EMS Care in National Parks

In popular culture and modern media, EMS isn’t highlighted much, and rural providers and austere EMS even less so. No longer! Author and paramedic Kevin Grange has written a new book, Wild Rescues, about this largely unknown side of EMS and his experiences as an EMS provider for the National Park Service.

A New Home

Grange was feeling frustrated. He’d graduated from paramedic school in the Los Angeles area in 2011 and was working for a private transport service while hoping to get a call from a local fire department. He hit the proverbial “wall” while waiting and began looking to do something different.

Grange remembered back to when he used to go camping in Yosemite National Park as a child. From the RVs in the parking lot, he’d seen the occasional National Park Service ambulance pass by. He’d never really thought about EMS in national parks but figured it might be an opportunity to do something different. Heeding this call to adventure, he left the warmth of Southern California to become a seasonal EMS provider in the national parks.

Over the next several years, Grange worked as a seasonal and full-time paramedic/park ranger in Yosemite, Yellowstone, and Grand Teton National Parks. Through that Grange found combining his passions—the outdoors and providing good EMS care—gave him a new home. In his own words, he “now bleeds green and grey”—the colors of the iconic National Park Service uniform.

EMS in the National Parks

Working in the national parks gives responders a wide variety of incidents to handle. They range from medical emergencies on the trail and climbers who have falls to encounters with grizzly bears and bison. Some responders are law enforcement rangers, and some are EMS-only. In all cases they are multihazard responders who could find themselves providing medical care, engaging in search and rescue, doing a swiftwater rescue, controlling a hazmat spill, fighting a structure fire, managing a wildland fire, performing a high- or low-angle rescue, or more.

In the book Grange describes many incidents, and readers get a clear sense that EMS in the national parks is different from working in an urban or suburban system. First are the long transport times. “In Yellowstone we had nearly a three-hour transport time to the closest trauma center. If we did a handoff halfway, it could cut it down to 90 minutes each way,” Grange recalls.

As a result of the long transports, EMS crews would run whole treatment algorithms and had some broad protocols designed by the park’s medical directors. “Dr. Will Smith has a military background. Military medicine is sometimes years ahead of street medicine,” Grange says. “As a result we had access to some medications years ago that only relatively recently are on urban trucks, like TXA and ketamine. We also have antibiotics we can give in the field.”

In rural and austere medicine, providers are sometimes by themselves with patients for some time before additional help arrives. Additionally, helicopters are used a great deal for the more-serious cases, with both short- and long-haul capabilities.

Reader Takeaways

“I’m not the hero of the book. I’m very public about my mistakes and how I learned from them,” Grange says. “Several of my mentors have told me to make strong decisions. Also, don’t be afraid to make mistakes; just don’t make them twice!”

Grange credits several mentors and through pseudonyms pays tribute to them in the book. “Some people say I’m a good medic. If they are complimenting me on a call, I can always think of a mentor or instructor who helped me get good with that skill or whose method of assessing or treating a patient I’m modeling,” he adds.

With recent storms and wildfires in the news, people are thinking more about wilderness medicine. “I wanted to give them some insights into an area they might not have heard a lot about and show them there’s an opportunity there,” Grange says.

The national parks aren’t easy places to work, but there are great opportunities for both volunteers and seasonal and career staff. Grange knows of several volunteer paramedics who are retired and given RV parking spots in exchange for on-call shifts in parks. “Many of these folks are outdoorsy people,” Grange says. “They are ski patrollers, hikers, climbers, or just love being in the parks and meeting all kinds of people from around the world.”

Wild Rescues: An Excerpt

A family hiking Yosemite’s Valley Loop Trail had recognized Alex, who was barely alive, from the missing person flyers and called it in. It was quite surreal to spend days with your eyes peeled for someone on a missing person flyer and then suddenly see them.

Alex was drenched and covered with dirt, pine needles, and leaves. He was barely conscious, pale, shivering, and his frail body was one big injury. Purple bruises like Halloween paint framed both his eyes and the spots behind his ears. Although we had yet to learn what had happened to him over the last 48 hours, the raccoon eyes and other battle signs suggested Alex had a serious head injury.

Ben was lead for the call and announced his initial treatment plan. “Let’s get a cervical collar on him and move him from the rocks to a vacuum mattress.”

“Copy,” we said, jumping into action.

We quickly applied a cervical collar and moved Alex to the vacuum mattress. We cut away his wet clothes, which clung to his body like dirty Saran wrap.

We quickly immobilized Alex on the vacuum mattress and carried him to the waiting ambulance. In accordance with prehospital trauma life support, we were off-scene in less than 10 minutes. All our hours of training and working together had made us a well-oiled EMS machine.

I drove as Ben, Luke, Noah, and Brad Miller, the physician assistant, tended to Alex in the back of the ambulance.

As we raced to Ahwahnee Meadow to rendezvous with a medevac helicopter, I heard them cranking the heat—“We need to warm you up”—starting IVs—“Just a little poke”—and reevaluating Alex’s mental status—“What’s your name? Where are you right now?”

As we arrived at Ahwahnee Meadow, Yosemite firefighters clad in yellow bunker gear stood by their engines, waiting to help us land the helicopter. As I spotted them—and thought about dispatch, law enforcement, EMS, search and rescue, volunteers, and firefighters—I realized again that it really took a village to save a life in a remote setting.

But as so often happens in rural EMS, there was a problem: “The helicopter needs to turn around due to weather,” dispatch said.

“Damn!” I yelled before keying my mic and assuming a very calm and polite tone for dispatch—and everyone else listening to the radio traffic. “Copy, ma’am. Can we find an LZ outside the valley?” The flight team requested Batterson Fire Station, three miles north of the town of Oakhurst. It was an hour and 20 minutes away, but it was our only option.

“We’re en route,” I replied, spinning the ambulance around and hauling down Southside Drive.

As I drove, veering around impossible corners, I scanned the road for deer and coyotes, but my ears were firmly attuned to the back of the ambulance. I was listening to every word Ben, Luke, Noah, and Brad uttered, and based on their conversation, I could tell when they were seat-belted or standing, starting an IV, or pushing a medication, and I sped up or slowed accordingly. Along with the standard two IVs for a critical trauma patient—warmed saline fluid and antinausea medication—they also gave Alex the antibiotic Ancef to prevent infection in his dirty open wounds.

“Alex, open your eyes if you can hear me!” Brad instructed. “Come on, buddy,” added Noah. “Open your eyes.”

I could tell by their questioning that Alex’s mental status was declining fast. But why? I’d assumed his condition would improve with our efforts. I’d heard about the afterdrop phenomenon with hypothermia, but I’d never encountered such a patient before. According to the literature the afterdrop phenomenon occurred when a hypothermic patient was rewarmed, and cold blood and lactic acid—a toxin—returned to the heart. As this “bad blood” from the periphery entered central circulation, it could cause a patient’s heart rate and blood pressure to drop, known as “rewarming shock,” or cause the patient to go into cardiac arrest.

“Alex, can you hear us?” Brad demanded. “Open your eyes!”

“GCS 3 now,” Ben said ominously. A GCS 3 is the lowest the scale goes. That meant Alex was in a deep coma—or dead.

I floored it as Noah brought up the idea of inserting a breathing tube down Alex’s windpipe, but Brad said to hold off.

“He still has a gag reflex. He could throw up,” Brad said, before calling up to me. “How much farther?”

“Fifteen minutes!” I said.

As we left the park boundary, the road straightened, and my speedometer twitched with speed. Batterson Fire Station was home to the U.S. Forest Service’s Sierra hotshot crew, an elite team of wildland firefighters. While the summer season was still a few months away, a few firefighters, dressed in yellow wildland fire shirts and green pants, were standing there to help us land the chopper.

When the flight team arrived, they gave Alex a sedative and paralytic and performed a rapid sequence induction to control his airway by inserting a breathing tube. We quickly moved him into the bird before it lifted off in a whirlpool of dusty wind.

Later, as we drove home, I inquired more about the afterdrop phenomenon. Was the arrival of first responders paradoxically the most dangerous part of the incident? Did the afterdrop phenomenon have a mental aspect?

“Definitely,” Brad replied.

Brad explained that a patient in shock would have a fight-or-flight reaction, which increased a patient’s respiratory rate, constricted blood vessels, and raised a patient’s heart rate to maintain blood pressure and perfusion.

“When first responders arrive, however, it often causes the patient to relax, which can knock out this compensating mechanism, causing the patient’s vital signs to crash,” he said.

“How do you prevent it?” I asked.

“I always tell the patient that my team is going to help,” Brad explained. “But then I tell the patient to keep working with us. Whatever you do, I tell the patient, don’t give up now.”

Miraculously, Alex survived and returned to the University of Washington to graduate with a degree in cinema and media studies. Soon after, he wrote, shot, and produced a short film about a selfish man who learned to care more for his community, his close friends, and nature in order to win over the girl of his dreams.

Kevin Grange is a firefighter/paramedic with Jackson Hole Fire/EMS in Jackson Hole, Wyo. He has worked as paramedic/park ranger for the National Park Service in Yellowstone, Yosemite, and Grand Teton National Parks. His memoir Lights and Sirens: The Education of a Paramedic, published in 2021, is available at Amazon.com. Contact him at https://www.kevingrange.com/contact/.

Barry Bachenheimer, EdD, NREMT/FF, is a 35-year veteran of the EMS and fire service as well as a career educator and professor in New Jersey.