Residents Perspective Ann Burelbach, MD Matthew R. Lewin, MD, PhD Marc Shalit, MD Geoff Stroh, MD

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1 EMERGENCY MEDICAL SERVICES/RESIDENTS PERSPECTIVE Residents Perspective Ann Burelbach, MD Matthew R. Lewin, MD, PhD Marc Shalit, MD Geoff Stroh, MD From the Department of Emergency Medicine, University of California, San Francisco Fresno, Fresno, CA (Burelbach, Shalit, Stroh); and the Department of Emergency Medicine, University of California San Francisco, San Francisco, CA (Lewin). Section Editor Clare Atzema, MD University of Toronto, Royal College Emergency Medicine Postgraduate Training Program Toronto, Ontario, Canada Introduction [Ann Emerg Med. 2004;43:114.] The Residents Perspective column was introduced in 1998, and in its 6-year life span, has examined a multitude of pertinent resident issues, from pregnancy during residency to ultrasonography training, financial considerations to conflict resolution in the emergency department (ED), medical publishing to employment contracts. Last year in his introductory column, Matthew Lewin, MD, PhD, the resident fellow for 2003, set forth a goal to make the column more international. As a Canadian emergency medicine resident and the new resident fellow, my appointment nicely dovetails with that objective. As I take the torch that is passed to me, I will continue his endeavor to make the column multinational, as well as to maintain the phenomenal quality of the columns. Set in a milieu of life and death, pain and disease, and against the backdrop of our training efforts, our daily lives are fraught with issues, both profound and slight, practical and ethical. And that only addresses our interactions /$30.00 Copyright 2004 by the American College of Emergency Physicians. doi: /mem with patients. This is an opportunity for you to promulgate to your peers and to remonstrate the ills of the system. It is also an experience from which to learn some of the details of publication and a bolster to your curriculum vitae (the importance of which I was forced to concede when I applied for this position). Some possible topics to cogitate as we start the year 2004 include the effect of ED crowding on resident teaching, drug company sponsorship and residency training, the requirements and daily life of a researcher, opportunities in flight medicine, and training and certification in different countries. If you have an area of expertise that relates to emergency medicine, or if you have recently been through a process in emergency medicine that you have learned from, share the wealth. Topics covered in previous years may also be considered because of the changing nature of the regulations that guide our nascent specialty and because of the varying perspectives of each writer. Whether you have a column, some comments, or even just an idea (which may include any of the aforementioned possibilities), please take the time to submit them to me at Annals. We look forward to working with you. Clare L. Atzema, MD. The National Parkmedic Program: Residents Make a Difference in Our National Parks [Ann Emerg Med. 2004;43: ] INTRODUCTION We present an overview of the US National Parkmedic Program and the University of California San Francisco Fresno Emergency Medicine Residency Parkmedic Program s history and evolution. We focus on emergency medicine residents involvement in emergency medical services (EMS) and wilderness medicine and discuss how such a program may benefit other recreational areas and emergency medicine residencies nationwide. The Parkmedic Program is an emergency medicine resident run and faculty-supervised training, education, and EMS program. National Park Service rangers from across the country are certified as Parkmedics, a group defined as emergency medical technician intermediates (EMT-I) 114 ANNALS OF EMERGENCY MEDICINE 43:1 JANUARY 2004

2 with additional training in pharmacology and environmental medicine. Originally created to manage the medical needs of visitors to Sequoia and Kings Canyon National Park in the Sierra Nevada of California, and then expanded to cover the entire National Park Service, this program now provides an EMS system to millions of national park visitors and park employees each year. What makes this program unique is the hands-on opportunity for resident education and leadership in a functional EMS system and wilderness medicine setting. At the same time, residents provide a necessary service to the public on both a local and national level. Those involved are presented with challenges in out-of-hospital care that reflect the varied and often unpredictable character of our national wilderness areas. BACKGROUND The Parkmedic program began in 1975 after the director of the National Park Service determined there was a need for an improved EMS system in our national parks. The impetus for this development is now referred to as the Soldier Cave Incident. 1 While visiting Sequoia and Kings Canyon National Parks, a hiker became trapped in a cave after a fall. Because of a limb injury, extrication was not possible without adequate analgesia and assistance from a rescue team. Although Sequoia and Kings Canyon National Parks search and rescue personnel were present, none of the park rangers were authorized to provide pain medication to the park visitor. An impromptu lesson in rappelling allowed a registered nurse access to the trapped man, and she provided narcotic pain relief by physician s order. After this successful rescue, medical training for Sequoia and Kings Canyon National Parks rangers began as a pilot program managed by 2 emergency physicians in Visalia, CA, a Central Valley community approximately 50 miles west of Sequoia and Kings Canyon National Parks. In 1977, Valley Medical Center (now University Medical Center), located 70 miles northwest of Sequoia and Kings Canyon National Parks in Fresno, CA, started a new program run by emergency medicine residents, with faculty oversight. 2 The goal was to train local park rangers with EMT-basic (EMT-B) certification to become what are now known as Parkmedics a group with EMT-I certification and additional training in pharmacology and environmental medicine. Beginning as a local EMS system designed to serve only Sequoia and Kings Canyon National Parks, the Parkmedic Program has evolved to be the national train- ing center for Parkmedics from national parks across the country. In addition, decades of effort by University of California, San Francisco Fresno emergency medicine residents and faculty has created standardized Parkmedic policies and protocols used by Sequoia and Kings Canyon National Parks Parkmedics and EMTs that are being implemented throughout the country. Faculty advisors from the Parkmedic Program provide oversight and consultation services to the National Park Service EMS system on a national level. RESIDENT INVOLVEMENT As a unique and challenging opportunity for emergency medicine residents at the University of California, San Francisco Fresno, the Parkmedic Program continues to attract much interest. Residents with a particular interest in EMS are able to participate in the Parkmedic Program as an additional focus of their emergency medicine training. Involved residents participate in EMS and wilderness medicine education on a local and national level. The success of the Parkmedic Program requires dedicated attention from participating residents. The majority of residents stay in the program for all 3 years of eligibility in our 4-year program. Including their research projects, the monthly Parkmedic group meeting at one of the faculty advisor s houses, and their senior year in EMS training, Parkmedic residents dedicate somewhere between 10 and 20 hours per month to Parkmedic activities. The average annual commitment of postgraduate year 2 and postgraduate year 3 residents is approximately 180 hours. Postgraduate year 4 residents who elect to do a 3-month focus in EMS may dedicate as many as 450 to 500 hours of time to Parkmedic activities during the fourth year of residency. The resident educational goals of the Parkmedic Program are outlined in Figure 1. The goals are accomplished by participation in EMS activities in our local, tricounty system and EMS activities in Sequoia and Kings Canyon National Park and other national parks. The Parkmedic resident curriculum is summarized in Figure 2. Providing continuing education and EMS medical oversight to Sequoia and Kings Canyon National Parks Parkmedics and EMTs is the cornerstone of the program. Parkmedic residents have the opportunity to learn how an EMS system is constructed through the development of Sequoia and Kings Canyon National Parks Parkmedic policies and protocols based on both urban EMS guidelines and wilderness medicine principles. With guidance from faculty advisors, residents continually write and revise the Sequoia and Kings Canyon National Parks EMS JANUARY :1 ANNALS OF EMERGENCY MEDICINE 115

3 manual used by local Parkmedics and EMTs. The juxtaposition of a vast wilderness area against scattered urban areas of the Central Valley of California often creates treatment and transportation dilemmas that must be considered. For example, flight decisions must take into account weather conditions at altitudes up to 14,000 feet, as well as the fact that the closest facility may be a rural hospital unable to provide definitive care for the patient. The possibility of radio failure, a situation in which radio contact with a base hospital physician is not possible because of circumstances such as the remoteness of the incident, is a common reality in the wilderness out-ofhospital care setting. Residents must use problem-solving skills, EMS experience, and the expertise of Parkmedics and EMTs to create policies and procedures that reflect the dynamic and unpredictable environment in which wilderness-based out-of-hospital care is provided. By doing so, and comparing these with the more sophisticated local EMS system, the residents become familiar with the various elements of EMS, as well as fundamental issues and controversies that influence EMS policy and protocol in any setting. The educational experience of the Parkmedic resident does not end with policy and procedure development. Residents provide continuing education to Parkmedics and EMTs through a lecture series held monthly in Sequoia and Kings Canyon National Parks. During these small group sessions, Parkmedic protocols are reviewed Figure 1. Educational goals of the Parkmedic Program. 10 (All elements of this curriculum are under the direct supervision of the Parkmedic faculty.) in detail, allowing residents and Parkmedics to ask questions or provide feedback to each other. Medications and procedures related to the monthly topics are also reviewed. For instance, in conjunction with a lecture on high-altitude pulmonary edema, the use of nifedipine would be discussed with a demonstration of how to use a Gamow bag. Through continuing education and annual refresher courses (also run by residents), Parkmedics are able to maintain their certification. CONTINUOUS QUALITY IMPROVEMENT Another critical component of resident education in EMS is continuous quality improvement. Continuous quality improvement allows for scrutiny of current policies and protocols and the medical care provided through review of the patient care report. Patient care reports are EMS run sheets used by all National Park Service Parkmedics to record each patient interaction, including assessment, treatment, and disposition. All patient care reports are reviewed by a postgraduate year 2 or postgraduate year 3 resident whose job it is to analyze the decisions made and actions taken by the Parkmedic. After specific issues in question are highlighted and resolutions proposed by the junior resident, a postgraduate year 4 resident and faculty advisor review all the completed continuous quality improvement forms. Approved feedback can be given to the individual Parkmedic and appropriate action taken, such as group education, policy or protocol revision, or tracking of an issue. Resident reviewers also receive faculty feedback regarding their interpretation of policies and procedures. Such ongoing, thorough review of the Sequoia and Kings Canyon National Parks EMS 1. Provide an educational experience in EMS such that, on completion of the program, residents will have the skills necessary to direct any EMS system in the country. Necessary skills include, but are not limited to: continuous quality improvement, EMT training, continuing education and oversight, and base-hospital medical control. 2. Train eligible National Park Service rangers to become Parkmedics (EMT-I) and to provide continuing education and training services on a regular basis. 3. Provide an educational experience such that, on completion of the program, residents will have a working knowledge of wilderness medicine. 4. Provide an opportunity for residents to pursue personal interests in wilderness medicine/ems (eg, disaster medicine, search and rescue, hazardous materials, aeromedicine). 5. Contribute to the knowledge base of EMS and wilderness medicine. Figure 2. Summary of the Parkmedic resident curriculum National Park Service EMS operations a. Supervision and administration of entire Sequoia and Kings Canyon National Parks EMS operations b. Responsibility for management of continuous quality improvement system c. Management of all training and continuing education d. Participation in educational National Park Service EMS projects 2. Education a. Completion of postgraduate year 3 EMS rotation 3. Scholarly activities a. Production of 1 scholarly activity by end of postgraduate year ANNALS OF EMERGENCY MEDICINE 43:1 JANUARY 2004

4 manual and Parkmedic performance promotes a high quality of patient care and provides invaluable EMS experience through meaningful discussion of fundamental issues in out-of-hospital medicine. NATIONAL PARKMEDIC CERTIFICATION COURSE Although the majority of the Parkmedic residents efforts may be directed toward the training and education of Sequoia and Kings Canyon National Parks Parkmedics and EMTs, perhaps the highlight of the Parkmedic Program is the National Parkmedic Certification Course. National Park Service rangers from across the country participate in this 6-week course, which is held every other January in Fresno, CA. Emergency medicine residents, faculty, and staff, along with guest lecturers affiliated with multiple institutions and EMS agencies, join forces to turn National Park Service rangers with EMT-B certification into Parkmedics during an intensive course. Parkmedic alumni, both residents and rangers, often return to participate, demonstrating their dedication to the program. The Parkmedic course is a rigorous one for residents and students alike. It is organized and run by 1 or 2 postgraduate year 4 Parkmedic residents and includes daily lectures, procedure labs, clinical rounds to demonstrate physical findings, EMS ride-alongs, and hands-on patient care opportunities in the emergency department (ED). Individual and small group tutorials by residents are offered to Parkmedic trainees daily and during the evening hours to help clarify challenging but essential areas of knowledge. All Parkmedic residents participate by giving lectures on a variety of EMS and wilderness medicine topics. Residents teach procedure labs relevant to the Parkmedic scope of practice and lead clinical rounds in the hospital, demonstrating relevant physical examination findings exhibited by ED and admitted hospital patients. Many non-parkmedic residents volunteer their time to lecture and teach during clinical rounds. In addition, the Parkmedic course has been adapted into a wilderness medicine elective that is open each summer to medical students nationwide. Figure 3 describes the Parkmedic Certification Curriculum for enrolled National Park Service rangers. Parkmedics must complete clinical requirements including patient evaluations, procedural skills such as intravenous line starts and splinting, 48 hours of ED observation, and 40 hours of ambulance ride- Figure 3. National Parkmedic Certification Course Curriculum. National Park Service rangers seeking to become EMT-I certified Parkmedics must complete this intensive 6-week course directed by a postgraduate year 4 Parkmedic resident and a postgraduate year 2 Parkmedic resident apprentice. Week 1: Lectures Surface anatomy Medical terminology Patient assessment Autonomic nervous system Cardiac physiology Cardiac assessment Cardiac arrest Respiratory physiology Respiratory assessment Abdominal pain Altered mental status Pharmacology Drug calculations Medicolegal issues in EMS Week 2: Lectures Scene management Pediatric illness Infectious diseases Multicasualty incidents Trauma Week 3: Lectures Psychiatric emergencies Commonly seen medications Toxicology Hypothermia/hyperthermia High-altitude illness Near-drowning Marine emergencies Bites and stings Epi-pen certification Medical decisionmaking Week 1: Labs Daily clinical rounds Physical assessment Introduction to tape review Documentation Tape review: chest pain Tape review: against medical advice/release at scene Breath sounds tape Medication delivery systems Drug review Mannequin deliveries Week 2: Labs Daily clinical rounds Practice documentation and call-in Tape review multicasualty incident Mock multicasualty incident triage Tape review: respiratory distress Cardiac and respiratory anatomy: porcine lab Trauma lab and skills (2-day course) Week 3: Labs Daily clinical rounds IV labs Mock NREMT skills testing Weeks 4 through 6 88 hours of clinic and field time (see Figure 5) JANUARY :1 ANNALS OF EMERGENCY MEDICINE 117

5 along and familiarization with EMS run sheets. Figure 4 describes the clinical requirements for graduation. The course culminates with written and practical examinations proctored by Parkmedic residents, faculty, and staff. Final examination requirements are listed in Figure 5. The National Registry of EMTs (NREMT) part of the examination is proctored by a designee of the NREMT. Those who successfully complete the course receive University of California, San Francisco Fresno Parkmedic and NREMT EMT-I certification. ACADEMICS AND RESEARCH In addition to the teaching experience afforded emergency medicine residents through the Parkmedic Program, there are also abundant research opportunities. Through Figure 4. Clinical requirements for National Park Service ranger graduation from the Sequoia and Kings Canyon National Parks Parkmedic course. Patient evaluations and EMS run sheets (25 patients): 2 major trauma 2 shortness of breath 2 chest pain 1 seizure 1 decreased mental status 1 agitated/psychiatric 1 weakness, headache, dizziness 1 fracture or isolated wound 1 vaginal bleeding Intravenous therapy administration (15) Medication administration (10) Cardiac monitor use (3) Airway (15) Childbirth (2) Cervical spine and extremity immobilization (7) Figure 5. Testing requirements for graduation from the Parkmedic Program. To become a certified Parkmedic, graduates must also pass the NREMT examination. All testing requires a score of 80% or better to pass. EMT-B pretest EMT-B day 1 skills test Daily quizzes Midterm examination (150 questions) Final examination (180 questions) Trauma skills testing revision of policy and procedure, field experience, and personal interests, a multitude of research ideas are conceived and put to the test. Research topics have included injury prevention of National Park Service employees, the use of patientowned vehicles for transport of the injured, EMT-B administered epinephrine for anaphylaxis, 3 subterranean medicine, 4 and high-altitude medicine, 5-7 among many others. Academic projects in both EMS and wilderness medicine generated by Parkmedic residents can potentially influence out-of-hospital care on a national level. In conclusion, with more than 420 million US national park visits annually, representing a nearly 100-fold increase from 20 years ago, the public s attraction to wilderness and urban national park areas is growing. 8 With this influx of visitors comes an increase in the number and complexity of medical problems experienced by skilled outdoor enthusiasts, park employees, and people from all walks of life. The National Park Service perceives a need for medical advisors to oversee the out-of-hospital care of this population. This was stated explicitly at the national conference held in San Diego, CA, in September Through participation in the Parkmedic Program, residents help provide a necessary public health service on both a local and national level, while developing an understanding of how an EMS system is constructed and functions. The educational gain for both emergency medicine residents and Parkmedics is evident. Other residencies, especially those near national parks and wilderness recreation areas, could organize similar programs. This would facilitate productive relationships between residencies, the National Park Service, and the public. The longevity and success of the Parkmedic Program at the University of California, San Francisco Fresno Emergency Medicine Residency Program suggests its utility as both an educational tool and a rewarding public service. In addition, the Parkmedic experience, combined with the local urban, suburban, and rural EMS system, provides an unsurpassed breadth of EMS training and experience to our emergency medicine residents. We thank all the residents and staff who dedicate their time and energy to make this program possible. We also thank the National Park Service and their dedicated rangers who wear so many hats during the performance of their many public services. The authors report this study did not receive any outside funding or support. 118 ANNALS OF EMERGENCY MEDICINE 43:1 JANUARY 2004

6 Reprints not available from the authors. Address for correspondence: Geoff Stroh, MD, Department of Emergency Medicine, University of California, San Francisco Fresno, Room 275, 445 South Cedar Avenue, Fresno, CA 93702; , fax REFERENCES 1. John Chew. History of National Park Service EMS. Presented at: National Park Service EMS Conference; May 14, 2001; Harper s Ferry, WV. 2. Kaufman TI, Knopp R, Webster T. The parkmedic program: prehospital care in the national parks. Ann Emerg Med. 1981;10: Fortenberry JE, Laine J, Shalit M. Use of epinephrine for anaphylaxis by emergency medical technicians in a wilderness setting. Ann Emerg Med. 1995;25: Hooker K, Shalit M. Subterranean medicine. Wilderness Environ Med. 2000;11: Weichenthal LA, Hendey G. Altitude-related illness in two California national parks. Wilderness Environ Med. 1998;9: Johnson J, Maertins M, Shalit M, et al. Wilderness emergency medical services: the experience at Sequoia and Kings National Parks. Am J Emerg Med. 1991;9: Braude D, Shalit M. The Mount Tyndall incident. Prehosp Emerg Care. 1999;3: National Park Service Visitation Database Available at: nps.gov/stats/. Accessed May 1, National Park Service Medical Advisory Committee EMS Conference; September 2002; San Diego, CA. 10. Parkmedic Program Homepage. Available at: parkmedic.htm. Accessed May 16, JANUARY :1 ANNALS OF EMERGENCY MEDICINE 119

EMERGENCY MEDICAL SERVICES (EMS)

Bismarck State College 2018-2019 Catalog 1 EMERGENCY MEDICAL SERVICES (EMS) EMS 110. Emergency Medical Technician Credits: 4 Prerequisite: Completion of a healthcare provider level CPR (BLS) Course. Corequisites: