Emergency medical evacuations are challenging, but everyday occurrences for AirMed&Rescue readers. However, those operating in urban HEMS may be less familiar with the unique additional layer of challenges associated with carrying out the same operations in less favourable environments.

The right tools for the job

When it comes to the types of aircraft used, there is quite the selection available, and the chosen aircraft depends on the particular environment it will be flying into. For example, Global Rescue Senior Operations Manager Matt Napiltonia highlighted that no two evacuations are the same, and for this reason, Global Rescue doesn’t limit itself to specific aircraft, or even to aircraft at all. “Decisions are all situation dependent, but we use jets, prop planes, rotary-wing aircraft, 4x4 vehicles, small and large maritime vessels, pack animals and even people to carry our members to safety,” he said.

Elsewhere, Oskar Haugli Norderval of the Nordic Joint Rescue Co-ordination Centre (JRCC), said that while the Westland Sea King Mk43 helicopter has been in operation since 1972, there are plans to fly using the Leonardo AW101 in the future: “It will be set in service in Norway in 2020-22,” he told AirMed&Rescue.

Switzerland’s Air Zermatt AG said that its rescue missions are operated with B429 and AS50 helicopters, while by contrast, the New Zealand Defence Force uses the Royal New Zealand Air Force C-130 Hercules aircraft. “These aircraft have been used to medevac patients from Antarctica and conduct SAR in Antarctic waters,” said a spokesperson. “The US Antarctic Program (USAP) conducts medevacs using C-130 and C-17 aircraft.” AirMed&Rescue also spoke with Robb Clifton, who is Operations Manager at the Australian Antarctic Division. “A range of aircraft are available including A319, Basler, Twin Otter, Challenger and Defence assets,” he revealed. The Great North Air Ambulance, which operates in northern England, flies AS365 Dauphin N2s, while the Icelandic Coast Guard (ICG) uses one Bombardier Dash 8-314 MPA and three Super Puma helicopters. This veritable selection of aircraft ensures that the correct type is available for the mission at hand, whether medevac, SAR onshore or offshore.

A hand with landing

When it comes to landing said aircraft, the environment in which the medevac is being performed may necessitate specific preparations. For Great North Air Ambulance, for example, there are a number of elements to consider, both regulatory and practical. “We need to make sure that the landing site complies with the regulations, i.e. minimum size of 2D (D being the value of the aircraft at its longest length x 2). Also, the site should be recced using the size-shape-surrounds-surface-slope technique,” said a spokesperson for the charity.

Preparation and evaluation are key when executing landing, as Norderval explained: “Before we land, we execute a before-landing check, preparing the helicopter, technically, for landing (gear down, etc.). We also brief the specific landing and the crew members´ tasks. We make a high reconnaissance to evaluate the landing site, and discuss further among the crew how to deal with challenges and safety issues.” JRCC has a training programme that covers all of its different helicopter operations, including landing in rough and difficult terrain. “Each training event has a time limit of validity; 90, 180 or 360 days. To stay on rescue duty, you have to be up-to-date on all events. It must be mentioned that the advantage with our helicopter is that a hoist is installed, and we therefore do not need to land to pick up survivors. We hoist over land as well as over the sea,” he told AirMed&Rescue.

While helicopter pilots ideally locate a suitable helicopter landing zone as close to the patient as possible, this isn’t always possible. Napiltonia recounted a recent example of a tricky landing: “Recently, during one field rescue in a remote area of Canada, the pilot and aircrew had to land their helicopter quite a distance from the injured member because there was no suitable landing zone at his location. The pilot and aircrew swam across a river with chainsaws and cut a path to the member’s location. They then stabilised and packaged the member for transport, subsequently transporting him across the river to the helicopter.” Napiltonia also pointed out that some rescues don’t lend themselves to landing at all, and that in these instances long-line rescues from helicopters are required.

If we look specifically at ice runways, the Australian Antarctic Division implements strict preparations for landing, and there are limitations, as Clifton explains: “Approximately four weeks is required to open it and then ongoing maintenance works are needed throughout summer. Our runway is typically open late October to mid-March but shut during late December and January due to high ice temperatures.” For the New Zealand Defence Force, there are no particular preparations required from the RNZAF to land a C-130 on the ice runway. “However, the ice runway used by Scott Base and McMurdo Station is maintained and prepared for landings by US personnel,” a spokesperson told AirMed&Rescue.

Primed and ready to go

Another key consideration when performing medevacs from extreme environments is ensuring that pilots are adequately trained and well equipped to perform the job. For example, as Napiltonia pointed out, pilots who conduct speciality SAR operations such as those in extremely remote or high-altitude situations are highly trained with specialised flying skills. Indeed, Air Zermatt AG confirmed that specific training for landing on difficult terrain is given to new crew members, according to regulations. The situation is slightly different for existing crew. “Crew members who are already engaged have specific training during flight operations on the job (by exercising their daily flight job which includes commercial transports as well as tourist flights) and recurrent training according to the regulations,” said a spokesperson for the company

The New Zealand Defence Force told AirMed&Rescue: “Pilots are trained by experienced instructors to land on the ice, including training for low-visibility approaches conducted in a flight simulator.” For Great North Air Ambulance, all of the HEMS pilots are ex-military pilots. This means that they have considerable training and experience in landing in hostile environments. “Specific mountain flying training is often carried out for refresher training,” a spokesperson for the charity said. Once landed, or once the patient is onboard, as not all aircraft necessarily need to land in order to pick up the patient, it is time to administer care. When it comes to the medical care available on site, this varies according to the air medical provider. “As one of the crew we always bring an anaesthesiologist, and we can compare our medical equipment with an emergency room’s equipment. So, you may call us an airborne emergency room,” said Norderval.

More on medical care

Air Zermatt HEMS crews are capable of providing medical care according to the international recommendations (ATLS/PHTLS/ACLS/PALS etc.). “We are able to fully stabilise airway / breathing / circulation and also capable of applying pre-hospital administration of blood,” it stated.

Dr Jeff Ayton, who is Chief Medical Officer at Australian Antarctic Division, provided an insight into the care that the Division provides. “Comprehensive medical, surgical and dental care by a lone Australian Antarctic Medical Practitioner supported by 24/7 telemedicine and four ‘lay surgical assistants’ is available,” he said. Great North Air Ambulance is a critical care provider able to deliver intensive care at the roadside, including pre-hospital emergency anaesthesia; surgical interventions (thoracotomy, thoracostomy, amputation, surgical airway etc.); blood and plasma; sedation; and teaching and training. For ICG, helicopters carry EMTs and an emergency room doctor.

And what of the types of injuries that are commonly treated on scene? For Great North Air Ambulance, injuries that it commonly treats can occur as a result of such incidences as road traffic collisions, serious assaults, and sports and leisure trauma, including horse riding, mountaineering, glider crashes and parachuting. Global Rescue’s Napiltonia said that the injuries seen depend on a combination of location and activity: “For example, in high-altitude situations, high-altitude pulmonary oedema, high-altitude cerebral oedema, frostbite and GI disorders are common. In more tropical areas, infectious diseases like malaria and yellow fever keep us busy. For skiing, severe extremity fractures are the issue. For travellers we sometimes call ‘the average tourists’, head injuries while biking without a helmet are surprisingly common,” he told AirMed&Rescue.

“In any case, navigating local medical systems is often a daunting task.” JRCC’s Norderval said that the most common SAR missions are sick or injured fishermen at sea, lost hikers, mountain rescue of climbers and ships in distress, while the most common air ambulance missions are stroke, cerebral haemorrhage and heart diseases.

Unique challenges for unique situations

Obviously, medevacs from extreme environments are challenging by their very nature, but what are they key challenges? “The challenges that arise are unique to locations. Getting evacuation assets to injured members, highly variable levels of available medical care, availability of appropriately equipped jets, language and cultures … it all affects the operation and it’s always different,” said Napiltonia. “Changing government regulations, unplanned security events or natural disasters only add layers of complexity to what would otherwise be a pretty simple evacuation. You have to drill down into the DNA of an operation. It takes a tremendous amount of unconventional manoeuvering to successfully evacuate our members from remote regions of the world.”

For JRCC, the key challenges are bad weather and great distances, while for Air Zermatt AG, the ability to adapt is key: “On the flight operation side, the key target is to always maintain a safe operation. From a medical standpoint, we have to continually adapt our medical intervention with environmental factors (temperature, wind, weather, terrain),” said a spokesperson. For ICG, weather and resources present the key challenges and, similarly, for the UK’s Great Western Air Ambulance charity, challenges present themselves in the form of triaging and bad weather tasking (risk versus need). When it comes to particularly challenging cases it has been presented with, ICG said that the most difficult are usually SAR at sea, in the dark and in bad winter conditions.

Australian Antarctic Division’s Dr Ayton said that any case in Antarctica is challenging due to the environment and the distances involved. AirMed&Rescue asked the New Zealand Defence Force to recount a particularly challenging case. A spokesperson said: “In December 2011, an RNZAF C-130 aircraft provided assistance to the MV Sparta, a 48-metre-long Russian fishing vessel that hit an iceberg 600 miles from Scott Base with 32 sailors on board. The C-130 flew a total of 20 hours over two and a half days to locate the vessel and conduct an airdrop of a salt-water pump and diesel fuel in order to prevent the vessel from sinking.”

Challenging case studies

JRCC’s Norderval also spoke of a challenging case: “We performed a rescue mission on the Russian coast east of Kirkenes (easternmost city in Norway). Forty-knot wind, five-metre-high waves and a ship with a crew of 12 drifting towards shore,” he told AirMed&Rescue. “By the time we got there the ship had run on a headland and started sinking. We did not know whether the crew had jumped overboard, if they were in life rafts or if they still were onboard. The challenge was that if they were in the sea, one by one, the operation would take a while and we would need a lot of fuel. If they still were onboard, we would be able to hoist them up fairly quick, but then become too heavy if we had a lot of fuel. The crew were still on board, and as we started hoisting, the ship broke in two. We got all of them onboard before the ship sank.”

Napiltonia of Global Rescue recounted: “One of our members was travelling in a remote part of Turkey and needed medical attention. He got five different diagnoses in five days. We had very limited communications capability with the remote hospital where he was. At the time, the government wouldn’t let US citizens into the country, but we were able to work with our Turkish medical operations provider and immediately get them bedside with our member. The partner served as our eyes and ears on the ground and was able to get key medical information to our physicians for their review, which allowed them to make a transport recommendation,” he said.

“Our medical operations and security teams worked with the US Ambassador’s staff in Istanbul and were able to get our paramedic to Turkey where we could meet the patient, get him to Istanbul and from there, make a proper medical transport back to his home. The review from our physicians determined it was safe to fly the member, but only at very low altitude. The success of the operation depended on many co-ordinated moving parts and strong teamwork.”

These fascinating case studies are testament to the hard work and dedication of the crew members on the ground and in the air on a daily basis. Whether operating from ‘extreme’ environments or not, each medevac is individual and must be treated as such, with a specific set of requirements.

As Napiltonia pointed out: “Every case and every day is different,” and the crews must be prepared for this. “They do know it will involve multiple cases around the world with different levels of severity and variety, requiring extensive collaboration to rapidly come up with an evacuation plan to get our members to the next higher level of care and ultimately, home to their families,” Napiltonia said.

Great North Air Ambulance pointed out too, that despite challenges, it is a privilege to be able to assist people in their time of need. Ultimately, whatever the situation and no matter how challenging the medevac, these people are committed to serving and saving lives, and the reward of completing a successful medevac outweighs the challenges faced, time and time again.

This article first appeared in the March 2020 Firefighting Special Edition.