty
minutes. If CPR is successful, transport patient gently, providing rescue breathing as needed. If
there is no return of spontaneous circulation after 20 minutes, stop CPR and consider dead. The
rationale is that the patient is not cold enough to be pulseless because of hypothermia
2. If burial is >30 minutes, and an air pocket of any size was present around the face, treat
according to the hypothermia protocol.
3. If burial is >30 minutes and no air pocket is present, stop CPR and consider dead.