Medical Control Quandries

The following is a copy of a letter sent to Superintendent Joe Alston from the gcrg Board of Directors on January 31, 2004 regarding medical control.

The Grand Canyon River Guides board received, and has discussed at length, your December 5, 2003 response to our letter dated January 27, 2003. There were several questions regarding first aid certification requirements that remain unanswered, although we have been discussing this with Grand Canyon National Park (gcnp) for four years. As the National Park Service (nps) moves toward requiring that guides be certified as Wilderness First Responders (wfr), these concerns must be answered, and quickly.
The commercial season is approaching and guides who have been forced to learn advanced wilderness medical protocols still have not been told why this training is deemed necessary, nor which protocols are appropriate for them to follow. We ask you to please respond to these questions promptly and thoroughly, in writing, before the beginning of the 2004 river season. We also request that a gcnp representative attend the Guides Training Seminar, and be prepared to respond to these questions:
1) Which of the protocols (list attached) are approved by the nps?
When a minimum of Advanced First Aid was the nps requirement, although many guides had higher levels of training, the expectation of standard of care was unambiguous. Guides were expected to provide advanced first aid. Changing the minimum requirement in the Commercial Operating Requirements to wfr raises the implied standard of care beyond that which we can legally provide. The advanced protocols taught in wfr courses require medical control, which most outfitters have been unwilling or unable to acquire. Our question has been, and remains, without medical control, which of these protocols are appropriate for guides to use?
In your letter, you stated that “If you do not have medical control you may not perform invasive procedures, such as administering of medications and reducing fractures.”
You must understand that this vague statement only complicates the matter. Pulling traction on an open femur fracture, for example, drastically reduces pain, bleeding, and tissue damage. Advil is a medication used to reduce pain and swelling. Electrolytes are used for heat and dehydration emergencies. Your letter ruled out these protocols, as well as many others.
First aid courses do not distinguish procedures on the basis of “invasive” vs. “non-invasive.” Cleaning a wound would doubtless be considered invasive and, according to wfr protocols requires medical control. Are you saying we should not clean wounds?
Protocols vary widely depending on the company teaching the course, and by the individual instructor, because there is no standard for wfr. Attached is a list of wilderness protocols that could be considered “invasive.” Because the nps is requiring this level of training, you should review this list, correct it as necessary, and clearly state which protocols are appropriate for guides to use in gcnp, and which are not.

2) Why require this level of training for every guide when the bulk of the course teaches protocols that, without medical control, we should not use?
If the nps is unwilling to approve or disapprove of protocols, or believes that none of them are appropriate, then why should guides be compelled to be trained in them? According to one instructor, “these protocols are what make wfr a wfr. Without them, they would be first responders.”
3) At the meeting between board members and nps personnel last January, Sherrie Collins, Deputy Chief Ranger, told us that “wfr is the national standard.” How, specifically, did she reach that conclusion?
To which “industry” was Ranger Collins referring? The job of a guide, after all, is not providing Emergency Medical Service (ems); it is preventing illness and injury. A guide who is honing his first aid skills in Grand Canyon isn’t doing his job very well. But regarding river guiding, the industry standard clearly is not wfr. In California, Oregon, Idaho, Utah, North Carolina, South Carolina, Tennessee, and Montana, land management agencies require basic or advanced first aid.
Each wfr course is different; protocols vary, and course lengths range from 60 to 100 hours over six to eleven days, because there is no standard, nor is there an overseeing organization that defines what a wfr certification means. Because of this, providers of the training often won’t recognize each other’s courses when it’s time to recertify.
Is wfr recognized by the state of Arizona? We are investigating this now, because it is not recognized by the state of Utah, nor by the state of New Mexico. In both these states, someone certified in wfr who follows wfr protocols, is considered to be practicing medicine without a license. Is the same true in Arizona?
Please understand, we agree that wilderness medical training is valuable. Many guides voluntarily took these courses long before they were required to, and they will continue to do so. But the level of training required of guides implies a standard of care. Yet there is no standard for wfr, and guides cannot legally follow the protocols. This sets us up for a very scary lose-lose situation.
When a trip participant is injured or becomes ill, guides are expected to decide quickly, in the heat of the moment, what action to take. Because we have asked these questions, verbally and in writing, for over four years, we reasonably expect the nps to deliver a clear response by the weekend of March 27, this year.
Until these concerns are addressed, it is unreasonable for the nps to raise the minimum first aid certification required by the Commercial Operating Requirements beyond the level of Advanced First Aid.