EMTs in a cave

[Stridergdm]

Based on discussion in the 2007 weeklong thread, I wanted to toss out an observation and see what people's reactions are.

Time after time during mocks I've seen EMTs perform below their skills during in-cave actions. This includes things such as failing to recognize a "hypothermic" patient sitting in knee-deep water, failing to perform a secondary survey, failing to monitor vitals.

I've actually seen trainers who have only had light medical training (basically enough to do the above) do far better.

My theory is that for non-caving EMTs, the environment is SO foreign, that it rattles them.

In the event of the patient sitting in water, it was clear the EMT was starting to go down other diagnosis for mental impairment, despite standing in the same water himself.

I think in that case, cavers (at least "up north") are SO ingrained to think hypothermia that it becomes second nature. Meanwhile, an EMT, fresh upon the scene, hot and sweaty is thinking anything but.

However the failure to do a secondary or monitor vitals is a bit more surprising to me.

Now, in several cases I've known the EMTs personally and would certainly trust their skills above ground.

And to be clear, this is not intended to disparage any EMTs out there, just an observation I've had.

Thoughts?

[mabercrombie]

I have just started to work with a rescue squad in my area, and with all honesty I am leaning towards a wilderness EMT course or at least wilderness first responder training rather than going to NCRC, because of the very thing that you are talking about.

[NZcaver]

I have just started to work with a rescue squad in my area, and with all honesty I am leaning towards a wilderness EMT course or at least wilderness first responder training rather than going to NCRC, because of the very thing that you are talking about.

Not sure if you realize this, but doing both is good! They are two very different types of training which still compliment each other well, and ultimately make for a handy person to have around on rescue callouts (or cave trips that go really bad).

During regular weekend and weeklong seminars, as far as I know the NCRC does not specifically conduct medical training above first aid/BLS - at least not in the "certified" sense. And I highly doubt most WEMT students ever set foot in a cave during their WEMT training. I think Greg's point was that *some* competent street EMTs can unfortunately become a little disoriented when thrown into a wilderness/cave medical situation. It's understandable, many are used to scooping up a patient and having them at the hospital in 5 minutes. Things like improvising treatment methods and providing extended care are beyond their normal scope, unless they have WFR, WEMT, WALS or similar qualifications.

If your local rescue squad can sponsor you for an WEMT or WFR course - go for it! If (like some) they "don't recognize training in wilderness protocols" hopefully you can still get them to put you through EMT training. From there, you can always choose to do the 1-week wilderness "bridge" course later if you want to.

[Carl Amundson]

I will be taking the Level 3 course this year and 'm planning on taking a wilderness first responder next year.
Like any old boy scout, I like to be prepared...

The only problem is that my pack keeps getting heavier with every course I take...

[NZcaver]

The only problem is that my pack keeps getting heavier with every course I take...

You as well?

The WFR is a great course - I highly recommend it. If you want to know where to go, http://www.wildmed.com is a good place to start.

Here's a couple of other threads to check out -

Wilderness rescue no walk in the woods
How much first aid training do you have?

[cob]

My theory is that for non-caving EMTs, the environment is SO foreign, that it rattles them.


Thoughts?

You are not alone.

Some years ago, after 2 major rescues in St. Louis Co., a paramedic working for one of the local fire departments came to something of the same conclusion. He recognized that cavers were always going to be integral to any cave rescue, and at times the ONLY people in the cave with the victim, due to the sometimes extreme situations and locations rescues happen in.

On his own, he set up a 1st Responders medical training course and a dozen plus cavers signed up for it. His stated goal was limited to the hope that at the very least we would be able locate, recognize, and describe the extent of injuries to above ground medical professionals, who would then be able to instruct us on treatment.

While he did get into treatment, by far most of our time was spent on anatomy and the proper medical terminology. It was well worth the time, for me anyway.

tom

[Ralph E. Powers]

Which is why, with all due respect and admiration to above-ground emergency medical personnel, it's better that cavers rescue spelunkers.

Having as many cavers trained in basic first responder courses is a good way to go. Having a few go into the type of courses that Marty talked about is also a great way to go as well (per grotto).

Having EMT's trained in caving and caving related medical problems is likewise a good way to go. Particularly in cave rich states.

[johnlhickman]

This is an interesting discussion. I have been a member of a cave rescue team for around 10 years. Previous to joining the team, I volunteered to help with several large cave rescues in the TAG region. One in particular had us escorting a couple of paramedics into the cave to stage for a rescue that too several hours due to environmental conditions. They seemed a little intimidated by the cave and left before the operation was complete. This prompted me to pursue my EMT-B license. Since, then I have upgraded to EMT-IV. I would consider obtaining a paramedic license if there was a way to do that and still work.

I have also received a W-EMT certification, which has since lapsed. The EMT training has been very helpful through the years. I can also say that I have been able to utilize the wilderness EMT training. There is a lot of improvisation in the wilderness (and cave) setting, and the training helps you get into that mindset.

In the last few years, I have been involved in several rescues where we had support from cavers who weren’t necessarily trained in rescue. If the situation isn’t highly technical, just having someone who is comfortable with the environment can be a benefit.

John Hickman, EMT-IV
Nashville, TN

[NZcaver]

Which is why, with all due respect and admiration to above-ground emergency medical personnel, it's better that cavers rescue spelunkers.

True, and sometimes rescue other cavers too.

Having as many cavers trained in basic first responder courses is a good way to go. Having a few go into the type of courses that Marty talked about is also a great way to go as well (per grotto).

Good idea, but I suggest a basic First Responder course would not be the best use of time and money if training for the cave environment. That course is probably better for people such as non-medic firefighters and police officers who are often first on the scene, just ahead of the EMTs. The Wilderness First Responder course is far better suited to cave incidents, but also requires twice as much training time (about 8 full days, although I believe they now do a 5-day even more intensive version). The Wilderness First Aid or Wilderness Advanced First Aid courses (2 days and 4 days respectively) are also excellent options. The WAFA is on a 3 year recert cycle (like the WFR), and the WFA has no standard recert requirement. I feel either of these last two courses would be very useful - even ideal - for the "average" caver to consider taking.

The key difference to note with a FR/WFR and anything above (EMT etc) is you now become accountable as a responder. You're no longer a first aider - you can find yourself in a position with legal medical control over a patient (if directly or procedurally delegated by an MD, I recall). You are required to follow procedure, and thoroughly document everything about the patient's condition and all your own actions. Also once you accept responsibility for a patient, I believe you cannot relinquish their care to anyone less qualified than yourself. If you "happen on a scene" outside of any normal work/volunteer duties, the Good Sam law covers actions in good faith to a certain point - but you are still expected to provide a level of care appropriate to your training and certification.

Not to discourage anyone, but this makes for a bit leap between WFA/WAFA and FR/WFR/EMT and above. Choose wisely. Judging by his previous post, johnlhickman probably knows all about this stuff as well. Anyone who knows more or has corrections, feel free to chime in.

[cavedoc]

The Wilderness First Responder course is far better suited to cave incidents, but also requires twice as much training time (about 8 full days, although I believe they now do a 5-day even more intensive version). The Wilderness First Aid or Wilderness Advanced First Aid courses (2 days and 4 days respectively) are also excellent options.

Seems like a nice setup for the Western Region's Wilderness First Aid course September 29-30 in Sequoia National Park. This is the 3rd year since it was first offered so time for folks to re-up or for new folks to take it for the first time. Arranged by the Western Region with instructors from NOLS. Watch the Western Region site at caves.org for further details. The instructors won't be cavers but most if not all of the students will be. Should be fun.

[james huffaker]

Good afternoon ladies and gents, I'm new here and to caving, in fact this is my first post on your site. I looked for a place for introductions, but didn't find any. If any exist, please redirect me.

Reason for my post, I am an RN at a trauma center in the Bronx and an ex-EMT. I am interested in wilderness medicine and rescue.
As stated above, taking street EMS and their protocols and trying to apply them in scenarios for which they were not designed ( like most municipalities and state licensing agencies are want to do) never seems to work very well. Take a street medic or EMT and place them in a wilderness, or tactical or technical rescue situation, and they will try to "adapt and overcome" with only mixed success. Yes there are basic competencies that apply in any scenario, but if the medic was never trained to function in the environment, if no one ever told them that body temperature is a vital sign and that all of the patients that you treat in the "wilderness" will be "temperature stressed" ( either hot or cold depending on the scenario), dehydrated, and hungry in addition to whatever else is wrong with them, they won't know to look. Should they be able to figure it out anyway, probably, but most won't because it's outside their frame of reference. Are there EMT's, medics, RN's and MD's that are trained in various "rescue" skills? Yes, but they are the exception, not the rule.
What if there were training programs that taught folks to practice medicine (limited) in austere environments (IE, clearing C-spines, reducing select dislocations, pain management, Iv's, antibiotics etc?

Please see: wilderness medical society
wilderness medical associates
wilderness emergency medical services institute
global medical and rescue services LTD
remote, austere, wilderness and third world medicine .com

I think quality medical care can be provided in caves, but the individuals providing said care need to have the training, expanded protocols and "wilderness" mindset to function effectively. Regards, Jim

[NZcaver]

Good afternoon ladies and gents, I'm new here and to caving, in fact this is my first post on your site. I looked for a place for introductions, but didn't find any. If any exist, please redirect me.

Hi James. Welcome to cavechat.

If you'd like to, go ahead and introduce yourself by starting a topic under caver introductions (click here).

Some very good points you made in your post. The increasingly-more-accepted "wilderness protocols" are certainly one of the main factors that set the wilderness medical courses apart from the others.

Wilderness Medical Associates (whose training I have attended) has a list of the specific protocols they have adopted to teach here (PDF document). This includes clearing C-spine, reducing some dislocations, administering epi, that kind of thing.

Good discussion!

[james huffaker]

Sir, Thanks for the welcome and your kind response. Re wilderness protocols, WMA and Solo are among the first and most well known and respected wilderness medicine schools, but in the intervening years, we have seen the advent of wilderness ALS, and some of the schools I listed are really pushing the envelope as far as what is possible in remote medicine while always practicing good medicine. In allot of ways it's bridging the gap between urban medicine and wilderness medicine by combining emergency/critical care medicine and primary care medicine. Combine this body of knowledge with technical rescue, and you open a whole nother world of possibilities.
Dose every patient need a chest tube and a surgical airway? No, but if I can clear a pt's c-spine, give him some pain meds so I can reduce a dislocation, and start him on some antibiotics after dealing with his laceration, maybe he can walk out with assistance/support and how much time got cut off your carry out? Thanks again for the welcome. Regards, Jim

[Stridergdm]

Definitely agree on being able to clear the C-spine and all that.

In many environments, and especially a cave environment, you're probably going to do far more harm than good by doing "advanced" techniques such as intubating, back-boarding, etc. Yes, sometimes it's an absolutely necessity, but if I can get a patient out under their own power, I'm very inclined to do so. Especially if I can get someone with advanced medical training to OK it. (which is why having more caver EMTs and the like is nice.)

I won't speak in general for most cavers, but I suspect the average American figures that in a rescue we'll pack them and drag them. They don't realize the medical dangers of immobilizing a patient for long periods of time.

In the one extra-long call-out I was involved in, there was a decent discussion about whether the patient (who had been entrapped below the knee for over 24 hours) should be put in a sked and hauled out or allowed/encouraged (depends on who you talk to ;-) to get out under his own power with some assistance.

He got out under his own power. Medically I think this was the right decision by far. It kept him moving, kept his temperature up, kept his SPIRITS up (something that can be very important) and given how tight the cave was, got him out hours sooner than if we had tried to get him out in a sked.

[tncaveres]

Hi I'm new here too This only my second post on here.
I'm an EMT IV Caver that is a Training Officer for my County Technical Rescue team.
I work for The County ambulance service here but also like to get under ground as much as possible.
Being the one responsible for the training every month I try to make sure the EMT's & Paramedics get as much training underground as possible.
Our goal is to have atleast 2 mock rescues a year plus monthly training.
In our mocks the victims are from one extreme to the next ( can walk out on ther own to having to package the pt) .
The medics & emt's are graded on pt care so they can see where there is need for improvement.
The good thing about our group of medics is they are comfortable about being underground. They are usually asking when the next cave trip is so they can go.

My point in all this is that maybe yall should ask the local EMS service or who ever would handle your countys rescue & see if you could start taking some of the interested ones underground. Getting them used to the enviroment.
Just a thought