Considerations For A Medevac
Medevac is the term used more often in the expedition space and normally implies longer distance transfer accompanied by medical equipment and personnel. Some medevacs are time-critical, while others are more planned repatriations returning patients from overseas to their home country.
Casevac is a term most often used in the military and is usually applied to war zones, in which the casualty is removed swiftly from the battlefield over shorter distances often without accompanying medical staff. Often this is a time-critical movement and may be under fire.
Both involve transporting an injured or sick casualty away from the initial point of care (often in a wilderness setting) to a more definitive and secure location for more advanced treatment.
In both cases, the means of transport may include any combination of the following assets:
Casualty carry with stretcher or other means.
Vehicle (truck, van…)
Boat
Fixed-wing aircraft (i.e. a plane)
Rotary aircraft (i.e. a helicopter)
Providing ongoing care, facing backwards in the back of a cramped, noisy, moving vehicle is an art form in itself. Alongside managing the patient, you may also be dealing with your motion sickness, trying not to fall over, untangling lines, and discovering the key kit is running out of batteries!
Preparedness
‘Never say it won’t happen, just be ready for it when it does’ – A wise person.
Every expedition should have a robust medevac plan. It’s essential medics are familiar with this and ideally involved in writing it.
Key components of a robust plan include:
What assets are available? (vehicles, boats, aircraft etc). It’s equally important to know the limitations of each asset. For example, are the helicopter and pilot rated for night flying? Who are the key contacts to coordinate appropriate transport?
Where are the nearest health facilities? What level of care do they offer (i.e. are there ICU beds or just HDU) and what specialities are present (i.e. where is the nearest neurosurgery unit? Where is the nearest hyperbaric chamber)? It pays to physically visit these facilities to check them out and make notes.
For International Medevacs which companies could transfer a critically ill patient? For less critical ambulant patients where is the nearest airport and what are the flight times to the nearest international transport hubs?
What kit will be required to stabilise patients during transfer? Ensure you have provision for the following:
Stretcher/carrying device (i.e. basket stretcher, vac mat or Stokes litter). Ensure in advance that whatever you’re using physically fits within the vehicle/aircraft cabin.
Airway equipment (including ET tubes, igels, Guedels and NP airways in different sizes), suction.
Breathing/ventilation equipment including bag/valve/masks, sufficient bottled oxygen, masks and tubing.
Circulation equipment including IV cannulas, giving sets, and fluids.
Drugs such as adrenaline, ketamine, midazolam, propofol, glucose etc with the correct diluents and the means to draw them up
Monitoring equipment including 3 lead ECG, sats, and BP cuff as a bare minimum.
PPE includes gloves, apron, and sharps boxes.
Contacts list, chain of command and comms protocol. Each member of the team should have a list of who to contact to assist in coordinating the medevac. Ideally, the medics themselves should be able to focus on patient care whilst other members of the expedition party coordinate transport. It’s important to establish in advance who information should flow to and by what medium (i.e. mobile phone text message, radio etc). This helps to avoid duplication and ‘Chinese whispers’ messaging.
(Please note the list above is a guide only and is not all-inclusive).
Ensure the kit is contained in secure, clearly labelled, and robust bags that staff are familiar with through regular team training.
Plan for failure and build in ‘redundancy’ ensuring there are backup options for key pieces of kit.
It’s essential kit is checked regularly.
Casualty Carries
There are several different techniques for carrying casualties over a distance that we teach in our courses. Some of these use purpose-made equipment whilst others involve improvised techniques with rope, sticks or even rucksacks. On Kilimanjaro porters use a modified wheelbarrow to ‘run’ casualties down the mountain, it’s not a pleasant ride!
One thing is universal: people are heavy! You will need to recruit several people, ideally 3 on each side and rotation to achieve any significant distance, especially over rough terrain. On high-angle terrain, you may also need access to rope and anchors.
Some key principles:
Make sure the casualty is secure, dropping them is an extremely bad look.
Allocate one person to lead the lift to coordinate your efforts. This is normally whoever is at the head end ‘When everyone is ready I’m going to say ready steady lift, are we ready?’
Keep the casualty warm and protected from the elements. Consider putting them in a sleeping bag with a tarp over the top.
Continually check in with and reassure a conscious casualty – the whole process can be terrifying for them.
Consider nominating a ‘litter captain’ who calls out obstacles in front to those behind who will struggle to see where their feet are.
Switching sides (using a different arm) can be as good as a rest in consecutive carries.
A note on helicopters:
These are a rapid and effective way of getting casualties to safety in a range of environments, however, they have a significant number of limitations to be aware of including:
Adverse weather, high altitude and nighttime can affect clearance to fly.
Expensive assets to maintain and staff.
Limited range and payload (usually not an option for multiple casualties).
Relatively risky with high accident rates compared with other transport.
Can incur significant delays at each end due to difficulties loading and pre-flight checks. The medical crew will also need to be briefed on procedures for ditching over water.
In-flight emergencies are very difficult to manage due to cramped conditions and will like require landing the aircraft at the nearest safe location.
Some health facilities do not have dedicated helipads and therefore additional land transfer may be required.
Top tips: never refer to helicopters as a ‘chopper’, the pilot may never speak to you again! ‘Heli’ is fine. Always approach the aircraft from the front and await a thumbs up from the pilot.
Packaging a casualty
In the heat of the moment, it is common for patients to be transported on unsecured extrication devices such as scoop or webbing stretchers. Patients must be definitively secured to maximise patient safety, minimise movement, pain and clot disturbance in trauma and provide a mobile base for lines and equipment.
Be wary of using hard scoop stretchers or longboards for prolonged transfers as these can be extremely uncomfortable and lead to pressure sores.
Trauma patients should be packaged ‘scoop to skin’, but don’t forget to keep the patient warm (bear hugger, blankets or even just bubble wrap off the roll).
Vacuum mattresses consist of a bladder filled with Styrofoam balls. When air is removed by a pump the mattress moulds to the shape of the casualty for enhanced safety and comfort. It is not sufficiently rigid for spinal injury patients and therefore should be used alongside a rigid board.
All equipment and lines must be secured down. Often the oxygen cylinder fits nicely between the patient’s legs.
Ideally, load the patient into the vehicle feet first. It is thought that deceleration forces can increase intracranial pressure. Positioning the patient near the wheelbase of a moving vehicle helps to reduce vertical forces in trauma.
Pre-transfer checklists help to ensure nothing critical is left behind.
