Fear and Loathing

Let me share the irony. Fourteen years ago I took a Wilderness Emergency Medical Technician (wemt) course, and became a believer in wilderness-based training. Over the next several years I devoted hundreds of volunteer hours to make these courses available and affordable to guides. Through the courses offered by gcrg, hundreds of boatmen voluntarily achieved a level of training that better prepared them for illnesses and injuries on the river. We felt really good about that. Still do, in fact. But the National Park Service’s (nps) decision to require guides in Grand Canyon to be certified as Wilderness First Responders horrifies me.
I should explain.
Do you have medical control? Probably not.
Wilderness First Responder (wfr) is neither standardized nor regulated. Each training provider has a unique curricula that teaches skills beyond the scope of what guides can legally perform. Many of the protocols taught in wilderness courses can only be performed with “Medical Control”—a concept defined by one local doctor as, “putting my medical license on the line for someone I have never met, to perform procedures on patients that I will never know about until we end up in court.” Hardly a risk that doctors will rush to sign up for.
The nps, while mandating wfr certification, has not told us which of these medical protocols are appropriate and which are technically “practicing medicine without a license.” They deflect that burden to gcrg, whose concerns they have consistently ignored, and the outfitters, most of whom do not have the medical training themselves.
Gcrg informally surveyed the Grand Canyon outfitters. Some refused to discuss it; most asked that their responses remain anonymous. Three said they have medical control, but two of the doctors don’t have a license to practice in Arizona. When further pressed one outfitter said the doctor just “advised” them. “Advice” is not Medical Control. One company has a letter in their first aid kit that the guides believed constituted Medical Control. Signed in 1998 by a Utah physician they had never met, the letter was, in the opinion of a doctor who read it, “worthless.”
What can you do?
So few guides, if any, have Medical Control. And most guides don’t have a clear understanding of what protocols they can or should follow. Vague statements from the nps confuse matters further. For example, according to the Park’s letter, [see page 26] shallow wound care is appropriate for all Emergency Medical Service (ems) providers. Yet according to the Wilderness Medical Associates website, cleaning even a shallow wound requires Medical Control. Clearly neither the training agencies, nor the Park Service requiring that training, nor the outfitter, nor the guides themselves, are in agreement on what protocols they can follow.
Recently an instructor assured students that the company providing the training would “stand behind them” if they used the protocols. Did they mean they would testify in court? Make some phone calls? Send flowers? Tell the story in future wfr courses? They certainly can’t provide Medical Control; they don’t have it themselves.
Other instructors have told guides not to worry, as lawsuits go after the “deep pockets.” They assume that river guides have nothing to lose.
The Good Samaritan Law will only protect guides who treat victims on other trips, or hikers—does not cover people who are paid to provide service to their own clients.
Scenarios
A few years ago OC Dale nearly died from an anaphylactic reaction to a bee sting. On the gts river trip this spring he rarely ventured more than a hundred feet from his EpiPen. Was I glad I had the training, and had a clue about what to do if a bee stung him? You bet. Would I have hesitated to use that training? Not for an instant.
But let’s say you’re breaking down camp. A woman runs into the kitchen saying her husband is having difficulty breathing. You go up to his tent to find him pale and gasping for breath. He said a velvet ant stung him a little while ago. Aha! In wfr class you learned about anaphylactic shock; maybe that’s it. Your outfitter said they would reimburse you if you bought an EpiPen, so you got a prescription filled and put one in your ammo can. Should you use it? They taught you that you must decide quickly.

An EpiPen injects epinephrine—a stimulant that increases heart rate, blood pressure, mental activity, and blood flow to muscles. It also constricts blood vessels, which is why it’s the preferred treatment for anaphylactic shock.
Side effects include headaches, cardiac arrhythmias, angina, hyperventilation, and excessive rise in blood pressure that can lead to intracerebral bleeding and strokes. Peripheral vascular constriction could cause pulmonary edema. Does this guy have coronary artery disease, hypertension, or serious ventricular arrhythmias? If so, your EpiPen could kill him.
Is he taking sympathomimetics like ventolin or isoprenaline? Those can increase the effects of epinephrine. Digitalis can increase the proarrhythmic effects, and Monoamine oxidase inhibitors increase cardiovascular effects. EpiPens also contain sodium metabisulfite, a sulfite that may cause allergic reactions such as anaphylactic shock.
Got all that?
Have you stored your EpiPen between 59 and 86 degrees Fahrenheit? That shouldn’t be a problem in Grand Canyon. If it’s discolored or contains precipitates, you shouldn’t use it. If it’s outdated, the effectiveness is significantly diminished (which could be good news, I suppose, if you’re wrong about your diagnosis.) So if you’ve chosen to supply one with your own prescription you’d better keep it current, cool, and in the dark. You had also better be right. Giving him your prescription is a felony, punishable by a fine of up to $20,000.
Or let’s say you don’t have an EpiPen and it really is anaphylaxis instead of a heart attack. Requiring wfr implies a “standard of care” that sets guides up for a lawsuit by “failing to act.” (Isn’t it true, Ms. Wilson, that you are required to be a Wilderness First Responder to work in Grand Canyon? And isn’t it true that part of that training is in using an EpiPen, and that your outfitter would have compensated you for its purchase? Then please explain to the jury…)
What is our job, and what’s the goal?
Professional ems personnel have advanced equipment, Medical Control, regular contact with a physician and consistent hands-on experience with providing emergency care.
We don’t have that. We are not ems providers. We are river guides; our job is preventing illness and injury in order to avoid the need for medical care. And we are extremely good at it. When there is a medical emergency, we handle that too—but in most cases we have no equipment, no Medical Control, no contact with a doctor and limited hands-on experience. Realistically our best bet is to provide basic first aid, call professional ems personnel and evacuate the victim quickly.
I contacted land management agencies throughout the country that oversee whitewater recreation and not one—not one—requires anything beyond Advanced First Aid. Wfr is not the industry standard for whitewater recreation, and for good reason. By requiring it, the agency makes itself liable for any actions taken by the guides affected by that requirement.
The park has thrust guides into a legal and ethical limbo, putting them in a position where they can be screwed no matter what decision they make. Yet it is not just the guide who is at risk. The outfitter who is paying that guide to act is equally liable. The training agency, likewise, is liable. But most vulnerable of all, and the entity with the largest pockets and most likely to be sued, is the managing agency that requires the training: The National Park Service. In an effort to reduce liability and increase safety for park visitors, the nps has inadvertently done the exact opposite.
What’s the answer?
In the past the National Park Service required at least a 40-hour first aid course. The implied “standard of care” was advanced first aid—do no harm, package and evacuate. We inquired regularly, and were told that guides were doing an excellent job. As the Park’s letter points out, most guides voluntarily pursued additional training, and many outfitters encouraged or required it.
There is no problem to solve. The nps should revert to the requirements that were working, and we will continue to provide exceptional care at the level of Advanced First Aid.

Jeri Ledbetter