COAST GUARD HELICOPTER MEDICAL EVACUATIONS
BACKGROUND INFORMATION FOR CRUISE LINE MEDICAL STAFF
In the event that a guest or crew member becomes seriously ill or is injured, it may be necessary to evacuate them by MEDEVAC while the ship is under way at sea. In the US Coast Guard, 7th District, they perform an average of 30 – 40 helicopter medical evacuations per year.
The decision to request a helicopter evacuation is perhaps one of the most complex decisions the ship’s physician has to make and the decision-making factors are unique to each case. This decision often needs to be taken in a short time frame and is taken at the same time as managing a critical patient.
This briefing has been written to provide some background information to assist in the decision making process, by explaining the advantages and limitations of U.S. Coast Guard helicopter evacuations. There is also information on what to expect when assisting in the coordination of the evacuation, in the event you are the shipboard medical teamf member who will be accompanying the guest or crew member during the evacuation.
Although this chapter has been written mainly about the US Coast Guard, similar operational policies are in effect for the Canadian Coast Guard and other international Search & Rescue agencies who operate helicopters.
US Coast Guard Operations
The US Coast Guard (USCG) is one of the five Armed Forces of the US military, organized under the auspices of the US Department of Homeland Security. The USCG is tasked with many varied missions. Principal in these, is a primary responsibility for search and rescue (SAR) at sea, selected inland areas, such as Alaska, and where other agencies do not have the capability and resources to conduct search and rescue.
In addition to their SAR duties, they are responsible for investigating marine accidents, pollution incidents, inspecting passenger and cruise vessels, maintaining aids to navigation, and US port security and safety, They also provide aircraft and vessels in support of federal, state and local law enforcement, drug interdiction, and migrant interception. These varied roles place multiple demands on oftentimes scarce resources, and the activation of USCG assets for patient MEDEVAC’s must only be considered when there is no alternative to safely manage the patient.
The USCG is organized into nine districts. The Seventh District (D7) is based in Miami, and covers an operational area that stretches from South Carolina down to the North coast of South America. The Eleventh District (D 11), based in Alameda, California covers the Western Seaboard from San Diego up to San Francisco. The Seventeenth District (D17) covers Alaska. Typically cruise ships will be dealing with the 7th, 11th, and 17th USCG districts. The phone numbers for the USCG districts are attached as appendix 1.
In the event that the ship’s physician determines that a patient requires evacuation by the USCG, this initial call from the vessel should be directed to the local (meaning closest in proximity to the incident) district Search & Rescue (SAR) desk. This desk is available 24 hours per day, 365 days per year. This call is usually made by the ship’s Master.
Canadian Coast Guard Operations
Search and Rescue and MEDEVACs in Canadian coastal waters are coordinated by the local Joint Rescue Coordination Centers (JRCC’s). The Canadian Department Defence has overall responsibility for the operation of JRCCs. These rescue centers are jointly staffed by Canadian Forces personnel and Canadian Coast Guard staff. There are three in Canada, one in Central Canada, at Trenton, which is rarely used by the cruise industry, and one on the West coast in Victoria, British Columbia, which is responsible for the west coast of Canada, and one on the east coast in Halifax, Nova Scotia.
The phone numbers are listed here:
- RCC Halifax (902) 427 8200 or (800) 565 1582 Fax (902) 427 2114
- RCC Victoria (250) 363 2333 or (800) 567 5111 Fax (250) 363 2944
SAR operations in Canadian coastal waters are coordinated by the local JRCC using aircraft assets from the Canadian Defence Force and occasionally the Canadian Navy. All primary maritime resources are operated by the Coast Guard.
In the event that you are in Canadian coastal waters, and require a MEDEVAC by boat or by helicopter, the vessel should immediately contact the appropriate JRCC, Halifax on the east coast, and Victoria on the west coast. This can done via the local Coast Guard Radio Station, telephone, fax or telex. The JRCC will assist in determining the most appropriate and efficient method of disembark and will also help with suggesting a destination hospital, based on local weather conditions, and operational issues associated with the flight duration and endurance of the aircraft.
Canadian SAR Aircraft
Currently Canadian SAR agencies use CH-149, Comorant helicopters for their SAR missions, and occasionally Sea Kings from the Canadian Navy. The importance of this fact is that the avionics in this new helicopter are more sensitive to interference from medical equipment, than the previous aging Labrador helicopters, and consideration will have to be given to the type of medical equipment used in helicopter MEDEVACs.
As soon as it becomes clear that a patient may need helicopter evacuation, the Master of the vessel should immediately be advised. A call should then be placed to the local USCG District SAR coordinator or Canadian JRCC. Early notification will assist them in proper mission planning, and give time to put in place supporting arrangements.
It is important to remember that at times, in Canada for example, it may take up to two hours to launch a helicopter. In certain circumstances it may be necessary to also launch a fixed wing aircraft to assist in the MEDEVAC mission. For MEDEVAC missions in excess of 150 miles offshore, or for complex missions, both the US Coast Guard and the Canadian SAR agencies may launch a fixed wing aircraft, such as a C130 Hercules to provide additional communications and coordination to enhance mission safety.
If it transpires later that the patient can be better managed on board or through some other transport arrangement, the USCG and the Canadian agencies will appreciate having been involved early. They will not launch a helicopter immediately upon receiving a call, but rather will consult with a designated USCG Flight Surgeon or Canadian Duty Medical Officer (DMO) who will provide a recommendation regarding potential patient transport.
Direct ship doctor to USCG Flight Surgeon communication is highly encouraged and can be coordinated by the USCG SAR Coordinator or Canadian JRCC. In addition to all the usual patient information, it is important to know that, should the patient eventually be a MEDEVAC, a physician or nurse will need to accompany the patient. Any patient who is sick enough to require MEDEVAC requires a physician or nurse to accompany them.
Coastguard helicopters usually carry a rescue swimmer, or SAR technician. These staff are qualified to the level of EMT-basic, and their skills are in aquatic helicopter rescue, not necessarily the care of a complex cardiac patient, or someone on a ventilator.
If there is a suspicion of a potentially communicable disease, such as TB or meningitis, I is critical that information be communicated to the USCG or JRCC at the time of the initial call
At some point, early on, in the decision-making process an attempt should be made to contact the Corporate Medical Operations department in your company. This will enable shoreside assistance with the logistics and coordination of the evacuation to be provided in a timely manner.
In certain circumstances the USCG will ask the cruise line to assist in making arrangements to have an air ambulance meet their aircraft at a pre-designated location, perhaps where no adequate medical facilities exist. This is because operational restrictions and the flying distances involved may not allow the USCG helicopter to fly the patient directly to a shoreside hospital. In these cases arrangements for this need to be made before the evacuation from the ship can take place.
For example, a USCG helicopter based at Great Inagua may hoist a patient from a ship and take them to the Turks & Caicos, and it will be the responsibility of the cruise line to coordinate an air ambulance to take the patient from Providenciales back to Miami.
Additionally, it is important to contact the receiving hospital and ensure that they are able to accept and treat the patient. For example, if you are dealing with a patient who is unconscious from a possible intra-cerebral bleed, the risk of MEDEVAC is not justified if the only receiving hospital within MEDEVAC range does not have a functioning CT scanner or neurology or neurosurgical services.
The USCG currently operates two types of helicopters for SAR. (For pictures of the aircraft please see Appendix 3). The larger is the UH 60 Jayhawk, the marine equivalent of the military UH 60 Blackhawk. This aircraft has a total payload of 22,000 lbs and can carry up to 8 people including a crew of four. This aircraft is normally predominantly white in color and has an operational range (out and back) of 500 nautical miles.
In the Seventh District these aircraft are based at USCG Air Station Clearwater and at Great Inagua. Time on scene hovering above the ship consumes large amounts of fuel and can greatly reduce operational range. Patient packaging for transport should be completed before the aircraft arrives on scene and the patient moved to the hoisting area to mimimize the time the aircraft has to hover above the ship.
The other aircraft is the smaller HH-65C Dauphin helicopter, which is normally orange in color. This aircraft can carry a total of 6 people including crew and has a total fuel payload of 1900lbs. This has an operational range of 300 nautical miles (out and back). In the Seventh District these aircraft are based at the USCG Air Station Miami at Opa Locka and Borinquen, Puerto Rico. These aircraft can also be deployed on the larger USCG cutters and may be in the area of your ship.
In addition to these helicopters, Air Station Clearwater operates C-130 transport aircraft for logistics support and longer range reconnaissance, Air Station Miami also has 6 HC-144 aircraft (Casa) which are used for prolonged search & rescue missions and maritime patrol duties.
MEDEVACs In and Around the Bahamas
Additionally, the USCG deploys HH-60’s to the Bahamas. These aircraft, stationed in Nassau and on the small island of Great Inagua, are deployed for law enforcement and drug interdiction missions. However, in an emergency and if available, these deployed helicopter resources may be used for a cruise ship MEDEVAC.
These Bahamian based USCG resources are minimally equipped for SAR and may not have a qualified Emergency Medical Technician onboard. Additionally, these aircraft are not able to fly back to Miami. When using these aircraft, the USCG usually requires that the cruise line organize an air ambulance to meet their helicopter at a pre-designated location, such as the Turks & Caicos, for transport to the United States.
Another alternative patient transfer location is the airport in Nassau, Bahamas. In the event that the patient was scheduled to be flown to Miami and the air ambulance has not arrived when you land at the airport, and depending on the condition of the patient, it may be appropriate to transport the patient to Doctor’s Hospital in Nassau.
Keep in mind that the USCG is only responsible to facilitate transport to the nearest location where the patient can receive additional medical care or further transport to a medical facility.
The pilot or aircraft commander (AC) is the sole authority for the safety and operation of the helicopter mission. His/her decision on the conduct of the mission is final, including who may accompany the patient and whether the MEDEVAC occurs at all. The USCG is not able to return the nurse to the ship, and normally do not allow a family member to accompany the patient. The exception to this is in the case a parent/guardian being transported with a child patient.
Patient Criteria for Helicopter Evacuation
While each patient case is unique due to the specific medical problems, on board medical expertise, location of the vessel, time to next port of call and available shoreside medical facilities, there are some very general and basic criteria that should be considered when making an evacuation request.
The actual evacuation of a patient is not without potential hazards. While the USCG has an outstanding safety record, the very nature of the operation requires that great thought and a detailed risk assessment is conducted prior to making this decision. Apart from the risks involved, USCG aircraft are a valuable resource, that should only be requested when there is simply no other way to manage the patient appropriately on board.
Physicians should always contact the Master of the vessel to alert them to the possible need for a MEDEVAC at sea prior to contacting anyone shoreside.
The decision to request a helicopter MEDEVAC is a complex risk-benefit analysis, with the risk of transport being considered against the potential benefit of earlier care in a medical facility. For example, a patient with a large food impaction, in which there are concerns about airway compromise, but who has not been intubated, should not normally be put in a helicopter. Any anticipated airway difficulties likely to be encountered in a well-lit and organized medical center, are many times more complex and difficult to manage in the back of a helicopter. Murphy’s Law was probably written to describe the clinical fortunes of a flight physician, nurse or paramedic with just such a patient!!
Often the cruise line Medical Operations departments are available 24 hours a day to assist the on board physicians with the logistics and operational issues associated with a MEDEVAC, but the ultimate decision about whether to request a MEDEVAC, by whatever method, rests entirely with the on scene ship’s physician.
Some of the issues to consider are:
- Decreased ability to monitor the patient during flight due to noise and vibration inside the aircraft cabin.
- Restricted space, light and access to the patient, who is on the floor of the aircraft.
- Extreme difficulty in defibrillating or pacing patient in USCG aircraft.
- Extreme difficulty in management of the airway in a patient who does not have a secure airway.
- Potential for basket stretcher to spin during hoisting which could induce vomiting.
- Psychological trauma of conscious patient being hoisted off ship in Stokes litter.
- Stretcher-bound patient must lie flat.
- Inability to allow next-of-kin to travel, unless patient is child.
To help explain the general categories of patients who do, and do not benefit from MEDEVAC, some examples of different cases are listed here. It must be stressed that these examples or anything contained in this briefing do not constitute medical advice, but are only clinical examples to demonstrate some of the issues involved. Each case will be unique and the on scene ship’s physician is the only one able to make the decision about the need for a MEDEVAC.
POSSIBLE BENEFIT OF MEDEVAC OUTWEIGHS RISKS OF MEDEVAC.
- A patient with an acute arterial occlusion to an extremity, where early intervention could save a limb.
- Suspected vascular emergency, such as thoracic or abdominal aneurysm.
- Trauma patient with injuries that require urgent surgical intervention.
- Unconscious patient, with secure airway, who may have intra-cerebral bleed or cerebral aneurysm.
- Patient seriously ill with acute surgical emergency where urgent surgical evaluation is indicated to prevent further deterioration. Suspected perforated bowel, acute, non-compressible hemorrhage or vaginal bleeding where blood transfusion is not available on board, and possible necrotizing fascititis are some examples.
- Acute serious eye injury, for example, globe rupture from champagne cork, or possible foreign body penetration of eye.
- Patient in acute renal failure where dialysis is available at the receiving facility.
- Unstable fractures with vascular or neurological compromise, where reduction and restoration of vascular or neurological integrity has been unsuccessful.
- Hypovolaemic shock where blood products are available at the receiving facility.
- Patient body weight < 350llbs.
- Patient with an acute MI, who is not a candidate for fibrinolytic therapy, or where fibrinolytic therapy has failed or is not available, with active and continuing chest pain, and the receiving facility has the capability to provide cardiac catheterization and percutaneous transluminal coronary angioplasty (PTCA).
RISKS OF MEDEVAC PROBABLY OUTWEIGH BENEFIT OF MEDEVAC;
- Acute Myocardial Infarction, assuming access to fibrinolytic on board vessel.
- Patient in cardiogenic shock, or unstable cardiac rhythm.
- Patient in acute respiratory failure who has not been intubated and ventilated.
- Any patient with potential airway compromise who has not been intubated, for example a patient with a foreign body obstruction or oesphageal impaction.
- Patient in active, premature labor, unless short journey to Special Care Baby unit.
- Patient with active psychiatric illness, psychosis or suicidal ideation.
- Overdose patient, unless only treatment is dialysis, or specific antidote is time sensitive and not available on board.
- Patient body weight> 350 lbs.
It would not be appropriate to request helicopter MEDEVAC for a patient in cardiac or traumatic arrest.
As mentioned above, once the ship’s physician has decided that the patient requires MEDEVAC from a ship at sea, the on-duty USCG Flight Surgeon will be contacted by the USCG SAR Coordinator. Their recommendation is required prior to the dispatch of any USCG MEDEVAC aircraft or other rescue assets. The basic medical information will be provided to the SAR coordinator by means of the USCG MEDEVAC checklist (attached as appendix 2). It may be faxed or e-mailed by the infirmary staff. A physician to physician contact should be established wherever possible.
USCG Flight Surgeon Evaluation
The USCG flight surgeon will generally use five criteria to evaluate a request for a USCG MEDEVAC
|1||What does the patient have?||This will be a best guess, based on the shipboard physician evaluation.|
|2||What does the patient need?||This may be a CT scan, neurosurgeon, general surgery or blood transfusion.|
|3||When do they need it?||Educated guesses are all that is required, but specifics are most helpful. Please avoid statements like, “as soon as possible.”|
|4||Where can they get what they need?||USCG will always take to the closest, appropriate facility. USCG Command Center/SAR desk can confirm with the projected receiving facility that they have the capability to manage the patient.|
|5||Can the USCG meet the “window of opportunity”?||If the mission plan will not result in transfer of the patient to the appropriate receiving facility within the time-frame needed, then there is no expectation of medical gain, and there is only risk associated with the flight.|
Once the USCG Flight Surgeon has evaluated the request, and assuming that the mission request is approved, patient preparation should commence.
The patient should be advised that it is medically necessary for them to be MEDEVAC’d and that it will not be possible for them to travel with anyone except the physician or nurse. The only exception to this will be if the patient is a child under 16 years of age.
The patient will not be hoisted in the ship’s stretcher. A special folding litter, supplied by the USCG aircrew, will be lowered. ONLY this stretcher may be used to hoist a patient. This litter and the hoist cable are rated to hold up to 600 lbs. Two blankets should be placed under the patient to ensure that they are well insulated from the metal of the Stokes basket.
If the patient is conscious the accompanying nurse should clearly explain what the patient should expect during the airlift. In addition the nurse should explain that the patient will find it very difficult to hear or communicate, and a system of hand signals should be agreed. If it is daytime, and the patient’s vision is reasonable, a notepad and pen will greatly aid in communication during the flight.
Normally the helicopter will lower the rescue swimmer or corpsman down to the ship to supervise the patient placement in the litter and the hoisting operation. If flight time is limited due to fuel considerations it may not be possible for the rescue swimmer to be lowered to the ship. In this situation the infirmary staff will place the patient in the helicopter Stokes litter.
AS THE LITTER IS LOWERED TO THE DECK, ALLOW IT TO SETTLE ON THE DECK TO ALLOW DISCHARGE OF ANY STATIC ELECTRICITY, PRIOR TO TOUCHING THE LITTER. IF A TRAIL LINE IS USED TO GUIDE THE LITTER, DO NOT EVER TIE THIS LINE TO ANY PART OF THE SHIP.
Ensure that the patient is placed in the Stokes litter the correct way up. The red or orange tubular flotation devices that are secured to the litter should be at the patient’s head end. Otherwise if the stretcher ends up in the water his feet will float and his head will be under water.
All IV sites should be well taped and bandaged. All tubes or lines should be well secured and tucked under a blanket to avoid ‘snagging’ during patient movement or hoisting. If an 0-2 mask is in use it should be taped as well as secured using the elastic band.
Helicopters in a hover can develop severe downdraft winds in excess of 70 MPH, any loose objects can get blown off the patient, and risk being sucked into the helicopter’s engine intakes. In the case of an USCG HH-65, the sudden loss of an engine during a hoist, could be catastrophic. Blankets in particular pose a great hazard to the rotor blades, tail rotor and engine intakes.
Any unconscious patient requires a secure airway. If the patient is intubated it is absolutely critical that the ET tube is adequately secured. It is almost impossible for a patient to be re-intubated in the back of a helicopter. The ventilator must be secured between the legs of the patient, and one of the litter straps must pass through the carrying handle of the ventilator. The oxygen tank should be secured by the side of the patient, but ideally under the patient’s arm to help counter-balance the weight of the ventilator. Alternatively the oxygen tank can be secured between the patients ‘ legs and the ventilator under one arm, adjacent to the chest. Special care must be taken to ensure that the ventilator tubing is firmly attached to the ventilator and the ET tube.
A properly balanced litter will greatly assist with patient handling in and out of the aircraft. It is important to remember that at times as the hoist litter is being maneuvered into the doorway of the aircraft the “feet end” may drop down. Any equipment not firmly secured may fall out. If this is the ventilator, you may be watching on deck as the ventilator, with the ET tube attached, falls towards you.
It is strongly recommended that you assume the helicopter crew does not have additional oxygen or medical supplies. The accompanying nurse should take all that they need, including sufficient oxygen for the flight and any ground transport after the flight. A chart for calculating oxygen consumption and capacity of the tanks is attached as appendix 4.
The nurse should also be carrying the patient’s passport and other documentation, including the medical summary and additional clinical information for the receiving facility. This should be placed in a waterproof or Ziplock bag. The accompanying medical team member should also have a credit card and the cruise company Medical Operations 24 hour phone number.
The physician or nurse should be wearing a manually inflating life jacket for helicopter evacuations. They should not wear the standard ships “Sterns Vest” life jacket, as this is too bulky to enable patient care, and in the event that the aircraft cabin filled with water, would make exit from the aircraft, virtually impossible. Additional safety information for the nurse is attached as appendix 5, and is also on the laminated card attached to the lifejacket
Under normal operating conditions, the medical team member will be hoisted in the small rescue basket, along with any medical equipment. Then the patient will be hoisted and the monitor reattached once in the aircraft.
Non Coastguard Helicopter/Air Ambulance
In certain circumstances the US or Canadian Coastguard may not be able to fly the patient all the way to the receiving facility. A private air ambulance, Lear Jet or helicopter may be arranged to meet the Coastguard aircraft and take the patient. The nurse will always need to go with the patient.
In the Miami area, or for MEDEVAC from Coco Cay or other private islands you can contact Lifeflight at Cleveland Clinic and Miami Children’s Hospital. The Lifeflight helicopter is a Sikorsky S76C. This aircraft can carry two patients and up to four crew or two crew and a relative. The interior is a custom-designed EMS interior that provides a high level of intensive care monitoring, (see appendix 6). This aircraft cannot hoist.
This aircraft is equipped with a ventilator, arterial monitoring lines, and can provide ECMO or Intra-Aortic Balloon pump capability. Communication is easier as the crew and patient all use an intercom system. In the event that this aircraft is used, be aware of the safety rules associated with all helicopters, in particular while the tail rotor is high up on the S76C, the rotor blades can dip down at the front of the aircraft to just below 6 feet (see schematic as appendix 7).
I hope you find these guidelines useful in the event that you are involved in requesting or assisting in an emergency MEDEVAC. It is inevitable that a guest or crew member will become sick at some point. The successful outcome of any MEDEVAC is highly dependent on the smooth interface between the ship’s infirmary staff, your corporate medical team, the US or Canadian Coast Guard, any assisting air ambulance company, and the receiving hospital. Anything that we can do to better prepare you to face this challenge will help ensure a good outcome, and most of all a safe mission. If you have any questions, comments or concerns about these issues, you are actively encouraged to raise them.
I would like to thank the following for their assistance in preparing this briefing:
- Captain Brent Pennington MD, Chief Operational Medicine, US Coastguard HQ.
- Captain Kenneth R Harman MD, Aviation Medicine Standardization Officer.
- Commander Tim Denby, Aviation Resource Manager, USCG District 7
Steve Williams RN, CEN, CFRN
- Institute of Cruise Ship Medicine
- October 2016
UNITED STATES COAST GUARD COMMAND CENTERS
|COAST GUARD ATLANTIC AREA (LANTSARCOORD, PORTSMOUTH VA)||
|FIRST COAST GUARD DISTRI CT (BOSTON, MASSACHUSETTS, USA)||
|FIFTH COAST GUARD DISTRICT (PORTSMOUTH, VIRGINIA, USA)||
|SEVENTH COAST GUARD DISTRICT (MIAMI, FLORIDA, USA)||
|EIGHTH COAST GUARD DISTRICT (NEW ORLEANS, LOUISIANA, USA)||
|NINTH COAST GUARD DISTRICT (CLEVELAND, OHIO, USA)||
|GUARD PACIFIC AREA (PACSARCOORD, ALAMEIH CALIFORNIA)||
|ELEVENTH COAST GUARD DISTRICT (ALAMEDA, CALIFORNIA, USA)||
|THIRTEENTH COAST GUARD DISTRICT (SEATTLE, WASHINGTON, USA)||
|FOURTEENTH COAST GUARD, DISTRICT (HONOLULU, HAWAII, USA)||
|SEVENTEENTH COAST GUARD DISTRICT (JUNEAU, ALASKA, USA)||
|COAST GUARD GREATER ANTILLES SECTION (SAN JUAN, PUERTO RICO)||
OTHER MEDICAL ASSISTANCE
INTERNATIONAL RADIO-MEDICAL CENTER (CIRM ROMA) (ROME, ITALY)
- PHONE: 0 11-3906·592·333 112
- FAX: 011-3906-592-3333
UNITED STATES COAST GUARD
STANDARD MEDICAL INCIDENT CHECKLIST
|Vessel Name:||Call Sign:||Flag:|
|Position: Lat _______ Long ____||Course:||Speed: _______ Knots|
|Cellular:||VHF Y N, Freq: _____||HF Y N, Freq: ____|
|Standard Medical Kit on Board? Y N|
|Nature of Injury / Illness:||Time of Injury/Illness: _____ (GMT/ZULU)|
|Vitals: Time Taken:||B/P: ____/____||Temp:||Pulse:|
|Respiration Rate: ________ None / Shallow / Normal / Deep / Labored||Skin Color:|
|Patient Conscious: Y N||Ambulatory: Y N||Bleeding: Y N||Vomiting: Y N|
|Current medical treatment rendered:|
|Patient Medical History:|
|Recommendation of Ship’s Dr.:|
|Medical Personnel Qualification: Doctor / Nurse / Medical Technician|
|On scene Weather
|Seas:||Swells:||Visibility:||Cloud Ceiling: _____ Ft|
|Vessel Last Port of Call:||Date:|
|Next Port of Call:||Date:|
|Reporting Person/Doctor Name:||Tile:|