Smokejumper wilderness rescue missions: experience of the North Cascade Smokejumper Base, ::-

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1 Journal of Wilderness Medicine 2,37-48 (1991) ORIGINAL ARTICLE Smokejumper wilderness rescue missions: experience of the North Cascade Smokejumper Base, ::- B.A. SMITH Department ofemergency Medicine, Emergency Medicine Residency Program, Darnall Army Community Hospital, Fort Hood, Texas 76544, USA Wilderness emergencies present unique problems in rescuer access and medical evacuation. An innovative prehospital care system utilizing United States Forest Service smokejumpers has evolved in north central Washington state. Trained primarily as airborne forest firefighters, smokejumpers have unique talents in rough terrain parachuting. Coordination between the North Cascades Smokejumper Base, a local primary care physician, and the nearby county sheriffs office has made the access, initial treatment and evacuation of wilderness patients possible. Utilizing data from the United States Forest Service Logbooks and personal records of the base manager, the rescue mission experience of North Cascades Smokejumper Base between 1957 and 1988 is presented. The urgency of patients rescued was high, with 18% being in the critical or fatal outcome category, and 67.5% of patients being classified as urgent. The majority of rescues (80.5%) were for trauma patients. An average of four smokejumpers per rescue was utilized. Medical evacuation was predominantly by helicopter; horseback, litter carry, hiking and ground ambulances were also used. Medical training of smokejumpers has improved since 1973 with Emergency Medical Technician training of selected smokejumpers. Key words: emergencies, prehospital, fires, emergency medical services, rescue, Forest Service Introduction Millions of Americans visit the nation's parks and wilderness areas each year. Medical and trauma emergencies in wilderness areas present a difficult problem for service organizations and prehospital care personnel. First responders are often hampered by mechanical, meteorological, and physiologic barriers from reaching patients in a timely manner. A unique system of prehospital care has evolved in one region of Washington state, utilizing United States Forest Service (USFS) smokejumpers as first responders. Trained primarily as airborne firefighters, smokejumpers have unique skills which have been used to accomplish initial treatment and evacuation of wilderness patients (Fig. 1). A description of the wilderness rescue missions done by the North Cascades Smokejumper Base between 1957 and 1988 is presented. *The opinions and assertions contained herein are those of the author and should not be construed as official or as representing the opinions of the Department of the Army or the Department of Defense /91 $ Chapman and Hall Ltd

2 38 Smith Fig. 1. ForestService smokejumperdescending into the typical rough terrain found in wilderness areas. This ability to access wilderness patients is unique. System description System components The North Cascades Smokejumper Base (NCSB), one of several USFS smokejumper bases found in the western United States, is located in north central Washington (WA) state near Twisp, WA. Utilized primarily as seasonal airborne forest firefighters, these adventuresome individuals have also been used as first responders to medical and trauma emergencies in remote areas. Smokejumpers are experienced firefighters trained in specialized parachuting techniques developed by the USFS. Utilizing special protective jump suits and headgear, the smokejumpers parachute into inaccessible areas on short notice to attempt to halt forest fires before they enlarge to disastrous size. Initial experiments in rough terrain parachuting began at NCSB in 1939, and the base has been fully operational since that time. Dr William Henry, a long-time resident of the area, is an integral part of the smokejumper rescue plan. Since 1967, he has developed the Aero Methow Rescue Service (AMRS), a civilian group dedicated to wilderness search and rescue in the north Cascade mountain region. Dr Henry helps coordinate both the USFS aircraft and personnel, as well as civilian resources. In addition, he provides medical control when possible for rescue personnel, and participates personally in many rescue missions with

3 Smokejumper wilderness rescue missions 39 the AMRS. Rescued victims are often initially treated at Dr Henry's clinic after evacuation. The zone of operation of the smokejumper rescue program and the AMRS includes most of the north central Cascade mountain region, as well as the Pasayten Wilderness Area. On rare occasions, rescue jumps have been made as far away as the state of Oregon (Fig. 2). System integration Wilderness emergencies involving federal employees on federal lands are usually handled by the agency alone (usually, USFS), since mechanisms for rescue (communication, personnel and equipment) exist within the agency. For civilian emergencies, initial access to the system, coordination and delegation of resources for rescue missions is usually obtained through the County Sheriffs office in Okanogan, Washington. However, since civilian wilderness emergencies often occur on federal lands (Forest Service, Bureau of Land Management, Bureau of Indian Affairs), they are often first reported through these respective agencies and are more likely to involve USFS smokejumper personnel in the rescue operation. Overall, the coordination for civilian rescues is performed by the County Sheriffs office. 1\ \..... ~ ~....,,\. I\.,.,.~.. c A -/\. ]}Okanogan s /.\ c ~I\ E ]} Spokane ~ 1\WASHINGTO~ -\ G E 1\ OREGON 1\ 1\ 1\ Fig. 2. Rescuejumps (. ) made by NCSB smokejumpers based near Twisp, WA between

4 40 Smith The final determination of rescue jump feasibility is determined by the smokejumper base manager. This decision involves consideration of smokejumper and aircraft availability, weather conditions, patient location, remaining daylight hours, and clinical urgency. Depending on the nature of the rescue request and smokejumper availability, the rescue team may include a combination of smokejumpers, AMRS personnel, and County Sheriff's office search and rescue personnel. The estimated time from receipt of a rescue request to evacuation is five hours [1]. An overview of the system is depicted in Fig. 3. System operation The equipment loaded onto the aircraft for a rescue jump includes many standard prehospital care items. The equipment manifest varies with the nature of the anticipated rescue, but basic items such as wound dressings, intravenous supplies, immobilization devices (cervical collars, Kendrick Extrication Devices, air splints, etc.) and bee sting (anaphylaxis) kits are usually taken. Smaller items are prepackaged into first-aid kits and locked directly onto the smokejumper's harness for the jump. Heavy or bulky equipment, such as oxygen supplies, rescue stretchers, and crash tools are packaged and dropped 1 1Io"""'al 1a,,,1- ~RESCUE REQUE.'\T~ I""""a' 1",1"0"" r-----., Henry Coordination U.S. Foresl Service Smokejumper Base Coordinate Helicopter.Hike.,-~-=-:--:----, or Vehicle, First Responders MEDIVAC I------l!' Fig. 3. Schematic Overview of the Smokejumper Rescue System: Components, Coordination and Operation.

5 Smokejumper wilderness rescue missions 41 from the aircraft as paracargo (Fig. 4). A checklist for an efficient primary and secondary patient survey is standard equipment. Vital signs and treatment are documented on a flow sheet. For most inaccessible wilderness rescues, at least two smokejumpers with EMT or paramedic training parachute into the area. Once safely on the ground, the first rescuers communicate feedback to the aircraft concerning the 'level of risk' for further deployment of smokejumper personnel. If a patient has minor injuries, or conversely, appears dead, further smokejumpers may not be deployed during adverse conditions. Paracargo must sometimes be retrieved from tall trees, utilizing the smokejumpers' specialized training (Fig. 5). Smokejumpers extricate the victim, effect stabilization and immobilization, and procure a suitable helicopter landing site if indicated. Depending on the nature of the rescue, specialized skills such as operation of extrication crash tools or technical rock climbing may be employed. However, smokejumpers have rarely been utilized in these types of rescues. Arrangements for either a USFS or civilian helicopter evacuation are usually made simultaneously. Radio communications between the rescuers and the base station (AMRS and/or NeBS) facilitate treatment and evacuation of the victim. System protocols and training Dr Henry has developed medical protocols and guidelines for assessment and treatment of patients. Areas covered include patient assessment, snake bites, selective prehospital analgesia with meperidine, wound management, splinting, and lightning and electrical injuries. Specific details of these are beyond the scope of this article. Fig.4. Heavy and bulky rescue equipment is dropped from thejumperaircraft as needed for wilderness rescues.

6 42 Smith Fig. 5. Paracargo must sometimes be retrieved from tall trees utilizing the smokejumpers' specialized training. Medical training of NCSB rescue personnel has changed over the years. Until 1972, smokejumpers received only American Red Cross advanced first-aid instruction. From 1973 until the present time, an effort to maintain a small, but stable, number of EMTtrained smokejumpers has occurred. While most smokejumper rescuers are EMTtrained, individuals with advanced skills, such as intravenous line insertion, are rare. In addition, occasional training sessions on search and rescue, extrication, and technical skills such as rock climbing are offered. These sessions are coordinated by the AMRS group or the smokejumper base. Materials and methods Logbooks from the NCSB, US Forest Service were reviewed for smokejumper rescue missions enacted between 1957 and 1988 [2]. In addition, personal records supplied by William Moody (NCSB Manager, 1972 to 1989) were analyzed for rescue-related data [3]. Information was tabulated according to the rescue year, medical problem, party injured, field treatment, method of evacuation (MEDIVAC), and number of smokejumpers involved in the rescue jump. Only rescues involving actual parachute operations by NCSB personnel were tabulated and reviewed. Certain details, such as the victims' age, final diagnosis and long term outcome, were not generally available.

7 Smokejumper wilderness rescue missions 43 Categorization of patient severity was done utilizing standard emergency medicine triage principles: CRITICAL: Life-saving treatment usually required or the rescue involved fatalities. URGENT: Not immediately life-threatening, but required prompt treatment to prevent morbidity and mortality. NONURGENT: Delay in treatment usually did not cause significant morbidity. For the purpose of categorization, it was assumed that patients who were dead on the scene and required body removal were 'critical' because in many cases the exact condition of the patient was not clearly known until rescuers arrived. Information regarding the AMRS was obtained from personal communication with W.H. Henry, MD. Results Results of the 62 rescue operations done by NCSB smokejumpers between 1957 and 1988 are summarized in Table 1. An average of four smokejumpers participated in each rescue, with a range of 1-20 jumpers. One half of victims rescued were civilians (hikers, hunters, plane crashes, etc.), while the other half were USFS workers, including other smokejumpers. The predominant medical problem in all categories was trauma (Fig. 6). Figure 7 depicts the percentage of various methods of patient evacuation and transport. Helicopters were involved in nearly 65% of all rescues. The medical condition of victims rescued by smokejumpers is shown in Table 2. The vast majority of patients fell into critical or urgent categories. Three rescue operations involved multiple patients (cases 17, 27 and 48). Discussion Trauma and medical emergencies in isolated wilderness areas present unique challenges to local and regional service-oriented groups, including physicians. As more people seek recreational opportunities in isolated areas, the need for unique solutions to these problems will intensify. In an exemplary fashion, the National Park Service in California has addressed the need for prehospital care in remote areas with utilization and training of advanced Emergency Medical Technicians (EMT) [4]. The use of smokejumpers for rescue missions in wilderness areas is not unique to the North Cascade region. Other smokejumper bases are located in Idaho, Montana, Oregon, California and Alaska. While all of these bases conduct rescue missions for wilderness emergencies involving other federal employees, routine involvement of smokejumpers in civilian rescues is uncommon. Utilization of the North Cascades smokejumpers for selected wilderness emergencies spans more than 30 years. Features unique to this system are motivated physician involvement in the rescues, as well as a cooperative, committed local US Forest Service. A number of features make utilization of smokejumpers as rescue personnel attractive: (1) Availability for rapid deployment during peak periods of wilderness use. (2) Unique ability to reach the patient; trained in rough-terrain parachuting. (3) EMT-trained smokejumpers (numbers vary from base to base).

8 44 Smith Table 1. Summary of NCSB smokejumper rescue missions: Medical No. ofrescue Field No. Year problem Patient smokejumpers treatment Medivac Shoulder SJ* 6 Immobilization HB** dislocation Cervical fracture SJ 1 HC*** Insulin reaction Civilian 2 Food, rest HB Spine fracture SJ 4 Immobilization Litter Ankle dislocation SJ 6 Immobilization, HC Meperidine Acute abdomen Forest Svc 4 Litter Litter employee Femur fracture SJ 5 Immobilization HC Chainsaw lacerations SJ 1 Bleeding control Hike Tibia fracture SJ 6 Immobilization HC Knee injury SJ 2 Immobilization HC Pelvic fracture Civilian 3 Immobilization Litter (Fatal outcome) Lumbar spine SJ 5 Immobilization HC fractures rd degree burns SJ 6 Dressing Litter Ankle sprain SJ 6 Immobilization Litter Tibia fracture SJ 6 Immobilization Litter Ankle sprain SJ 4 Immobilization HC Plane crash: Civilians 8 Immobilization HC Multiple contusions (2 patients) Gunshot wound Civilian 3 Dress, immobilization, Litter thigh Meperidine Multiple trauma Civilian 4 Body removal Litter (fatality) Unknown Civilian 4 Unknown Unknown Wrist fracture SJ 2 Immobilization Hike Pneumothorax SJ 4 Dressing, IV Litter rib fractures Rib fractures, Trail 4 Immobilization Litter/HC neck injury Crewman Rib fractures SJ 4 Litter/HC Acute abdomen Civilian 4 Litter HC Hand amputation Trail 4 Immobilization, HC Crewman Meperidine Plane crash: Civilians 8 Body removal: Litter/HC multiple trauma (2 patients) No survivors Ankle fracture Civilian 2 Immobilization HC Patella fracture Civilian 4 Immobilization Litter/HC Acute abdomen Civilian 5 Litter Litter/HC Perforated Civilian 5 IV Litter/HC peptic ulcer Premature labor Civilian 6 Litter HC Sepsis Civilian 6 Dressing Litter Shoulder dislocation SJ 2 Immobilization HC Lumbar fractures SJ 6 Immobilization Litter/HC Head and chest Civilian 4 Body removal Litter/HC trauma (fatality)

9 Smokejumper wilderness rescue missions Ankle fracture Civilian 3 Immobilization HC Blunt abd Civilian 4 Immobilization Litter/HC trauma Blunt abd SJ 3 Immobilization HC trauma Hypothermia/ Civilian 20 Shelter, Food HC exposure Anaphylaxis: Forest Svc 2 Subcutaneous HC bee sting employee Epinephrine Leg fracture Civilian 2 Immobilization HC Pelvic fracture Civilian 2 Immobilization HC Femur fracture SJ 3 Immobilization, HC Meperidine Ankle fracture Civilian 2 Immobilization, HC Meperidine Angina Civilian 2 Oxygen, IV HC Myocardial infarction Civilian 2 Oxygen, CPR # Ambulance (fatal outcome) Plane crash: Civilians 6 Immobilization HB multiple contusions (3 patients) Tibia fracture Civilian 6 Immobilization, Litter, Meperidine Ambulance Fall on glacier Civilian 6 Body Removal Hike Cervical spine Forest Svc. 4 Immobilization Litter, injury employee Ambulance Plane crash: Civilian 6 Body removal HC multiple trauma (no survivors) Lumbar fractures SJ 6 Immobilization Litter, HC Back contusion SJ 6 Immobilization Litter, HC Lumbar fractures SJ 7 Immobilization HC Cervical fracture SJ 6 Immobilization Litter, HC Back contusion SJ 5 Immobilization HC Patella dislocation Civilian 3 Immobilization HC Gunshot wound Civilian 4 Body removal Litter neck (fatality) Back contusion Civilian 8 Immobilization Litter, Ambulance Closed head Civilian 8 Body removal HC injury (fatality) Closed head SJ 4 Immobilization HC injury *Smokejumper "Horseback,, 'Helicopter # Cardiopulmonary resuscitation

10 46 Smith Trauma V8 Medica. Illne by Patient Type 100% 75% P E R C E N 50% T A G E 25% 0% Patient Civilians Smoke Forest Type Jumpers Workers Patient Profile All Patients -Civilian -Jumpers []]] USFS Worker g Medical 0 Unknown IIlIlI Trauma Illness Fig. 6. Characteristics of smokejumper rescues: Primarily Helicopter 45 Primarily Litter 18 Unknown 1.5 Litter/Helicopter 19.5 Horseback 5 Hike 5 Litter/ Ambulance 6 Fig. 7. Evacuation method(s) of patients rescued by smokejumpers (%).

11 Smokejumper wilderness rescue missions Table 2. The medical condition of patients rescued by smokejumpers according to severity. 47 Patient severity N Percentage Critical or fatal outcome Urgent Nonurgent Unknown % 67.5% 13% 1.5% (4) Bases are generally located near major wilderness areas. (5) The infrequency of rescue missions does not prohibit smokejumper availability, since firefighting is their primary mission. Several points regarding the results should be made. While 42% of rescue jumps were for injured fellow jumpers (Fig. 6), the incidence of smokejumper injuries requiring rescue jumps was quite low. For example, in 1985, NCSB made a total of 585 individual jumps, of which 68% were fire mission jumps. During this particular year, only 6 (1%) jump-related injuries occurred and only 2 (0.3%) injuries required rescue assistance [5]. No data were available to ascertain whether specific interventions in the field were lifesaving. While two medical cases (case numbers 41 and 46) involved specific treatment for life-threatening problems and six trauma cases (case numbers 5, 18, 26, 44, 45 and 49) received parenteral narcotics for severe pain, the vast majority of field treatment was supportive. Only three patients received intravenous fluids. This reflects the lack of advanced EMT or paramedic-trained smokejumpers, rather than a lack of indications for such therapy. Based on the data available, the real utility of the smokejumper was to effect extrication, immobilization and evacuation in an isolated, harsh environment. Conclusions As long as people enter isolated areas, wilderness emergencies will continue to be a unique problem requiring innovative solutions. The USFS smokejumpers at NCSB near Twisp, WA, have been utilized for wilderness rescue operations for many years. The decision to utilize smokejumpers involves weighing the risks against benefits. The vast majority of rescue requests were for trauma victims. Medical evacuation of patients to medical facilities involved helicopters in nearly 65% of cases. The smokejumpers' contribution to the successful treatment of wilderness patients was most evident in their unique abilities to access and evacuate the patient. Although there are few advanced EMT and paramedic-trained smokejumpers, in view of the relative infrequency of smokejumper rescue missions, the feasibility of a more sophisticated approach is uncertain. Acknowledgements The author acknowledges William Moody for assistance in providing material for this manuscript. He has spent his entire working life fighting forest fires and holds the

12 48 Smith smokejumper record for the most fire, rescue and training jumps. I thank Dr William Henry for providing information about the Aero Methow Rescue Service, and Dr Daniel Dire and Dr Dennis Plante for advice in preparation of the manuscript. References 1. Henry, W.H. Personal communications, Moody, W. et al. North Cascades Smokejumper Base Operational Logbooks, , (unpublished), United States Forest Service, USDA, Winthrop, WA. 3. Moody, W. Personal communications, Kaufman, T.!., Knopp, R. and Webster, T. The Parkmedic Program: prehospital care in the National Parks. Ann Emerg Med 1981; 10, Moody, W. NCSB Annual Report 1985-Historical Data, USDA, Forest Service, NCSB, Winthrop, WA, Oct 28, 1985: Davis, K.M. and Mutch, R.W. Wildland fires: dangers and survival. In: Auerbach, P.S. and Geehr, E.C., eds, Management of Wilderness and Environmental Emergencies, Macmillan Publishing Company, New York, 1983, Chp 16: Serra, J.B. Management of Trauma in the Wilderness Environment, Emerg Med Clin of N.A., Aug 1984, 2(3): Cohen, S. A pictorial history of smokejumping, Pictorial Histories Publishing Company, Missoula, MT, 1983: 171 pages.