Medevac: How We Got Here

[Over the last several weeks we have been featuring content on this Blog related to “Growth in the Wildland Fire Service.” This content will also be featured in the forthcoming Spring 2019 Issue of Two More Chains. This Blog post “Medevac: How We Got Here” is the central cover story in this issue of Two More Chains.]

By Alex Viktora

Here’s a fireline conversation I can’t imagine happening back in the 1990s (the red highlights indicate our more recent achievements and successes):

DIVS D: “Make sure to tie-in with your FEMPs down at DP 20. They’re from a big department in California. They have everything we might need, and they’re super experienced and ready to hike wherever. Also, there’s a REM Team that will be at DP 30, just a mile down from 20. They’re pretty dialed-in. They’ve got this crazy UTV that can transport, they’ve also got a wheeled litter, and they’re ready to do high- or low-angle rope work. Our Short-Haul helicopter is down at helibase, which is maybe a ten-minute flight from where you’ll be working today. I think the Short-Haul crew is from Grand Teton National Park. They’ve got all the Short-Haul stuff, a bunch of EMTs, and one Medic. Remember, we can Short-Haul a Green or Yellow, not just a Red. If you have a medical, get stuff moving to it, and make sure to use the 9-Line…uhm…I mean the 8-Line.

Me: The Medical Incident Report, in the IRPG, right?

DIVS D: Yeah, that! It’s also in the IAP on the last page, so you don’t have to flip through the entire IAP novella to find it.

Me: Sweet. I think we’re good to go! Thanks!

A Basic Truth

WTF?

That’s a lotta jargon, and I love my jargons! (I sometimes joke that I get $1 for each acronym I use. Just check out the conversation above.) All this jargon—which will be spelled out and clarified in this piece—highlights a basic truth: Today, we’ve got a ton of stuff for fireline medical and rescue work.

Here’s a partial list of achievements and accomplishments—successful improvements—you might have the benefit of encountering on your next large fire assignment:

• FEMP (Fireline Paramedics. This pneumonic is unique to California. Other fireline qualified medical personnel are denoted in the NWCG’s “2018 Federal Wildland Fire Qualifications Supplement Guide”: https://www.nwcg.gov/sites/default/files/publications/historical/hist-federal-wildland-fire-qualifications-supplement-2018.pdf and in this memo: https://www.nwcg.gov/sites/default/files/memos/eb-m-16-028.pdf.
• REM (Rapid Extraction Modules, which come in various shapes and sizes).
• 8- or 9-Line Reports (officially known as the “Medical Incident Report” on pages 118-119 of the 2018 IRPG).
• Short-Haul Helicopters.
• And small but important things like the placement of the Medical Incident Report at the back of the IRPG and, in some cases, at the back of IAPs. When someone’s bleeding, just flip to the back and call it in. (I know it’s not exactly that easy.)

Has it always been like this? The short answer is no. The long answer is, well, it’s longer.

Short-Haul operation successfully gets an injured firefighter off the 2011 Las Conchas Fire. Photo by Kari Greer.

The Fire Incidents that Provided Key Medevac Lessons

This particular story of medevac lessons and progress is filled with the names of fires like Dutch Creek, Deer Park, Las Conchas, Big Meadows, Freezeout, Strawberry and San Antonio. Some of these stories involve firefighter deaths; some of these stories were merely close calls; all of these stories involve chance and luck and each event is chocked-full of lessons.

This story also includes boards of review, memos, “Pink Stickers”, 9-Lines, as well as lessons from the world of structural fire. Through it all, there’s never been a single effort or a single Incident Commander tasked with “fixing” the medevac problem. Countless efforts at different organizational levels and at different places around the country have contributed to this effort. Bucket by bucket, the tank is being filled.

A Complex, Tragic Story

To many of us, the fireline medical story begins with Dutch Creek (https://www.wildfirelessons.net/viewdocument/dutch-creek-tree-fel). As a National Park Service employee and firefighter at the time, just like Andy Palmer, his death on this incident hit particularly close to home. I didn’t know Andy. I didn’t know his brother, Robert (a former firefighter as well), and I didn’t know anyone on the Eagle Fire in Northern California that afternoon.

But over the next decade, I came to know people who worked at Olympic National Park, Andy’s home unit. I even hired one of Andy’s coworkers to join our Module in Utah during the following (2009) season. Words like “golden hour” and “definitive medical care” started peppering our conversations about medical emergencies on the fireline.

The Pink Sticker.

The First Version of the 9-Line

As the conversation around fireline medical emergencies evolved, folks were eager for additional tools in the toolbox. It was in the Dutch Creek follow-up where one tool began to emerge, the “Dutch Creek Protocol”, which established a basic process and expectations for calling in medical incidents on large, IMT-managed fires.

It’s this memo that became the “Pink Sticker”—almost literally a band-aid applied to the IRPG until 2014. That’s when the first version of the “9-Line” became part of the IRPG. Technically called the “Medical Incident Report” (MIR), this tool was designed for firefighters—not just EMTs or ICs—to call in a size-up and get resources moving to the scene of a medical emergency. This tool was designed to be used on fires of all sizes, with incident communications and local dispatch units as well. While not perfect, this first version of the MIR was a major step forward from the basic stuff in the IRPG, and an improvement on the Dutch Creek Protocol.

As the Medical Incident Report began to be used, numerous lessons began to emerge on how medevacs actually take place, how preparation and training are critical to good medical response, and how to improve the MIR itself. New tools have come on scene. REMs and Short-Haul are among the most noteworthy.

The Medical Incident Report (above) is available in the back of the IRPG, as well as in some IAPs.

Our Collective Medevac Journey

In the wake of Dutch Creek, other incidents shed light on where we were on our collective medevac journey. The 2010 “Deer Park Fire Hit By Rock FLA” (https://www.wildfirelessons.net/viewdocument/deer-park-fire-hit-b) (still one of my personal favorites) calls out some hard truths, right there on the cover of the report: “The organization is ethically and morally obligated to put an EMS program in place that is supported by the organization, and given the standardized training and equipment to make the program succeed.” The organization—in this case—is the United States Forest Service, which has been working to develop an agency-wide EMS program over the last several years.

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Next, helicopter Short-Haul entered the wildland fire medical story in 2011, when a firefighter with a broken leg was short-hauled off the Las Conchas fire in New Mexico. At the Wildland Fire Lessons Learned Center (LLC), we thought this was such a big deal that we made a video to help spread the word and tell this success story. If you’re not familiar with Short-Haul, check this video out: “ROCK: Firefighter Extraction Success Story” https://www.youtube.com/watch?v=sinqJsUrYzE.

The effects of deliberate medical planning, combined with specialized equipment—in this case an Automated External Defibrillator (AED)—and a touch of luck, showed up in 2013 on the Big Meadows Fire at Rocky Mountain National Park. The Lessons Learned Review (https://www.wildfirelessons.net/viewdocument/big-meadow-medevac-2013) and eight videos produced to capture the lessons from this event are among the most thorough we’ve seen at the Lessons Learned Center. (This AED incident on the Big Meadows Fire is discussed in this Blog post https://wordpress.com/post/wildfirelessons.wordpress.com/2671.)

Rapid Extraction Modules entered our lexicon in 2015, with two reports regarding their use on the Rough Fire in California: “Firefighter Pinned Beneath Burning Log Lessons Learned Review” (https://www.wildfirelessons.net/viewdocument/rough-fire-pinned-by-burning-log); and the “Rapid Extraction Module Support RLS” (https://www.wildfirelessons.net/viewdocument/rapid-extraction-module-support-20).

Throughout the last decade, a persistent reality occasionally emerges: firefighters sometimes have to innovate on the fly due to system-level shortcomings. If you don’t have a hammer, well, you can actually pound a nail with a pulaski. It’s not pretty, or fast, and it might not be the safest. And there’s certainly no policy to support it, but sometimes the pulaski is the only option. In the case of the 2014 Freezeout Ridge Fire snag incident medevac (https://www.wildfirelessons.net/viewdocument/freezeout-ridge-fire-snag-incident), the only tools available at the time weren’t widely known as “approved” or supported as the best tools for the task of extracting a critically injured firefighter in a timely fashion. In that situation, the use of the helicopter, long line, remote hook and Traverse Rescue Stretcher were the only tools available.

These tools were the aforementioned “pulaski” scenario. And for many years, helitack crews all over prepared to use a “pulaski” when folks knew a “hammer” would be better.

(To many folks, what took place on the Freezeout Ridge Fire set expectations for what Short-Haul programs would provide. There are critical distinctions between what happened at Freezeout and what Short-Haul is. For more information on this subject, read: https://www.wildfirelessons.net/viewdocument/short-haul-procedures-and-the-trave .)

Lessons and Takeaways

When I personally look at what has changed over the last ten years, I have some key thoughts and lessons that I think folks can take action on. Each of these is associated with a set of actions, and they’re examples of fruit you can reach. (See the Summer 2017 “Fruit We Can Reach” Two More Chains https://www.wildfirelessons.net/viewdocument/two-more-chains-summer-2017.)

1. Practice Medical Responses. This lesson has shown up in reports of all kinds, from Rapid Lesson Sharing documents to Accident Investigations and Facilitated Learning Analysis reports. Practicing medical emergencies can pay huge dividends. Whether it’s crew or module-level training; a drill conducted by an Incident Management Team; or a larger-scale scenario with a patient triage, agency and non-agency aircraft (with piles ignited to provide realistic effect).

• A Related Lesson: Do medical training, refreshers and scenarios before you do stuff that could get you or your folks hurt. Things that can get you hurt are numerous, but some of the lessons we’ve seen that stress this order of operations include chainsaw and physical training.
• A Second Related Lesson: Ensure that more than just crew leadership is ready to run a medical incident, because supervisors aren’t immune to being injured. (See: https://www.wildfirelessons.net/viewdocument/chainsaw-training-tree-injury-2012.)

2. Get familiar with the tools in your medevac toolbox. The things we have available to us will vary from fire to fire and Division to Division. If you find yourself in close proximity to a REM, tie-in and chat about what kind of gear and experience they have. If you can swing by the helibase and say hello to the Short-Haul folks, do the same. Ask them if your backboard will work in their Bauman Bag. Don’t know what a Bauman Bag is? Yeah – you should go to helibase and say hello. In the meantime, read this: “Short-Haul Procedures and the Traverse Rescue Stretcher” written in 2016 (https://www.wildfirelessons.net/viewdocument/short-haul-procedures-and-the-trave).
3. Medical responses can be traumatic events. Regardless of the eventual outcome, and even when “everything works out OK,” a medical response can have huge impacts on numerous groups. These impacts extend beyond those firefighters on the line who experience or witness an injury. This group also includes: those who help with the medical response (adjacent crews, helitack modules, ambulance crews, etc.), as well as folks who work in communications units or dispatch centers. (See the Summer 2018 “Are Our Dispatchers Exposed to Trauma?” Two More Chains https://www.wildfirelessons.net/viewdocument/two-more-chains-summer-2018.)

One of these events can be enough to send folks into tough places; several of these events could be unbearable. The lesson for all of us here is this: Watch out for each other. Lend an ear or a shoulder in the days, weeks or months after a medical emergency. If there’s a group that wants to get together around the fire pit to talk about the close-call, go for it. Also, it’s a good stroke to get familiar with some of the resources available to us. Peer Support and Employee Assistance Programs are just of few of the tools we might need to reach for.

Final Thoughts

To wrap this up, here are a few final thoughts. Unlike the lessons above, these three noteworthy topics (below) are for you, for all of us, to discuss—and maybe even argue over. Translating discussion into action will be challenging.

1. There’s still some work to be done with regard to medical emergencies on the fireline. Here’s a sampling of the things that we still struggle with:
   • We still have a tough time talking to non-agency medevac aircraft. At the LLC, we’ve called this issue “Can’t Talk to Medevac” (we are genius namers, aren’t we?). We have a list of at least 11 reported incidents where communications between ground personnel and “Life Flight” aircraft were difficult or impossible.
   • Competition for resources like Short-Haul is high during peak fire season.
   • What exactly a “REM” (Rapid Extraction Module) is and how to reliably get one is still not widely standardized or even understood.
2. As wildland fire organizations expand their fireline medical programs, a critical question will need to be periodically addressed: Who is this service for? Is it just for firefighters and fire-support personnel? Is it for anyone who might need medical service? Depending on your perspective, this might be a simple question with a simple answer…or…not.
3. Some folks would argue—I occasionally count myself as one of them—that all these improvements may actually be increasing (we sometimes say “enabling”) the types of risks we’re willing to engage our wildland firefighters with. Unless we’re very careful, these improvements—just like any safety or PPE improvement—could result in exposure to more hazards and different risks. Here’s my favorite apropos comparisons:
   • Does a better football helmet prevent concussions? Or does it allow football players to hit harder, and actually cause more long-term damage?
   • Is it a good idea to put your shroud down when you’re close to active fire? Or, does the shroud allow you to stand too close to fire for too long?

All of these improvements (and those sure to come) are good news. I’d way rather get hurt on a fire today than 10 or 20 years ago. As we continue to get better, we need to keep having tough conversations about risk and hazard. Sometimes it will make sense to put folks in steep, rugged country, and add in extra lookouts, a REMs Team and a Short-Haul helicopter. (See the 2018 “San Antonio Tree Strike FLA [Water Flowing Uphill]”: https://www.wildfirelessons.net/viewdocument/san-antonio-fire-tree-strike-2018.)

In other situations, it might be best to get off the high ground and work where we’re closer to definitive care. Sometimes these situations align with operational objectives, but involve other trade-offs. The process of solving the dilemma of when, where and how to engage our firefighters should—every time—include this significant consideration:

Just as with any other safety measure, we must always be diligent in asking ourselves if our risk mitigation efforts enable, mitigate, or transfer risk.