When a medical emergency happens on the fireline, having an air medical evacuation plan in place can drastically decrease scene time and increase firefighter survivability. What is your plan?
When wildland firefighters request a helicopter for a critically injured patient at the scene of a motor vehicle crash on a rural highway, they rarely think about their own potential needs. But when the need for an air medical evacuation is requested on a wildfire incident, everyone near a radio seems to instantly increase their situational awareness — for themselves or their crew. The overhead staff also has to ensure that such resources are readily available as they hope the medical emergency is not as severe as it may sound.
Over the last several years, wildland fires have seen an increase in air ambulance requests, medical evacuations and short-haul rescue needs. The more well-known had tragic outcomes, such as the Dutch Creek Incident, or were more recent and complex, such as the 2010 Deer Park Fire in Fairfield, Idaho.
This increase in air ambulance requests and short-haul extraction demands has also caused an adamant stirring within the men and women who have boots on the ground, as demonstrated by the Cow Creek Fire in Colorado. The Type II incident management team assigned to that fire enlisted the help of the Grand Teton National Park Rangers to develop an extraction plan for those wildland firefighters serving in this high-altitude, remote fire setting. They now have a well-known, lessons-learned paper that shows their medical plan and decision-making process in the event of an emergency. Those lessons learned were in relation to the Dutch Creek Mitigation Measures developed in spring 2010. These measures are helpful in risk management, but many safety officers, medical unit leaders and others have never heard of them or seen a printed copy.
The lessons learned may also have considered Rob Palmer's The Palmer Perspective, which many wildland firefighters have seen on the Internet. A National Park Service employee, Palmer, documented the Golden Hour of advanced life support to the critically injured as well as some operational engagement practices involving wildland firefighters. His younger brother, Andy, died in the Dutch Creek Incident, and he witnessed the death of his Arrowhead Hotshot co-worker, Daniel Holmes, in a tree incident. His insight into these tragedies offers a valuable podium from which to provide information for those who are in the position to make changes.
Often, with tragedy comes change — not at the speed many of us demand of those above us or the rate we personally practice, but it does come. However, the Internet and social networking sources such as Facebook and Twitter are helping to immediately disseminate lessons learned and keep others safe. While this openness can be helpful to overhead, crews of all types and many others in the wildland fire environment during an immediate incident, it can also be detrimental to the confidentiality needed for tragic situations and subsequent investigations.
Helicopter Best Practices
Recently, the Incident Emergency Medical Subcommittee, under the auspices of the Risk Management Committee and National Wildfire Coordinating Group, published the Emergency Helicopter Extraction List. The EHEL provides a list of potentially available helicopters that can provide hoist and short-haul rescue services, but it may pose several problems. To help mitigate this, it is the responsibility of wildland firefighters who have knowledge of other supportive aircraft to help keep the EHEL committee updated on those changes.
While a great deal of work was done to accomplish this by Les Herman, a private contractor paid by the U.S. government, it did leave out many private EMS or hospital-based air ambulances, which often are the listed resource on ICS Form 206. Typically, many of the air ambulances listed in the shift plan do not have the capability or operational understanding to support hoists and short-haul extraction. Unfortunately, in many wildfire-prone areas, especially in less-populated states, the closest air ambulance is called when a medical situation arises. Often, those listed for hoist and short-haul rescue are not in close proximity due to cost and non-compete clauses that have a provision of care for all citizens, not just a focused group.
A potential problem with using only EHEL aircraft on the ICS 206 Form is that many private or hospital-based air ambulances are often called to the wildland fire incident, instead of EHEL aircraft. Therefore, they may not have the radio frequencies, as in Deer Park and Dutch Creek; they may not have the hoist; and they may have no experience speaking with air attack, who may have additional insight to the airspace situation. In addition, private and hospital-based air ambulances often have policies and procedures that may make the medical mission difficult to accomplish.
The use of private and hospital-based air ambulances could be controlled even more tightly in the near future as hundreds of recent helicopter incidents have resulted in crashes with multiple fatalities, near-misses, accidents and other related situations involving helicopter EMS. Currently, the Federal Aviation Administration, National Transportation Safety Board and helicopter EMS are having serious air ambulance policy discussions. These include subjects such as medical protocols, flight weather standards, crew configuration, funding and dispatching of aircraft. Idaho alone has seven air ambulance providers, all hospital-based, with two services based in Boise ultimately competing for dollars. In 2008, the Idaho EMS Bureau established a rotation system and issued a directive stating that ground EMS agencies and hospitals could no longer helicopter-shop when a different service denied a flight.
Another problem is that incident commanders, safety officers, medical unit leaders and line EMTs have, at one time or another, placed all of their eggs in the one basket of military aircraft. Although this idea is counterproductive due to current military operation tempo and deployments, it is still being used in many situations. In addition, many assume that military aircraft always have a combat medic. However, this is not always the case, and if the aircraft does show up with a "medic," he or she may only be a NREMT-Basic, due to military exemptions from a state requirement to have a licensed provider on military air ambulances. They also may not have the necessary equipment to provide ALS for the patient you want them to pick up.
The other military aircraft factor is the National Guard. Many weekend warriors are just that — one weekend a month, two weeks a year. They may not be around when you need them for a variety of reasons, such as not coming in during the day because they are flying at night to maintain night-vision goggle flying skills. The time delay for a life-threatening injury should be considered when calling on a National Guard aircraft that is not staffed 24 hours or one that may have a hoist but no ALS or medical provider on board. If this situation arises, be prepared to send the highest level medical provider with that patient.
Consider the Options
The Deer Park Facilitated Learning Analysis (FLA) provides a significant basis for things that can go right and things that can go wrong. This also holds true with the Dutch Creek Incident. While air ambulances are important to the safety and well-being of the wildland firefighter, they need to be the second transport option.
Almost 20 years ago (when I started in EMS in Montana), my First Responder instructor emphasized the need to always keep a ground EMS unit coming. Helicopters are expensive, have millions of working parts and cannot fly under certain weather conditions. However, they do offer a fast and productive means of caring for the patient and sustaining that patient until arrival at the hospital.
Of course, not every patient needs an air ambulance. Does a firefighter with a moderate-level injury from a falling rock, such as a closed tib/fib fracture, actually need an air ambulance? Would the injured firefighter benefit from pain control in the form of a narcotic? Possibly, but consider the following. Who is evaluating the injured? Someone with practical field experience or someone who just completed a health-care provider class? There is a difference between the two. Would it be more beneficial to secure the injured person to a SKED, Screamer Suit or Stokes Litter for transport to a waiting ambulance by short-haul with an incident helitack crew performing the task to a safe helispot for proper loading, or a little farther to a helibase for a waiting ground ambulance or air ambulance that has just landed in a more controlled setting?
These questions are not intended to demean those who are on the scene, but rather to help us think outside the box instead of always relying on the air ambulance or EHEL. There is a time and a place for the potential need, but they should be evaluated before the need arises, as the Cow Creek Fire example shows. Of course, much of this is driven by policy, but the old saying, "sometimes it is easier to ask for forgiveness, then it is for permission," still holds true when a life, limb or eyesight is on the line.
Options on the Ground
During the tragic 2003 Cramer Fire in the Salmon-Challis National Forest in Idaho, a member of a Hotshot crew was seriously injured. He was mid-slope in the late afternoon when a stump piece rolled downhill about 100 feet and struck him, causing him to roll downhill through a rock scree another 100 to 150 feet.
I was sitting at the Long-Tom Lookout with a full complement of ALS equipment when the call for help came. A Type 2 helicopter assigned to the incident immediately picked me up, flew me downslope to a helispot with a helitack crew member who also was an EMT. We met a division-group supervisor (trainee) who agreed to stay at the helispot and coordinate radio traffic, as the fire repeater had just gone out. After a 10-minute walk downhill to the injured with the helitack EMT in tow and a quick update from the on-scene division-group supervisor (who happened to be an EMT-Intermediate at his home department), we determined that this patient had significant multiple skeletal injuries with the potential for life-threatening internal injuries.
During patient care, I noted to the division-group super-visor and branch director that we were quickly losing daylight and it was too risky to walk downslope through the rock area a few miles, potentially injuring others. In addition, it would take the closest ambulance service (who were volunteers and not ALS-licensed) almost two hours to reach the road turnout below us, with another two-hour drive back to a small local hospital that would still have to fly the patient to a larger hospital with a trauma suite.
Although we needed to keep that ambulance coming as a backup plan, I suggested short-haul with an agency contract helicopter, which initially was considered a no-go option by others. Another option was to call the local sheriff, who might have a rope rescue team. Again, I noted this would be extremely time-consuming and not in the best interest of patient care. When I presented the short-haul option again with an explanation of how I would accomplish the handoff after the St. Patrick Hospital Life Flight landed at the lookout for handoff, it was accepted. I am sure the IC and others were holding their breath, but the mission was accomplished with great success. However, it was not a decision that was made in haste or without some understanding of what I was asking, as well as how I was going to accomplish it.
As far as I know, no facilitated learning analysis was ever typed up. But the very next day, Region 4 overhead and a Fire and Aviation Safety Team were in the incident command post asking me who, what, when, where, why and how. Explanation provided, questions answered and a simple "thank you for a job well done" from the Region 4 office concluded our meeting.
A Full Toolbox
There is no "just-right answer" to the often complex situations that we find ourselves in regarding the care and transportation of the injured or ill wildland firefighter. However, calling for a ground ambulance response, with paramedics who can provide ALS if available, should always be the first option in most situations. You can always cancel them if necessary, which is a more appropriate response than only requesting a helicopter and wasting valuable time on the Golden Hour when it cannot reach the injured. Far too many variables can go wrong.
Always consider your options. Maybe having an assigned incident helicopter pick up the patient for removal to a predetermined landing zone or helibase could be a more effective approach to keeping an air ambulance out of the work zone of a wildland fire, especially if you find yourself waiting for a hoist or short-haul helicopter. This would mean turning a rappel crew into a short-haul rescue crew. Or you could contract with a professional hoist/short-haul service that can also provide Advanced Life Support, cost-sharing them with multiple fires. In the end, it's important to have more tools for the toolbox.
Bill Arsenault is a 20-year veteran in emergency services including EMS, structural and wildland fire, and the U.S. military. He has performed in a number of different wildland fire positions, including Line-Paramedic for the last 12 years. He can be reached at email@example.com.
For More Information
National Park Service, Dutch Creek Incident, www.nps.gov/fire/fire/fir_wil_fatality_investigation_dc.cfm
Deer Park Wildfire wildfirelessons.net/documents/Deerpark_FLA.pdf
National Park Service, Cow Creek Fire, http://wildfirelessons.net/documents/Cow_Creek_Fire_Emergency_Evacuation_Mitigations_V.6a.pdf
Robert Palmer, The Palmer Perspective, http://wildfiretoday.com/documents/Palmer_perspective.pdf
NWCG, Incident Emergency Medical Subcommittee, Emergency Medical Extraction List, www.fs.fed.us/fire/aviation/av_library/Final%20EHE%20Source%20List%20_04-19-10_.pdf
National Transportation Safety Board, Helicopter Emergency Medical Services, www.ntsb.gov/aviation/HEMS-links.htm
National Park Service, Grant West Incident, www.nps.gov/fire/download/fir_wil_4DanHolmes_Accident_Investigation_Report.pdf
National Park Service, RM 51
Department of the Interior Handbook, Helicopter Short-haul (351 DM 1)