Delivering ALS Care on the Fire Line

Kern County is the third-largest county in California. Its 8,000 square miles include the southern end of the Sierra Nevada Mountains, as well parts of other mountain ranges. Steep, rugged terrain that rises over 8,700 feet is covered with forest and thick brush. It doesn’t take much imagination to know that fighting a wildland fire under these conditions is hazardous. The terrain calls for hard physical labor, with falling trees and rocks, smoke, snakes and insects presenting opportunities for injury.

“The Kern County Fire Department (KCFD) has two type-2 hand crews and one type-1 hotshot crew for fighting wildland fires,” explains Guy Lawrence, EMS coordinator for the department. “On many wildland fires, the hand crews are working in wilderness areas miles from road access. In the past, the hand crews only had an EMT with a first-aid kit. ALS care could be hours away. With our fire line paramedic program, ALS care can now be on scene in minutes.”

About five years ago, there was a request from the federal government for ALS care on the fire line. This request was made after an incident at a remote fire where a firefighter was hit with a snag and bled to death. Due to the heavy smoke, responders were unable to get a helicopter in immediately. It took more than three hours to get ALS care to the patient. KCFD’s hand crews are very active during the fire season, both in the county and traveling all over the west for large fires managed by federal agencies, so the department decided to set up its own fire line paramedic program to provide ALS care to its hand crews.

“We have about 50 paramedics in our department and one ALS fire station in a remote area of Kern County,” says Lawrence. “A private ALS ambulance service has a contract to provide paramedic service and transport for the rest of the county. We have a dozen paramedics who develop and teach our EMT, continuing education and refresher training for our 550 firefighters. We have 8–10 paramedics involved with the fire line medic program and another three fire line medics are assigned to our helicopter program.

“We had to get approval to develop the fire line medic program through our local EMS agency, which is the Kern County EMS Office. We had to write a fire line medic protocol and submit it for approval by the county EMS office. We also had to get approval from the Kern County EMS Commission. Then it had to go to the county board of supervisors through the EMS Advisory Board. It was quite a lengthy process and took about a year to get everyone’s approval.”

Protocols & Equipment

The treatment protocols the fire line medics use are the same as those for all paramedics in Kern County. One of the major differences is the paramedics are covered when they go out of Kern County. This means they can go to any federal incident in the country and use their paramedic protocols. The fire line medic protocol also outlines training requirements, experience requirements to become a fire line medic, charting requirements when out of county, and the equipment and medications that must be carried on the fire line.

All the equipment is carried in two packs that are locked in a large toolbox with wheels. The toolbox also carries restock supplies. To function at the ALS level requires a team of two people, a fire line EMT and a fire line paramedic, which is the requirement from the EMS agency. One pack has BLS gear and the other ALS. They are required to carry all the same medications as any ALS unit in Kern County; they just don’t carry as much. The only things not done are 12-lead ECGs and cardiac pacing. They carry an AED plus a small cardiac monitor, the Philips IntelliVue MP2. This weighs about three pounds and has automatic blood pressure and SpO₂ capabilities.

“The fire line medics have to be comfortable working in remote areas, so we don’t take new paramedics into the program,” says Lawrence. “They also have to qualify as federal wildland firefighters with a series of classes, as well as a helicopter crew member class and the fire line EMT class. As additional training, we are putting our fire line medics through the Advanced Wilderness Life Support class, a three-day course on wilderness medicine that reviews the types of injuries and illnesses a fire line medic might see.

“The fire line medics are not tied to our hand crews when they go out of the county. The medics are assigned to an incident and work for the medical unit leader within the ICS system. They may be assigned to a specific hand crew, but are usually assigned to an area and cover all the firefighters in that area. As an example, we had a team of an EMT and paramedic at a remote camp on one fire for two weeks. When the firefighters at the camp went out to the line, the medical team went with them.”

Air Support

With large fires lasting many days or weeks, there is a designated rescue helicopter assigned each day. The goal is to have it equipped with a rescue hoist, be able to perform rescues at night with night vision goggles and be ALS capable. Unfortunately, that doesn’t always happen. Often, it is only capable of BLS care. KCFD has two Bell UH-1 Huey helicopters that meet the higher standard. They have been sending one out of Kern County to do medical/rescue standbys for the past three fire seasons. During the 2014 season, they were on standbys for over 100 days.

“Our helicopter unit did 13 rescues while on out-of-county fires in 2014,” says Lawrence. “Three or four were very significant rescues. One in a remote area of northern California involved a firefighter who was struck by a falling tree. He sustained several fractures with internal bleeding. This occurred at about 2 a.m. Our helicopter flew in using night vision goggles and used the rescue hoist to extricate him.

He was then flown to the trauma center in Redding, CA. We had one of our fire line medics on scene caring for him and then the paramedic on the helicopter continued care en route to the hospital. The surgeon who worked on the patient said if it had taken any longer to get him out, he probably would have died.

“On a fire near Yosemite National Park, another tree fell and hit a firefighter who sustained several cervical fractures. Again, it was at night in remote, steep terrain. Ground evacuation would have taken many hours. A KCFD helicopter was on standby for that fire and had the patient at a trauma center within an hour of injury. Outside of Southern California, where many fire department helicopters are ALS, there are not many fire ALS helicopters with our capabilities. So we find our helicopter being requested for federal fires to act as the medical/rescue aerial resource.

“The best advice I can give for other departments that want to set up a similar program is don’t reinvent the wheel. Call someone who has already done it and get their input. I get calls on a regular basis from other departments asking us about our program. Start early because it takes time to work through all the regulatory agencies.

“The program has been phenomenal and we have had some very good patient outcomes, especially with the rapid transport capabilities with the helicopter component.”

Barry D. Smith is an instructor in the Education Department at the Regional Emergency Medical Services Authority (REMSA) in Reno, NV. Contact him at bsmith@remsa-cf.com.