Residents' perspective☆

Introduction 

We present an overview of the US National Parkmedic Program and the University of California San Francisco–Fresno Emergency Medicine Residency Parkmedic Program's history and evolution. We focus on emergency medicine residents' involvement in emergency medical services (EMS) and wilderness medicine and discuss how such a program may benefit other recreational areas and emergency medicine residencies nationwide. The Parkmedic Program is an emergency medicine resident–run and faculty-supervised training, education, and EMS program. National Park Service rangers from across the country are certified as “Parkmedics,” a group defined as emergency medical technician–intermediates (EMT-I) with additional training in pharmacology and environmental medicine. Originally created to manage the medical needs of visitors to Sequoia and Kings Canyon National Park in the Sierra Nevada of California, and then expanded to cover the entire National Park Service, this program now provides an EMS system to millions of national park visitors and park employees each year.

What makes this program unique is the hands-on opportunity for resident education and leadership in a functional EMS system and wilderness medicine setting. At the same time, residents provide a necessary service to the public on both a local and national level. Those involved are presented with challenges in out-of-hospital care that reflect the varied and often unpredictable character of our national wilderness areas.

Background 

The Parkmedic program began in 1975 after the director of the National Park Service determined there was a need for an improved EMS system in our national parks. The impetus for this development is now referred to as the “Soldier Cave Incident.”1 While visiting Sequoia and Kings Canyon National Parks, a hiker became trapped in a cave after a fall. Because of a limb injury, extrication was not possible without adequate analgesia and assistance from a rescue team. Although Sequoia and Kings Canyon National Parks search and rescue personnel were present, none of the park rangers were authorized to provide pain medication to the park visitor. An impromptu lesson in rappelling allowed a registered nurse access to the trapped man, and she provided narcotic pain relief by physician's order.

After this successful rescue, medical training for Sequoia and Kings Canyon National Parks rangers began as a pilot program managed by 2 emergency physicians in Visalia, CA, a Central Valley community approximately 50 miles west of Sequoia and Kings Canyon National Parks. In 1977, Valley Medical Center (now University Medical Center), located 70 miles northwest of Sequoia and Kings Canyon National Parks in Fresno, CA, started a new program run by emergency medicine residents, with faculty oversight.2 The goal was to train local park rangers with EMT-basic (EMT-B) certification to become what are now known as “Parkmedics”—a group with EMT-I certification and additional training in pharmacology and environmental medicine.

Beginning as a local EMS system designed to serve only Sequoia and Kings Canyon National Parks, the Parkmedic Program has evolved to be the national training center for Parkmedics from national parks across the country. In addition, decades of effort by University of California, San Francisco–Fresno emergency medicine residents and faculty has created standardized Parkmedic policies and protocols used by Sequoia and Kings Canyon National Parks Parkmedics and EMTs that are being implemented throughout the country. Faculty advisors from the Parkmedic Program provide oversight and consultation services to the National Park Service EMS system on a national level.

Resident involvement 

As a unique and challenging opportunity for emergency medicine residents at the University of California, San Francisco–Fresno, the Parkmedic Program continues to attract much interest. Residents with a particular interest in EMS are able to participate in the Parkmedic Program as an additional focus of their emergency medicine training. Involved residents participate in EMS and wilderness medicine education on a local and national level. The success of the Parkmedic Program requires dedicated attention from participating residents. The majority of residents stay in the program for all 3 years of eligibility in our 4-year program. Including their research projects, the monthly Parkmedic group meeting at one of the faculty advisor's houses, and their senior year in EMS training, Parkmedic residents dedicate somewhere between 10 and 20 hours per month to Parkmedic activities. The average annual commitment of postgraduate year–2 and postgraduate year–3 residents is approximately 180 hours. Postgraduate year–4 residents who elect to do a 3-month focus in EMS may dedicate as many as 450 to 500 hours of time to Parkmedic activities during the fourth year of residency. The resident educational goals of the Parkmedic Program are outlined in Figure 1. The goals are accomplished by participation in EMS activities in our local, tricounty system and EMS activities in Sequoia and Kings Canyon National Park and other national parks. The Parkmedic resident curriculum is summarized in Figure 2.

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Figure 1. Educational goals of the Parkmedic Program.10 (All elements of this curriculum are under the direct supervision of the Parkmedic faculty.)

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Figure 2. Summary of the Parkmedic resident curriculum.10

Providing continuing education and EMS medical oversight to Sequoia and Kings Canyon National Parks Parkmedics and EMTs is the cornerstone of the program. Parkmedic residents have the opportunity to learn how an EMS system is constructed through the development of Sequoia and Kings Canyon National Parks Parkmedic policies and protocols based on both urban EMS guidelines and wilderness medicine principles. With guidance from faculty advisors, residents continually write and revise the Sequoia and Kings Canyon National Parks EMS manual used by local Parkmedics and EMTs. The juxtaposition of a vast wilderness area against scattered urban areas of the Central Valley of California often creates treatment and transportation dilemmas that must be considered. For example, flight decisions must take into account weather conditions at altitudes up to 14,000 feet, as well as the fact that the closest facility may be a rural hospital unable to provide definitive care for the patient. The possibility of “radio failure,” a situation in which radio contact with a base hospital physician is not possible because of circumstances such as the remoteness of the incident, is a common reality in the wilderness out-of-hospital care setting. Residents must use problem-solving skills, EMS experience, and the expertise of Parkmedics and EMTs to create policies and procedures that reflect the dynamic and unpredictable environment in which wilderness-based out-of-hospital care is provided. By doing so, and comparing these with the more sophisticated local EMS system, the residents become familiar with the various elements of EMS, as well as fundamental issues and controversies that influence EMS policy and protocol in any setting.

The educational experience of the Parkmedic resident does not end with policy and procedure development. Residents provide continuing education to Parkmedics and EMTs through a lecture series held monthly in Sequoia and Kings Canyon National Parks. During these small group sessions, Parkmedic protocols are reviewed in detail, allowing residents and Parkmedics to ask questions or provide feedback to each other. Medications and procedures related to the monthly topics are also reviewed. For instance, in conjunction with a lecture on high-altitude pulmonary edema, the use of nifedipine would be discussed with a demonstration of how to use a Gamow bag. Through continuing education and annual refresher courses (also run by residents), Parkmedics are able to maintain their certification.

Continuous quality improvement 

Another critical component of resident education in EMS is continuous quality improvement. Continuous quality improvement allows for scrutiny of current policies and protocols and the medical care provided through review of the patient care report. Patient care reports are EMS run sheets used by all National Park Service Parkmedics to record each patient interaction, including assessment, treatment, and disposition. All patient care reports are reviewed by a postgraduate year–2 or postgraduate year–3 resident whose job it is to analyze the decisions made and actions taken by the Parkmedic. After specific issues in question are highlighted and resolutions proposed by the junior resident, a postgraduate year–4 resident and faculty advisor review all the completed continuous quality improvement forms. Approved feedback can be given to the individual Parkmedic and appropriate action taken, such as group education, policy or protocol revision, or tracking of an issue. Resident reviewers also receive faculty feedback regarding their interpretation of policies and procedures. Such ongoing, thorough review of the Sequoia and Kings Canyon National Parks EMS manual and Parkmedic performance promotes a high quality of patient care and provides invaluable EMS experience through meaningful discussion of fundamental issues in out-of-hospital medicine.

National Parkmedic Certification Course 

Although the majority of the Parkmedic residents' efforts may be directed toward the training and education of Sequoia and Kings Canyon National Parks Parkmedics and EMTs, perhaps the highlight of the Parkmedic Program is the National Parkmedic Certification Course. National Park Service rangers from across the country participate in this 6-week course, which is held every other January in Fresno, CA. Emergency medicine residents, faculty, and staff, along with guest lecturers affiliated with multiple institutions and EMS agencies, join forces to turn National Park Service rangers with EMT-B certification into Parkmedics during an intensive course. Parkmedic alumni, both residents and rangers, often return to participate, demonstrating their dedication to the program.

The Parkmedic course is a rigorous one for residents and students alike. It is organized and run by 1 or 2 postgraduate year–4 Parkmedic residents and includes daily lectures, procedure labs, clinical rounds to demonstrate “physical findings,” EMS ride-alongs, and hands-on patient care opportunities in the emergency department (ED). Individual and small group tutorials by residents are offered to Parkmedic trainees daily and during the evening hours to help clarify challenging but essential areas of knowledge. All Parkmedic residents participate by giving lectures on a variety of EMS and wilderness medicine topics. Residents teach procedure labs relevant to the Parkmedic scope of practice and lead clinical rounds in the hospital, demonstrating relevant physical examination findings exhibited by ED and admitted hospital patients. Many non-Parkmedic residents volunteer their time to lecture and teach during clinical rounds. In addition, the Parkmedic course has been adapted into a wilderness medicine elective that is open each summer to medical students nationwide. Figure 3 describes the Parkmedic Certification Curriculum for enrolled National Park Service rangers. Parkmedics must complete clinical requirements including patient evaluations, procedural skills such as intravenous line starts and splinting, 48 hours of ED observation, and 40 hours of ambulance ride-along and familiarization with EMS run sheets. Figure 4 describes the clinical requirements for graduation. The course culminates with written and practical examinations proctored by Parkmedic residents, faculty, and staff. Final examination requirements are listed in Figure 5. The National Registry of EMTs (NREMT) part of the examination is proctored by a designee of the NREMT. Those who successfully complete the course receive University of California, San Francisco–Fresno Parkmedic and NREMT EMT-I certification.

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Figure 3. National Parkmedic Certification Course Curriculum. National Park Service rangers seeking to become EMT-I–certified Parkmedics must complete this intensive 6-week course directed by a postgraduate year–4 Parkmedic resident and a postgraduate year–2 Parkmedic resident apprentice.

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Figure 4. Clinical requirements for National Park Service ranger graduation from the Sequoia and Kings Canyon National Parks Parkmedic course.

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Figure 5. Testing requirements for graduation from the Parkmedic Program. To become a certified Parkmedic, graduates must also pass the NREMT examination. All testing requires a score of 80% or better to pass.

Academics and research 

In addition to the teaching experience afforded emergency medicine residents through the Parkmedic Program, there are also abundant research opportunities. Through revision of policy and procedure, field experience, and personal interests, a multitude of research ideas are conceived and put to the test.

Research topics have included injury prevention of National Park Service employees, the use of patient-owned vehicles for transport of the injured, EMT-B–administered epinephrine for anaphylaxis,3 subterranean medicine,4 and high-altitude medicine,5, 6, 7 among many others. Academic projects in both EMS and wilderness medicine generated by Parkmedic residents can potentially influence out-of-hospital care on a national level.

In conclusion, with more than 420 million US national park visits annually, representing a nearly 100-fold increase from 20 years ago, the public's attraction to wilderness and urban national park areas is growing.8 With this influx of visitors comes an increase in the number and complexity of medical problems experienced by skilled outdoor enthusiasts, park employees, and people from all walks of life. The National Park Service perceives a need for medical advisors to oversee the out-of-hospital care of this population. This was stated explicitly at the national conference held in San Diego, CA, in September 2002.9 Through participation in the Parkmedic Program, residents help provide a necessary public health service on both a local and national level, while developing an understanding of how an EMS system is constructed and functions.

The educational gain for both emergency medicine residents and Parkmedics is evident. Other residencies, especially those near national parks and wilderness recreation areas, could organize similar programs. This would facilitate productive relationships between residencies, the National Park Service, and the public. The longevity and success of the Parkmedic Program at the University of California, San Francisco–Fresno Emergency Medicine Residency Program suggests its utility as both an educational tool and a rewarding public service. In addition, the Parkmedic experience, combined with the local urban, suburban, and rural EMS system, provides an unsurpassed breadth of EMS training and experience to our emergency medicine residents.