Working in remote locations is a challenge for EMS. This is the Dixie ICP on Rattlesnake Fire (July 18, 2007). It's 4 hours by road from the nearest medical facility (By the time MKUmphrey arrived a week later, this was Dixie Spike Camp and ICP had been moved to the Red River Ranger Station).

Thomas Pedigo, a paramedic from Colorado, has written a good article on current problems with the medical care provided on wildland fire incidents.

Among other things, he notes that the main cause of death on fires is heart attacks (28%) rather than burnover events (11.4%). But the treatment for breathless pulseless patients is defibrillation within 4-6 minutes and advanced cardiac meds within 10 minutes. Without such treatment, the survival rate plummets from 30% to 0-8%. To Pedigo, this suggests that “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.”

He also contemplates the possibility that it would be cheaper to have paramedics or physicians at fires than to pay for the unnecessary transports started by EMTs without much clinical training or experience in the types of problems that are encountered at wildland fires. A helicopter transport will cost $300-$400 dollars and an ER visit costs between $500 and $1100, which means an unneeded transport costs the fire from $1000 to $2000 per person. This does not iinclude lost time for the patient or others involved in the incident. It may be the case that Type 1 incidents with multiple injuries illnesses and transports would do better to have personnel on site who can “write prescriptions, suture a laceration, treat an allergic reaction” etc.

His main recommendations are (1) to study medical records from past incidents to determine the costs of treatment on site versus transport to a hospital, (2) develop a fireline EMT curriculum to prepare EMTs to treat injuries pertinent to wildland fire, and adopt a national curriculum for Fireline EMT/Fireline Paramedic, train incident managment teams to recognize the limits and abilities of various medical care providers, and an increase in medical personnel on the fireline--at least one EMT per crew and one paramedic per division and one clinical practitioner on each large incident. Remote crews should have a fireline paramedic with them.

Safety comes first, he observes, but when safety fails what comes second?

On my recent 14 days in spike camp, I dealt with a lost toenail on a big toe involving quite a dirty injury, but I did not have any suitable disinfectant to soak the injury. I ordered a bottle of iodine but it never came. And of course I could not prescribe or obtain antibiotics. I also dealt with a case of poison ivy that, on the seventh day after infection, became systemic. Nowhere in my training had I been given information about poison ivy this severe, and I interpreted the spreading red inflammation as a secondary infection from the sores rather than as a spreading of the allergic reaction. The only treatment I had available, evacuation, was the same in either case. 

I was grateful that the IMS protocols provide this information:

For more severe cases (multiple areas on body, swelling and edema of the face or genitals, progressive lesions unresponsive to topical therapy, intractable pruritus) obtain routine physician referral.  A “routine physician referral” is defined as “within 24 hours.”

The nearest defibrillator was at least two hours away if everything went right, but most of the time due to inversions that grounded the helicopters and the inability of jet boats to move on the river after dark such equipment may well have been twelve or more hours away.

The Flathead Agency, which dispatches us, has defibrillators available to EMTs for local fires, which puts them ahead of most agencies. Should they be in EMTs’ line packs, along with the fire shelter?

I’m new to wildland fire, and my initial experiences are giving me plenty to think about. I would like to see EMTs from our service photographing the conditions they encounter, along with basic information about interventions and outcomes, for our own training. Much of what we do is not taught in much detail in the state and national curricula for basic EMTs.