Prehospital Medical Care and the National Ski Patrol: How Does Outdoor Emergency Care Compare to Traditional EMS Training?

Transcription

1 WILDERNESS & ENVIRONMENTAL MEDICINE, 23, (2012) WILDERNESS INSTRUCTOR Prehospital Medical Care and the National Ski Patrol: How Does Outdoor Emergency Care Compare to Traditional EMS Training? Benjamin B. Constance, MD; Paul S. Auerbach, MD; David H. Johe, MD From the Stanford/Kaiser Emergency Medicine Residency, Stanford, CA (Drs Constance and Auerbach); and Elk Regional Health Center, Saint Marys, PA (Dr Johe). Objective. The purpose of this study was to identify the differences between the educational curricula, skill sets, and funds of knowledge required for certification as an Outdoor Emergency Care Technician (OEC-T), Emergency Medical Technician (EMT), and Emergency Medical Responder (EMR). Methods. We directly and in detail compared topics and skills presented in the OEC-T curriculum with those presented in the EMT and EMR education and training curricula. Results. The information and skills taught in the OEC-T curriculum are in general more extensive than those taught in EMR training but are not equivalent to EMT. The OEC-T program has more depth in environmental medical issues, such as altitude illness, hyperthermia and hypothermia. Completion of the EMR program is 112 hours shorter and constitutes 30% of the duration of the EMT program. Completion of the OEC-T program (for certification only and not including additional on-hill patroller training) is 80 hours shorter and is half the duration of the EMT program. Conclusions. The OEC-T curriculum includes a skill set and fund of knowledge that exceeds those of the EMR program, but does not include all the knowledge needed for an EMT program. The OEC-T program prepares out-of-hospital providers to care for patients in the wilderness, with special emphasis on snowsports pathology. The EMT program places a greater emphasis on medical disease and emergency medication administration. These differences should be considered when determining staffing requirements for agencies caring for patients with snowsports pathology. Key words: Outdoor Emergency Care (OEC), Emergency Medical Technician (EMT), Emergency Medical Responder (EMR), National Ski Patrol (NSP), Emergency Medical Services (EMS) Introduction Ski patrols are paid or volunteer organizations working for ski area or the US Forest Service, most often using the National Ski Patrol (NSP) curriculum to provide medical and transportation training for injured snowsports participants. 1 More than 95% of ski areas consider the NSP s Outdoor Emergency Care (OEC) program to be the standard for training ski patrollers. 1 Out-of-hospital (OOH) providers who successfully complete the OEC course are known as OEC-Technicians (OEC-T). Outside of the ski area environment, most Corresponding author: Benjamin B. Constance, MD, Stanford University, Stanford/Kaiser Emergency Medicine Residency, Division of Emergency Medicine, 300 Pasteur Drive, Always Building, Room M121, Stanford, CA ( benbc@stanford.edu). OOH care in the United States is provided by the Emergency Medical Services (EMS) system, largely composed of emergency medical responders (EMR) (formerly known as first responders), emergency medical technicians (EMT) (formerly known as emergency medical technician basic), and paramedics. 2 Each category of OOH emergency care provider is educated within unique training standards. This state of affairs has engendered some confusion about the specifics of education and skills. To understand the qualifications of individual providers, and to contribute to the discussions regarding 1) to what degree OEC-T training offered by the NSP is equivalent to EMR or EMT training, and 2) whether all ski patrollers should be trained at the EMT level, we decided that a logical first step is side-by-side comparison of programs. Therefore, we compared directly the differ-

2 178 Constance et al Table 1. Course infrastructure 2,3,5 Infrastructure OEC-T EMR EMT Table 2. Psychomotor skill sets 2,3,5 Skill sets OEC-T EMR EMT Course length, in hours Emergency department rotation Hands-on field training with instructors Medical oversight OEC-T, outdoor emergency care technician; EMR, emergency medical responder; EMT, emergency medical technician. ences among the OEC-T, EMT, and EMR educational curricula, skill sets, and funds of knowledge based on the fifth edition of Outdoor Emergency Care and indicated training for OEC-T, and the National Highway Traffic Safety Administration (NHTSA) National EMS Core Content, Scope of Practice Model, and EMT and EMR Educational Standards for EMT and EMR. The purpose of this comparison is to objectify the discussion to help EMS agencies, ski patrols, ski areas, and healthcare practitioners assess which program best meets their training, certification, and staffing needs. Another purpose is to improve interdisciplinary interactions and patient safety through better understanding of the differences in the training of OOH care providers. Methods We used the fifth edition of Outdoor Emergency Care as the basis for the OEC-T educational curriculum. 3 The NHTSA is responsible for developing and publishing guidelines for all US EMS practices. The National EMS Core Content sets the universal EMS body of knowledge, skills, and abilities. 4 That is further delineated into separate practices and licensing levels by the National EMS Scope of Practice Model. 2 Each level of EMS provider is educated based on the National EMS Education Standards, which are used to develop the specific EMT and EMR Educational Guidelines. 5 These documents replace the previously used NHTSA National Standard Curriculum. 4 Current documents were used to assess in itemized fashion the educational curricula, body of knowledge, and skill sets of the EMT and EMR. Airway and breathing Oral airway Nasal airway Oxygen delivery Airway suctioning Bag-valve-mask ventilation Mechanical ventilation Patient assessment Manual blood pressure measurement Pulse oximetry Automated blood pressure measurement Pharmacological intervention Unit dose autoinjectors Assisting patient with own medications Administration of physician-approved a emergency medications (eg, aspirin, glucose) Emergency trauma care Manual cervical spine stabilization Manual extremity stabilization Eye irrigation Direct pressure to control bleeding Emergency positioning and moving Spinal immobilization Seated spinal immobilization Long board spinal immobilization Traction splinting Mechanical patient restraint Tourniquet application Pneumatic antishock garment application Cervical collar application Rapid vehicle extrication Medical/cardiac care Cardiopulmonary resuscitation Mechanical cardiopulmonary resuscitation Automated external defibrillator Assisted normal childbirth Assisted complicated childbirth OEC-T, outdoor emergency care technician; EMR, emergency medical responder; EMT, emergency medical technician. a Emergency medication administration is discussed, but practice depends on local ski area protocols. Results Course duration varies among these programs, with the shortest being EMR, followed by OEC-T and EMT, respectively (Tables 1, 2, and 3). Completion of the EMR program is 112 hours shorter and constitutes 30% of the duration of the 160-hour EMT program (Table 1). Completion of the OEC-T program (for certification only and not including additional on hill patroller training) is 80 hours shorter and constitutes 50% of the duration of the EMT program. The OEC-T program is listed as 80 hours, indicating that OEC-T instructors incorporate

3 Prehospital Medical Care and the National Ski Patrol 179 Table 3. Fund of knowledge 3,5 Anatomy and physiology Medical terminology Pathophysiology Life span development Principles of pharmacology Medication administration Emergency medications Airway knowledge of anatomy and function of all human systems Uses foundational anatomical and medical terms and abbreviations in written and oral communication with colleagues and other health care professionals knowledge of pathophysiology of respiration and perfusion to patient assessment and knowledge of life span development to patient Simple depth and covering basic emergency medicines and medication safety Assist with selfadministration of patient s own medications Names Effects Indications Routes of administration Dosages for medications administered foundational Airway anatomy Airway assessment Techniques of assuring patent airway Uses simple knowledge of anatomy and function of upper airway, heart, vessels, blood, lungs, skin, muscles, and bones Uses simple medical and anatomical terms Uses simple knowledge of shock and respiratory compromise to respond to life threats Uses simple knowledge of age-related differences to assess and care for patients No knowledge related to this competency is applicable at this level Assist with selfadministration of patient s own medications Names Effects Indications Routes of administration Dosages for medications administered simple Airway anatomy Airway assessment Techniques of assuring patent airway knowledge of anatomy and function of all human systems Uses foundational anatomical and medical terms and abbreviations in written and oral communication with colleagues and other health care professionals knowledge of pathophysiology of respiration and perfusion to patient knowledge of life span development to patient Simple depth and covering basic emergency medicines and medication safety Assist with selfadministration of patient s own medications and administration of physician preapproved emergency medications simple Names Effects Indications Contraindications Complications Routes of administration Side effects Interactions Dosages for medications administered foundational Airway anatomy Airway assessment Techniques of assuring patent airway

4 180 Constance et al Respiration foundational Anatomy of respiratory system Physiology and pathophysiology of respiration Pulmonary ventilation Oxygenation Respiration External Internal Cellular Assessment and adequate and inadequate respiration Supplemental oxygen therapy (will vary depending on state regulations and physician medical advisor) Primary assessment simple Primary assessment for all patient situations Initial general impression Level of consciousness ABCDs Identifying life threats Assessment of vital functions Integration of treatment/procedures needed to preserve life Monitoring devices Obtaining and using information from patient monitoring devices including (but not limited to) Pulse oximetry Noninvasive blood pressure Medical overview Simple depth, foundational of medical complaints to include transport mode and destination decisions simple Anatomy of respiratory system Physiology and pathophysiology of respiration Pulmonary ventilation Oxygenation Respiration External Internal Cellular Assessment and adequate and inadequate respiration Supplemental oxygen therapy Primary assessment for all patient situations Level of consciousness ABCDs Identifying life threats Assessment of vital functions Begin interventions needed to preserve life No knowledge related to this competency is applicable at this level of of medical complaints foundational Anatomy of respiratory system Physiology and pathophysiology of respiration Pulmonary ventilation Oxygenation Respiration External Internal Cellular Assessment and adequate and inadequate respiration Supplemental oxygen therapy simple Primary assessment for all patient situations Initial general impression Level of consciousness ABCDs Identifying life threats Assessment of vital functions Integration of treatment/procedures needed to preserve life Obtaining and using information from patient monitoring devices including (but not limited to) Pulse oximetry Noninvasive blood pressure Simple depth, foundational of medical complaints to include transport mode and destination decisions

5 Prehospital Medical Care and the National Ski Patrol 181 Neurology Abdominal and gastrointestinal disorders Immunology Infectious diseases Endocrine disorders foundational Stroke/transient ischemic attack Seizure Status epilepticus Headache foundational Acute and chronic gastrointestinal hemorrhage Peritonitis Ulcerative diseases foundational Hypersensitivity disorders and/or emergencies including anaphylactic reactions Awareness of A patient who may have an infectious disease Discussion of various infectious diseases How to decontaminate equipment after treating a patient foundational acute diabetic emergencies Anatomy, presentation, and Decreased level of responsiveness Seizure Stroke Anatomy, presentations, and shock associated with gastrointestinal bleeding shock and difficulty breathing related to Anaphylactic reactions Awareness of A patient who may have an infectious disease How to decontaminate equipment after treating a patient Awareness that diabetic emergencies cause altered mental status foundational Stroke/transient ischemic attack Seizure Status epilepticus Headache foundational Acute and chronic gastrointestinal hemorrhage Peritonitis Ulcerative diseases foundational Hypersensitivity disorders and/or emergencies including anaphylactic reactions Assessment and of A patient who may have an infectious disease How to decontaminate the ambulance and equipment after treating a patient foundational acute diabetic emergencies

6 182 Constance et al Psychiatric Cardiovascular Toxicology Respiratory Basic principles of the mental health system foundational Assessment and Acute psychosis Suicidal/risk Agitation foundational assessment, and Acute coronary syndrome Angina pectoris Myocardial infarction Aortic aneurysm/dissection Thromboembolism Heart failure Hypertensive emergencies foundational assessment, and Inhaled poisons Ingested poisons Injected poisons Absorbed poisons Alcohol intoxication and withdrawal foundational Epiglottitis Spontaneous pneumothorax Pulmonary edema Asthma Chronic obstructive pulmonary disease Environmental/industrial exposure Toxic gas Pertussis Pulmonary embolism Pneumonia Viral respiratory infections Recognition of behaviors that pose a risk to the EMR, patient, or others Anatomy, signs, symptoms and Chest pain Cardiac arrest Carbon monoxide poisoning Nerve agent poisoning Anatomy, signs, symptoms, and respiratory emergencies including those that affect the upper and lower airway Basic principles of the mental health system foundational Assessment and Acute psychosis Suicidal/risk Agitated delirium foundational assessment, and Acute coronary syndrome Angina pectoris Myocardial infarction Aortic aneurysm/dissection Thromboembolism Heart failure Hypertensive emergencies foundational assessment, and Inhaled poisons Ingested poisons Injected poisons Absorbed poisons Alcohol intoxication and withdrawal foundational Epiglottitis Spontaneous pneumothorax Pulmonary edema Asthma Chronic obstructive pulmonary disease Environmental/industrial exposure Toxic gas Pertussis Pulmonary embolism Pneumonia Viral respiratory infections

7 Prehospital Medical Care and the National Ski Patrol 183 Hematology Genitourinary/Renal Gynecology Nontraumatic musculoskeletal disorders Diseases of eyes, ears, nose, and throat Shock and resuscitation of anatomy and physiology Complications related to Renal dialysis Urinary catheter (not insertion) Kidney stones assessment findings, and foundational Vaginal bleeding Sexual assault (to include appropriate emotional support) Infections foundational nontraumatic fractures nose bleed and eye injuries knowledge of the causes, and shock, respiratory failure or arrest, cardiac failure or arrest No knowledge related to this competency is applicable at this level Blood pressure assessment in hemodialysis patients shock associated with vaginal bleeding No knowledge related to this competency is applicable at this level nose bleed Uses assessment information to recognize shock, respiratory failure or arrest, and cardiac arrest based on assessment findings and manages the emergency while awaiting additional emergency response Sickle cell crisis Clotting disorders Complications related to Renal dialysis Urinary catheter (not insertion) Kidney stones assessment findings, and foundational Vaginal bleeding Sexual assault (to include appropriate emotional support) Infections foundational nontraumatic fractures of nose bleed and eye injuries knowledge of the causes, and shock, respiratory failure or arrest, cardiac failure or arrest, and postresuscitation

8 184 Constance et al Trauma overview Bleeding Chest trauma Abdominal and genitourinary trauma Orthopedic trauma foundational and the trauma patient Rapid transport and destination issues Transport mode foundational and bleeding simple and Blunt versus penetrating mechanisms Hemothorax Pneumothorax simple and Solid and hollow organ injuries Blunt versus penetrating mechanisms Evisceration Injuries to external genitalia Vaginal bleeding due to trauma Sexual assault and foundational Upper and lower extremity orthopedic trauma Open fractures Closed fractures Dislocations Sprains/strains Pelvic fractures Amputations/reimplantation No knowledge related to this competency is applicable at this level bleeding Blunt versus penetrating mechanisms Open chest wound Impaled object Blunt versus penetrating mechanisms Evisceration Impaled object Open fractures Closed fractures Dislocations Amputations foundational and the trauma patient Trauma scoring Rapid transport and destination issues Transport mode foundational and bleeding simple and Blunt versus penetrating mechanisms Hemothorax Pneumothorax simple and Solid and hollow organ injuries Blunt versus penetrating mechanisms Evisceration Injuries to external genitalia Vaginal bleeding due to trauma Sexual assault and foundational Upper and lower extremity orthopedic trauma Open fractures Closed fractures Dislocations Sprains/strains Pelvic fractures Amputations/reimplantation

9 Prehospital Medical Care and the National Ski Patrol 185 Soft tissue trauma Head, facial, neck, and spine trauma Nervous system trauma Environmental emergencies foundational and Wounds Avulsions Bite wounds Lacerations Puncture wounds Incisions Burns Electrical Chemical Thermal Radiation Crush syndrome foundational Penetrating neck trauma Laryngotracheal injuries Spine trauma Facial fractures Skull fractures Foreign bodies in the eyes Dental trauma foundational and Traumatic brain injury Spinal cord injury foundational and Near drowning Temperature-related illness Bites and envenomations Dysbarism High altitude Diving injuries Electrical injury Radiation exposure Wounds Burns Electrical Chemical Thermal Chemicals in eye and on skin Life threats Spine trauma No knowledge related to this competency is applicable at this level Submersion incidents Temperature-related illness foundational and Wounds Avulsions Bite wounds Lacerations Puncture wounds Incisions Burns Electrical Chemical Thermal Radiation Crush syndrome foundational Penetrating neck trauma Laryngotracheal injuries Spine trauma Facial fractures Skull fractures Foreign bodies in the eyes Dental trauma foundational and Traumatic brain injury Spinal cord injury foundational and Near drowning Temperature-related illness Bites and envenomations Dysbarism High altitude Diving injuries Electrical injury Radiation exposure

10 186 Constance et al Multisystem trauma Obstetrics Neonatal care Pediatrics foundational and Multisystem trauma Blast injuries Normal delivery Vaginal bleeding in pregnant patient Assessment of pregnant patient Discussion of Abnormal delivery Nuchal cord Prolapsed cord Breech delivery Third trimester bleeding Placenta previa Abruptio placenta Spontaneous abortion/miscarriage Ectopic pregnancy Preeclampsia/eclampsia Newborn care Neonatal resuscitation foundational Age-related assessment findings, age-related and developmental stage related treatment modifications for pediatric-specific major diseases and/or emergencies Upper airway obstruction Lower airway reactive disease Respiratory distress/failure/ arrest Shock Seizures Sudden infant death syndrome Gastrointestinal disease multisystem trauma Normal delivery Vaginal bleeding in pregnant patient Newborn care Neonatal resuscitation Age-related assessment findings, and age-related treatment modifications for pediatric-specific major diseases and/or emergencies Upper airway obstruction Lower airway reactive disease Respiratory distress/failure/arrest Shock Seizures Sudden infant death syndrome foundational and Multisystem trauma Blast injuries foundational Anatomy and physiology of normal pregnancy Normal delivery Vaginal bleeding in pregnant patient Assessment of pregnant patient Discussion of Abnormal delivery Nuchal cord Prolapsed cord Breech delivery Third trimester bleeding Placenta previa Abruptio placenta Spontaneous abortion/miscarriage Ectopic pregnancy Preeclampsia/eclampsia foundational Assessment and Newborn Neonatal resuscitation foundational Age-related assessment findings, age-related and developmental stage related treatment modifications for pediatricspecific major diseases and/or emergencies Upper airway obstruction Lower airway reactive disease Respiratory distress/failure/ arrest Shock Seizures Sudden infant death syndrome Gastrointestinal disease

11 Prehospital Medical Care and the National Ski Patrol 187 Geriatrics foundational Changes associated with aging, psychosocial aspects of aging and age-related treatment modifications for the major or common geriatric diseases and/or emergencies Cardiovascular diseases Respiratory diseases Impact of age-related changes on assessment and care foundational Changes associated with aging, psychosocial aspects of aging and age-related treatment modifications for the major or common geriatric diseases and/or emergencies Cardiovascular diseases Respiratory diseases Neurological diseases Endocrine diseases Alzheimer s disease Dementia OEC-T, outdoor emergency care technician; EMR, emergency medical responder; EMT, emergency medical technician; ABCDs, airway, breathing, circulation, disability. additional on the hill practical field sessions (usually 40 hours) to meet the educational needs for a person to become a ski patroller. To obtain an OEC-T certification and not become a ski patroller, a person must meet a minimum of 80 educational hours, as advised by the NSP National Medical Committee. The EMR program does not include a field-training component. Only the EMT program has a required clinical component, which typically occurs in a local emergency department (Table 1). The EMT curriculum provides the most comprehensive explanations, and greater hands-on training in certain topics (Tables 3 and 4). We used the same method of comparison as described in the National Emergency Medical Services Educational Standards where depth refers to the level of detail and refers to the amount of material taught in a course. 5 Depth is further separated into simple, fundamental, and complex levels of understanding. Breadth is further separated into simple, foundational, and comprehensive levels of understanding. 5 Both complex depth and comprehensive levels of understanding (according to the National Emergency Medical Services Educational Standards) are used only in reference to the paramedic curriculum and are not used in our comparison. The differences between the OEC-T and EMT curricula are highlighted in Table 4 and visually presented in a Venn diagram (Figure). Discussion Our comparison of the OEC-T, EMR and EMT programs demonstrate that the EMR program is significantly shorter in duration, provides a more simple level of Table 4. Comparison of material contained in emergency medical technician and outdoor emergency care technician programs Contained in EMT but not OEC-T Ambulance-based emergency care Emergency department exposure Mechanical ventilator use Automated monitoring equipment Mechanical cardiopulmonary resuscitation Complicated childbirth (delivery) Principles of pharmacology Methods of medication administration Pharmacology, indications and administration of emergency medications a More in-depth recognition and assessment of infectious diseases Management of hematologic emergencies Post-cardiac resuscitation patient care of common neonatal emergencies Contained in OEC-T but not EMT Wilderness operations Backcountry extrication considerations Adaptation and improvisation Specific snowsports pathology More in-depth environmental injuries OEC-T, outdoor emergency care technician; EMT, emergency medical technician. a Outdoor Emergency Care does discuss indications for patient self-administration of some emergency medications including aspirin, albuterol, epinephrine by Epi-pen autoinjector, and sublingual nitroglycerin.

12 188 Constance et al Figure. Visual representation comparing the programs: emergency medical responder (EMR), emergency medical technician (EMT), and outdoor emergency care technician (OEC-T). understanding, and teaches fewer psychomotor skills than the OEC-T and EMT programs. Therefore, the EMR level of training may not be appropriate for ski patrollers with first responder (and sometimes beyond) responsibilities for patients with medical conditions and injuries managed in isolated regions in the absence of higher level OOH providers. The OEC-T curriculum includes all of the NHTSA EMR requirements, but not all of the NHTSA EMT requirements. The EMT curriculum is twice the duration in hours of the OEC-T curriculum. It places greater emphasis on ambulance operations and pathophysiology of medical diseases, and has more depth when teaching skills in patient monitoring and emergency medication administration. The OEC-T program places greater emphasis on wilderness operations, backcountry extrication considerations, adaptation and improvisation, environmental injuries, and first aid specific to snowsports pathology. To achieve precise equivalency of the 2 programs, should such be desired, would be a function of adding to either program the missing elements from the other program. Ski patrollers are educated and trained to assist persons in distress at downhill and backcountry ski areas. Established in 1938, the NSP is dedicated to serving the public and outdoor recreation industry by providing OOH provider education. The organization has more than 26,000 members serving more than 600 patrols. The NSP provides OEC-T education, leadership training, safety programs, and transportation services, but is not a licensing agency. 6 The NSP s National Medical Committee must approve the OEC-T course, originally titled Winter Emergency Care (WEC). This training program continues to be the most accepted program for ski patrollers, with more than 95% of all US ski areas designating OEC-T certification as an entry requirement for their ski patrollers. Not all ski patrols (mostly professional or pro patrols) use OEC-T education. A small number require or accept EMT certification, rather than OEC-T plus on-hill training, and are not affiliated with the NSP. Also some patrols honor the OEC-T card for acceptance on a patrol, but are not members of the NSP. Healthcare professionals with current MD, DO, PA, NP, RN, LPN, paramedic, or EMT licensure may complete an abbreviated version of the OEC-T course, known as the Challenge Course, that focuses on providing OEC-T-specific knowledge and skills that may not have been learned during prior training. 7 On successful completion of the Challenge Course, these persons are granted an OEC-T card identical to that obtained by graduates of the standard OEC-T course. Outside of the ski area environment, EMS provides the majority of OOH emergency care. The NHTSA has been charged with establishing educational goals and standards for the various levels of EMS providers. These levels are EMR, EMT, advanced emergency medical technician (AEMT), and paramedic. Completed in 2009, the National EMS Education Standards constitute realization of the 1996 vision for updating and advancing education standards in OOH care. The revised system is composed of core competencies for each level of EMS provider, with corresponding scope of practice models. These education standards replace the Department of Transportation (DOT) National Standard Curricula (NSC) developed in the mid 1990s. 2,4,8,9 Not included for comparison in our evaluation are courses offered by organizations such as Wilderness Medical Associates (WMA) and the National Outdoor Leadership School Wilderness Medicine Institute (NOLS-WMI). These courses include wilderness first responder (WFR) and wilderness emergency medical technician (EMT-W) courses based on the prior NHTSA EMR curriculum and EMT National Standard curriculum. Graduates of these programs are eligible to take the National Registry of Emergency Medical Technician (NREMT) examination and apply for state certification or licensure. Wilderness education incorporated into these courses may count (depending on the state) as continuing education credit toward national or local recertification as an EMR, EMT, or paramedic. It should be noted that, similar to some knowledge and skills taught in the OEC-T course, the additional wilderness knowledge and skills not contained in the NHTSA core curriculum are usually not recognized by county EMS systems and state licensing boards. An OEC-T is granted certification from the National Ski Patrol and is commonly under the direction of a physician medical advisor, with local ski area advising the patrol on nonmedical issues. The EMR

13 Prehospital Medical Care and the National Ski Patrol 189 and EMT providers are either certified or licensed by state authorities and typically operate under the direction of a county physician medical director. The OEC-T scope of care may vary between ski areas as determined by physician medical director preferences and individual ski area policies because of different needs at individual ski areas, as some have medical clinics at the base whereas others are located far from any advanced medical care. As members of a county or state EMS system, EMTs follow policies set by the system medical director. A ski patrol s policies and procedures may not necessarily be identical to those of the EMS district in which they are located. That could lead to confusion or possibly conflict during patient transfers and mutual aid responses. However, the NSP encourages local ski patrols to interface with their local EMS system so that conflicts are minimized. The OEC-T has a national standard of training allowing portability of the credential from state to state, whereas EMR and EMT training and credentialing currently vary from state to state. The EMR and EMT training will become more standardized, however, if more states change to the new national educational standards used for comparison in this study. STUDY LIMITATIONS We used recently published materials to provide the most up-to-date information. A limitation of our analysis may be that the EMR and EMT curricula are not currently in use across the entire country or may not accurately reflect the current status of EMR and EMT educational standards. Because the most recent edition of OEC-T was recently published, we may have overestimated or underestimated the duration of medical training for the OEC-T course. Conclusions We show in this study that the EMT and OEC-T programs are not the same. We have enumerated the specifics of these programs in a side-by-side comparison. Although significant overlap exists between these programs, wilderness and ski resort providers and agencies need to take the differences into consideration when deciding on training curricula and staffing. Based on the curriculum, it is our impression that the OEC-T program adequately trains responders to initially manage snowsports pathology. We recommend that agencies anticipating significant non-snowsports medical pathology or prolonged evacuation times to definitive care consider augmenting the OEC-T training program or adding EMT providers. These providers could provide more advanced care for these situations. Also EMTs should consider augmenting their wilderness or snowsports medical training before caring for snowsports patients. Acknowledgment We would like to disclose that coauthor David H. Johe, MD, is Medical Editor of Outdoor Emergency Care, fifth edition. References 1. NSP Background and Evolution. Available at: nsp.org/about/background.aspx. Accessed May 11, National EMS Scope of Practice Model. Washington, DC: US Dept of Transportation NHTSA, US Dept of Health and Human Services, Maternal and Child Health Bureau; McNamara EC, Johe DH, Endly DA, Bowman WD, National Ski Patrol (U.S.). Outdoor Emergency Care. 5th ed. Boston: Brady; National EMS Core Content. Washington, DC: US Dept of Transportation NHTSA, US Dept of Health and Human Services, Maternal and Child Health Bureau; National Emergency Medical Services Education Standards. Washington, DC: US Dept of Transportation NHTSA, US Dept of Health and Human Services, Maternal and Child Health Bureau; Mission and Vision. Available at: mission.aspx. Accessed May 11, National Ski Patrol Board of Directors. National Ski Patrol Policies and Procedures Lakewood, CO: National Ski Patrol System, Inc; EMT-Basic: National Standard Curriculum. Washington, DC: US Dept of Transportation NHTSA, US Dept of Health and Human Services, Maternal and Child Health Bureau; First Responder: National Standard Curriculum. Washington, DC: US Dept of Transportation NHTSA, US Dept of Health and Human Services, Maternal and Child Health Bureau; 1995.