EMS in the National Park Service

"Do they turn the waterfalls off at night?"

A ranger at Yosemite National Park said this was a real question from a tourist. Many people think of national parks as a kind of Disneyland rather than wilderness. This complacency leads to swimming in swift rivers, trying to pet "cute" wild animals, and treating steep cliffs like climbing walls at a gym. Mix in the language barriers of foreign tourists, the aging population, and long transport times and you have an idea of the challenges of providing EMS in the national parks.

The National Park Service (NPS) was formed in 1916. Before that, the U.S. Army was tasked with protecting national parks and the tourists who visited them. Today, the NPS oversees almost 400 separate federal sites totaling over 84 million acres of land. Roughly 280 million people visit these sites every year.

Typically, all uniformed employees of the NPS are called rangers. However, emergency services are mainly provided by "protection" rangers who are federal law enforcement officers. These rangers may be certified in firefighting, EMS, and search and rescue. At larger parks, some rangers may specialize in a particular emergency service. But, in smaller parks, they may be a jack-of-all-trades. One minute doing a law enforcement vehicle stop, the next staffing an ambulance responding to a medical emergency, or manning a fire truck for a structure or wildland fire. On average, NPS personnel treat 15,000 patients each year.

Training

From the first days of the NPS, rangers have been trained in first aid. Advanced training began in the 1960's at Mt. Rainier National Park. Rangers went through a 110 hour course in winter survival, medical emergencies, and advanced shock treatment. It was taught at the University of Washington by a doctor who had climbed Mt. Everest and had worked as a seasonal park ranger. The first NPS EMT class was taught in 1972 at Camp Lejune Marine Corps Base in North Carolina. It was taught by Vietnam-experienced Navy corpsmen. The 100 hour course included child birth, reduction of dislocated joints, IV administration, and some drug therapies.

The definitive medical course for the Park Service was initiated in 1978 with the Parkmedic program. It took into consideration the unique circumstances rangers face when providing EMS. Today's program is based on the EMT-Intermediate/85 curriculum with some additional medications and procedures with backcountry medicine in mind. The scope is expanded to include pain and sedation medications due to the remoteness of many calls in national parks. In addition, they have had a selective immobilization protocol that allows for less use of Spinal Motion Restriction (SMR) techniques. It is very valuable in a wilderness environment since having to do SMR completely changes the complexity of a backcountry evacuation.

The Parkmedic program is overseen by the University of California San Francisco's Fresno Center for Medical Education and Research, a Level 1 Trauma Center. Each year, the medical school puts on the six week Parkmedic program for rangers and other park personnel. The center has a contract to serve as the National Medical Advisors for the NPS. The center has created standardized protocols for EMTs and Parkmedics and is currently working on a set of paramedic protocols.

"Each park does a need assessment for EMS to determine future requirements," explained Ken Phillips, Branch Chief for Search and Rescue (SAR) for the NPS and a paramedic. "They look at several years of records to look at volume and types of calls, transport times, available resources, and what other resources are near the park. For example, a small park near an urban area with EMS may only need a BLS response level. A large isolated park with many visitors will need a more complex response system."

Each park does this needs assessment every three years. Policy development and a reference manual is done at the national level to assist park management to complete the needs assessment. This assessment determines the numbers and types of EMS personnel the park will need, equipment, vehicles, etc. The EMS program for the entire NPS is in the process of transitioning to the new curriculum for EMR, EMT, AEMT, and paramedic. The Parkmedic program will be transitioning to the AEMT curriculum from the EMT-Intermediate/85.

Protocol Development

Individual parks have the flexibility to develop specific protocols to meet special needs such as high altitude medicine for some of the mountain parks in the west and Alaska. The coastal parks have marine envenomization issues that interior parks don't see. As a current example, Grand Canyon National Park, which has a large number of heat illness patients, is working on a treatment protocol for hyponatremia that involves infusion of a hypertonic saline solution based on some the latest treatment research. They have a local medical control physician who has researched this topic and developed the protocol with NPS staff at the Grand Canyon. It is currently being reviewed at Fresno for final approval, as are any park specific protocols.

While parks have the ability to develop protocols specific to their needs, the system design dictates a standardize core set of protocols for the entire Park Service. Many personnel transfer from park to park during their career. They don't want a different set of protocols for each of the 400 park units.

"The need for paramedics in national parks is addressed on a case by case basis," stated Jennifer Fetterley, a paramedic at Yosemite Nation Park (YNP) and the EMS Training Coordinator for the park. "Some of the larger, more remote parks with large numbers of visitors are looking at adding paramedics. A key for determining the need for paramedic level service is the number of cardiac responses. That is the major different between the Parkmedic training and paramedic training."

Some parks have hired single role paramedics who are called Health Care Technician-Paramedics by the NPS. The thinking is that it is very difficult to keep up all the qualifications for law enforcement, SAR, and firefighting as well as being a paramedic. In YNP, the single role paramedics are stationed in Yosemite Valley where 60% of EMS calls occur.

"We have about thirty Parkmedics assigned to YNP right now," stated Fetterley." They are well distributed so that some are available at any time in every district of the park. In addition, there are three dual role law enforcement ranger/paramedics. All seven ambulances in the park are equipped with ALS gear including 12 lead monitors. "

"We are fortunate because we have in house medical control from the doctors at the medical clinic which is located in Yosemite Valley. We have 24/7 online medical control available to us. The physician on call has a dedicated cell phone. We transport a significant amount of our patients by EMS helicopter. Our closest hospital is in Mariposa which is an hour and 15 minutes away. The closest cardiac and trauma centers are two and half hours away by ground. If we transport by ground to those centers, we will often rendezvous with a local EMS provider and transfer the patient to them so we can return to the park. When not on calls, the paramedics work in the medical clinic. Our scope of practice in the clinic is the same as when we are in the field. This helps maintain the skill level of the paramedics. "

"We do have a STEMI program. All of our ambulances have 12 lead capability. We work closely with several large medical centers which consult with our clinic staff on caring for these patients. We then fly out STEMI patients to one of these medical centers. Because of our long transport times we have added some procedures such as the use of CPAP. We were able to bring that on board last year. We are looking at some other medications and procedures as well. We have great medical control and the clinic physicians are very enthusiastic about getting involved with developing our EMS system. "

All the parks use the same electronic patient care report developed by emsCharts, Inc. This allows nation-wide data gathering and analysis, CQI, and aids in developing needs assessments and looking at new medications and procedures.

One of the challenges in the parks is the large number of foreign tourists who speak little or no English. "We do have a translation service through AT&T on our cell phones," explained Fetterley. "When we have no cell service, we have some basic cards with pictures and simple phrases in twelve different languages. In addition, some park personnel have used smart phone translation apps."

"I see a growth in the number of paramedic programs in the Park Service but it is up to the individual parks to make it a priority in their recruitment," said Phillips. "It is a standard the public expects today. Dedicated paramedic services will be difficult due to budget constraints. But, if a park manager can hire a law enforcement ranger who is also a paramedic, the park could benefit. Yosemite, Yellowstone, Grand Canyon, and Lake Mead all have dual role law enforcement rangers who are also paramedics."

Some parks have seasonal dedicated paramedics. Lake Mead just outside Las Vegas, Nevada, runs a paramedic ambulance program from May to October with single role paramedics who are not rangers. The rest of the year, Parkmedic and paramedic qualified rangers staff the ambulance when a medical emergency occurs.

Airmedical Response

Helicopters play an important role in EMS and rescue in national parks. Many of the large parks in the western U.S. have a contract helicopter during the fire season, usually May to October. Although the primary mission is wildland firefighting, they can be used for search and rescue and carrying EMS personnel into the backcountry. Some can perform "short haul" rescues. A ranger is attached to a long rope from the cargo hook and lifted into a scene. A victim and the rescuer can then be extracted in the same way. Because of the year-round use of the park and the difficult terrain, Grand Canyon National Park is the only park in the system to have a helicopter on a year-round contract. In addition, local EMS helicopters are frequently used in national parks due to the transport time to major trauma and medical centers.

Military helicopters are also used for rescues. Smaller civilian helicopters often cannot land at the high altitudes found in some parks. U.S. Army National Guard and Reserve as well as U.S. Air Force Air National Guard units train with NPS rangers and regularly perform rescues in such parks as Denali in Alaska, Mt. Rainier in Washington state, and Kings Canyon in California. They also support the parks with rescue helicopters when the contract helicopters are not available or rescues occur outside the fire season.

Staying current in all the disciplines can be difficult for the rangers. But, everyone I talked to said the diverse mission of park rangers is a draw. It is why they joined and have stayed. As one ranger put it, "My best days at work have been the ones where I changed clothes most often. I might be in structure fire gear in the morning. In Nomex flying in a helicopter and then changing into a wet suit for a swiftwater rescue in the backcountry in the afternoon. Then it is back in my patrol uniform."

Barry D. Smith is ground CQI coordinator for the Regional Emergency Medical Services Authority (REMSA) in Reno, NV. Contact him at bsmith@remsa-cf.com.