New “Minimum Standards for Medical Units”

The National Wildfire Coordinating Group has issued a new document titled Minimum Standards for Medical Units Managed by NWCG Member Agencies. Your first thought might be that this is a response to the death of firefighter Andrew Palmer who, three hours and 20 minutes after being struck by a falling tree, bled to death while he was being transported in a Coast Guard helicopter (which responded staffed by a rescue swimmer) to the Redding, California airport. But the document states that it is being published “after years of hard work”, and does not say it is because horrendous errors were exposed during the Andrew Palmer tragedy.

I am no medical expert…I used to teach Advanced First Aid and my EMT expired a long time ago. The new standards are only a very small step in the right direction. It covers credentials, scope of practice,  and some very basic principles of communication and patient transportation. But it does not cover to what degree Emergency Medical Services will be provided to fire line personnel, minimum EMS staffing for fires, or minimum time standards for treating and transporting patients.

Nor does it cover many of the principles that Andrew Palmer’s brother, Rob, outlined in his “2009 National Wildland Fire Reform: The Palmer Perspective”, such as transporting a severely injured firefighter to an appropriate medical facility during the “golden hour”.

There is a statement on page 14:

Following the adoption of the Minimum Standards for Medical Units Managed by NWCG Member Agencies, the IEMTG will develop NWCG Wildland Fire EMS Protocols.

Maybe that Protocol document, if and when it is developed, will be the meaningful one.

The NWCG needs to take the final step and address the issues that affect the treatment of firefighters during the “Golden Hour”. I used to tell my firefighters, “If we can’t do it safely, we won’t do it”.

Wildland firefighters face safety issues that have never been considered by urban firefighters. If a firefighter working on a structure fire is injured, a ground ambulance can access the patient 99.9% of the time. Almost by definition, where there is a structure, there is a road to it, so transporting an injured structural firefighter to a hospital within the Golden Hour is rarely a problem. And a landing zone for an EMS helicopter is usually within five minutes from the site of the accident by ground ambulance.

The NWCG agencies must develop an Emergency Medical System for firefighters that is unprecedented for civilian agencies. To ignore this issue, or delay it for years, would be negligent.

It may be difficult for executives in the federal land management agencies, whose expertise may be as a biologist or forester, to wrap their thoughts around how to adequately treat a firefighter who is seriously injured in the middle of a wilderness area. A person has to wonder if this issue would have been already addressed if wildland firefighters were part of their own fire management agency, rather than being farmed out to an assortment of land management agencies run by -ologists.

The military has been successfully and rapidly treating their injured warriors since the 1960’s. The NWCG needs to borrow their ideas and provide a safer working environment for wildland firefighters. Immediately.

The NWCG, including the National Park Service, US Fish and Wildlife Service, Bureau of Land Management, Bureau of Indian Affairs, and the US Forest Service, needs to immediately create a task force that will work full-time to create a policy that will address these issues.

Author: Bill Gabbert

After working full time in wildland fire for 33 years, he continues to learn, and strives to be a Student of Fire. Google+

8 thoughts on “New “Minimum Standards for Medical Units””

  1. Bill I agree with you, we have a LONG way to go with this issue, and I feel NWCG is not really addressing the issue. NWCG and the wildland agencies must take a hands on approch with EMS and get out of the 70’s !

  2. While I agree that there’s more work to be done, we can’t bash the whole system. I’ve been injured on a fire and I received timely and appropriate care, through the ICS system that was in place.

  3. This still misses one of the biggest issues…there is no MEDICAL AUTHORITY to practice on most fires, because there is no medical director issuing protocols/standing orders. They say to get one locally…yeah, right. I’ve worked with a lot of medical directors, and none I’ve known would authorize advanced level care to be provided by someone they don’t know, who’s in town for 2 weeks and they’ll never see again. Without an agency-level or NWCG-level medical director to authorize care, there will still be a lot of illegal care provided until someone gets sued or criminally charged for providing medical care without medical authority to do so.

  4. Eric,

    I just got back from the 2010 California Interagency Incident Management Teams Workshop. At least in CA, your issues are easily addressed by CA Title 22, which sets medical standards for both BLS (Basic Life Support) and ALS (Advanced Life Support) programs.

    FIRESCOPE actually has been working on this issue for over a decade, with the first STATEWIDE implementation of Fireline EMT program in 2000. Title 22 DOES NOT require medical direction for BLS programs IF they follow established local area protocols and the individuals are qualified/certified as either EMT-B or Medical First Responder.

    In terms of ALS, you can find some information on how the program has been evolving since the 2006 fire season… when the first Fireline Paramedics were field tested with CA IMTs. This year, the program is going fully online.

    You can get more info by visiting:
    http://www.firescope.org/specialist-groups/ems/specialist-ems.htm

    P.S. – Regions 1,4, and 6 of the U.S. Forest Service DO HAVE ASSIGNED medical directors assigned for certain EMS care and procedures. Many other areas (outside of the above) have local medical directors assigned.

  5. The National Wildfire Coordinating Group’s Interim Minimum Standards for Medical Units Managed By NWCG Member Agencies #015-2010 (Standard) made small changes to the operation of Medical Unit Emergency Medical Services (EMS) personnel. We not only need to applaud their efforts, but we also need to recognize this as the first of many necessary steps.
    While the Standard does provide a notification method to use licensed EMS providers in a foreign EMS jurisdiction, the Medical Unit’s mission articulated in the Standard is insufficient. The current Medical Unit mission provides: “(1) stabilization and emergency medical treatment of incident personnel, and (2) occupational health and preventative measures for incident personnel to remain safe and healthy” [FN1]. However, the mission statement does not incorporate rapid transportation or resource capacity. Being able to stabilize and treat injuries only buys time in anticipation of delivery to a definitive care facility. If the Medial Unit’s mission statement doesn’t include urgent access to definitive care, then is it within the mission statement of Operations?

    The ultimate lifesaving protocol involves field treatment AND urgent access to definitive care within the Golden Hour.

    A Golden Hour Response requires that the Medical Unit, fielded EMS providers, and Operations staff collaborate such that an injured fireline person can reach definitive care within one hour. In addition, the Standard does not supersede the archaic minimum EMS staffing standard adopted in 2008, NWCG#10-2008. To improve the care of injured fire personnel, the NWCG and IEMTG must take the next step to update the Medical Unit mission statement and follow through by dramatically increasing the medical capacity on fires. Currently, NWCG#10-2008 still only requires one field EMT per 499 fireline personnel or two field EMTs per 500+ fireline personnel. The IEMTG, collaborating with the Operations staff, needs to develop a progressive policy such that resources are not engaged unless EMS providers can be onsite within minutes. In addition, the policy would require that Operations staff must not engage resources such that the patient and EMS provider cannot be delivered to definitive care within an hour.

    A fireline employee’s life is more important than that of any potential effect of fire, and establishing notification and scope of practice policies are the very first steps to creating policies that recognize the importance of a coworker’s life. We have an opportunity and the ability to develop progressive fire policies that base engagement upon the Golden Hour Response. To do less would be inconceivable.

    [FN1] Standard, p8: “The mission of Medical Units on wildland fire incidents has evolved into a complex service which provides: (1) stabilization and emergency medical treatment of incident personnel, and (2) occupational health and preventative measures for incident personnel to remain safe and healthy.”

    1. Rob,

      Spot on.

      You stated the problem clearly when you said,

      “The ultimate lifesaving protocol involves field treatment AND urgent access to definitive care within the Golden Hour.”

      It is a clearly defined end state goal and recognizes that “ultimate” is rarely achievable but should always be our target…

      Unfortunately, we often fight fire in the “boonies” and definitive care IS OFTEN well beyond the “golden hour”, but we’ve (some areas) learned to provide adequate pre-hospital EMS services in the interim to our employees where possible.

      Actually, many communities in the remote areas of the U.S. are also not within the “Golden Hour” standard of definitive care nor in reach of the “most appropriate facility” designation that was used as a selling point in the 80’s for Regional Trauma Centers….

      There are lots of folks working to address the problem… Type 1 and Type 2 ICs to MEDLs to FEMTs to FEMPs… Actually quite a few MDs are also involved in the discussions.

      I’ve been an EMT for nearly 30 years and co-written some of the recent national “policies” (even though they were often plagiarized by various other working groups and watered down somewhat) and communicated with the past, current, and future folks focusing on the wildland fire EMS issues.

      These ongoing changes were written, researched, taught, and championed by MDs, firefighters, EMTs, and paramedics (and even ICs) who have been in the field of wildland fire and who have lost friends to substandard prehospital EMS care.

      All it takes is one person or group of folks… (no offense intended to Eric, ENGB, FF-EMTP, Combat Medic) to DERAIL years of progress if somehow they think by posting on “They Said” helps in communication or that they somehow know better than the folks who have been actually working on the issue for years.

      The EMS problem is being addressed and it NO LONGER has anything to do with the “snivelers” more interested in “legality” and protecting themselves, but rather actually doing what is right to protect OUR firefighters .

  6. Forgot to say:

    The 2010 goal of OUR extended team of professionals and experts is to provide ALS services to all fireline divisions, spike camps, and the incident base camps.

    All it takes is one “paramedic” or “politician” to derail proper definitive care and think they know better than folks who were in their shoes in the ACTUAL EMS devade…. just like what recently happened when proper treatment of wildland firefighter burn injuries were delayed for over two years as folks argued about liability vs ability…. instead of simply doing what is right.

    1. I’m not trying to get in an argument with anyone here, as that would be unproductive and certainly not the right venue. I am grateful for the progress that has been made, and that the issues of proper EMS care on fire incidents is being addressed at a variety of levels.

      I’ve also been involved in EMS care and fire for just shy of 3 decades, in a wide variety of settings and levels from rookie to management (not combat medic, not sure where you got that), and am VERY concerned about ensuring that firefighters get the best possible care on every incident. But I’ve also been told to “just do the right thing and it’ll be okay”, when that is not legally correct. I have a family to feed, which I can’t do well if I’m on an incident that wants me or those working under me to provide ALS care without medical authority to do so, and I get criminally charged or sued for doing so. That’s reality I have to live with.

      I’m glad California has taken the lead on this issue, and that a handful of USFS regions have been more proactive in establishing medical control. I only hope that the rest of “the system” will follow suit.

      I have ZERO interest in derailing the system! I only hope that with this progress that has been made, folks won’t say “there, it’s fixed”, and ignore it until something else tragic happens – we know that doesn’t work. But telling folks in the field to provide ALS care without medical authority is akin to telling the supply unit to wear a trench coat to walmart and shoplift needed supplies because we don’t have a system to do it legally.

      Bottom line:
      We need to be able to provide quality, BLS and ALS care, with the legal and medical authority to do so, on all incidents of any size, AND provide prompt evacuation to the most appropriate receiving facility based on the severity of injury/illness, the distance, and the capabilities of the receiving facility. It needs to be a planned and organized system, not an “oh %$#@, something bad just happened” response as has sometimes occurred in the past. Great progress is being made, but we’re not “there” yet. I believe we are all in 100% agreement on that, are we not?

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