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Wilderness Medicine - Risk Assessments and Casualty Evacuation

Risk Assessments and Casualty Evacuation

Intended Distribution: UK ATD/  Expedition Doctors

*Across the Divide Expeditions & Dr Sean Hudson*

'For scientific leadership, give me Scott, for swift and efficient travel, Amundsen; but when you are in a hopeless situation, when there seems to be no way out, get on your knees and pray for Shackleton'- Sir Raymond Priestly

Shackleton managed never to lose a member of his team to the harsh environmental dangers on any of his expeditions. He was obsessed with detail and safety, and his crisis management skills and sense of duty and responsibility were exceptional. Central to the management and assessment of risks on expeditions and casualty evacuation, are the skills, which Shackleton excelled at. These skills are increasingly becoming a prerequisite for organisers of expeditions and medical officers.

Risk Assessment. Hazards are inherent in any expedition; they may well be the reason why a person has become involved in a trip. Assessing from a medical perspective what is acceptable risk is increasingly difficult to perform as participants diversify in terms of age, abilities and health. Often the challenge may in fact dictate a greater level of accepted risk. Hence it can be seen that risk assessment is a multifactorial fluid issue, which will differ for people places and goals.

Risk assessments should be used in every element of expedition planning from team selection, to route choice, to mode of transport. For a medical officer it is essential to developing a casevac plan. We are subconsciously assessing risk every day of our life, whether crossing the road or leading a climb. What is the process we are going through?

· Identify the hazard
· Identify who is potentially at risk and why/how
· Identify methods of reducing or eliminating risk, or how to deal with it as it occurs

There are also two ways of assessing the risk to aid decisions about whether or not a particular action is too risky or not.

How likely is it that this adverse event occurs?
How severe are the consequences if it does occur?

For example on a 2-week trekking expedition the chances of a member straining an ankle are moderate but the consequences not too severe (although it may prevent their continuation in the expedition). A poisonous snakebite from a Black Mamba is highly unlikely in most areas, however the consequences of such a bite could in theory be fatal, so plans must allow for this if Mambas are known to be in the area.

All these things should be taken into account prior to the development of a casevac plan.

Casevac Planning. A Casualty Evacuation or casevac is the transfer of a casualty from an environment in which treatment, or investigation is not safe or possible. The scenario need not be a severe head injury, but may be a twisted ankle or suspected UTI. The person responsible for the medical care of the casualty in the field is unhappy with the environment and wishes to have the casualty in a more stable setting. The method of transferring the casualty from one place to the other requires the activation of the casualty evacuation plan. It is a step-by-step guide covering most eventualities and scenarios.

So why not react to events in the field and create a casevac plan as you go?

Casualties require sometimes-rapid evacuation, which necessitates a coordinated effort involving all available personnel. If the medical officer in the field only has poor comms and is unable to maintain contact with field base or home, this coordinated effort will not occur. Field base need to know who, where, and how things will progress, which the casevac plan will provide. The medical officer may be under considerable pressure and needs to concentrate for perhaps long hours on the casualty. Details concerning transport, hospitals, agents, airfields can confuse issues and complicate an already stressful situation. You do not want to travel long distances to a clinic to find it was destroyed 3 years ago or the nurse is on holiday and is the only person with keys!

The casevac plan is prepared in the pre-expeditionary phase and at the beginning of the in country expeditionary phase, and should attempt to cover any medical eventuality in every area in which the expedition is operating.

It is helpful when considering the development of a casevac plan in a potentially unknown developing country with poor infrastructure to apply a few simple frameworks, and build your plan around these.

CASUALTY CHAIN

Casualty event - Medical Report (medrep) to expedition base camp giving casevac priority and grid reference or location - Local medical services and support infrastructure contacted and activated - Evacuation to chosen location for assessment, stabilisation or definitive treatment. Insurance company involved early if assistance needed. 

The immediate questions that are highlighted by this framework are:

· What types of communication devices are available?
· Who are the local services and who will provide the infrastructure required?
· How will they be activated?
· Where will the casualty be stabilised, investigated or treated?
· The answers to these questions will differ depending on the casualty, type of injury and treatment required. For instance a serious head injury may require rapid evacuation to a neurosurgical unit by plane, which would obviously not be the appropriate response to a young person with a fractured distal phalynx.

The second framework, which is applied to each casualty, is a simple triage algorithm.

CASUALTY PRIORITISATION

Priority 1A
Priority 1B

Priority 2

Priority 3

Priority 4

Priority 1A Needs immediate evacuation from accident area if possible
Priority 1B Needs immediate evacuation but can be transferred from accident area
Priority 2 Needs evacuation in next 12 hours
Priority 3 Needs evacuation within 12-24 hours
Priority 4 Needs evacuation in time greater than 24 hours

This triage prioritisation framework will differ depending on the experience of the medical officer and the equipment available.

If the two frameworks are combined one should end up with 5 different strategies for each operational area of the expedition, possibly involving different hospitals, transport mechanisms and local contacts.

CREATING THE CASEVAC PLAN
Assess expedition medical team, experience.
Assess expedition medical infrastructure, kit, vehicles, and communication equipment.
As a team examine the operational area on maps
Locate hospitals, clinics, local doctors, urban areas, military bases, airfields, potential landing strips, road access, rescue teams, and NGOs operating in area.
Contact the identified local medical infrastructures, ascertaining the level of provision of care available, and visit the sites where possible
Non-medical contacts whom often provide valuable information are consular officials; they are also valuable allies in the event of a casevac. Local rural doctors in general provide the most valuable information since they may well be operating and evacuating casualties in the areas you are planning to visit.

VALUABLE INFORMATION
Telephone numbers: all contacts
Names: all contacts
Grid references and directions: all chains in casevac plan
Radio frequencies: field base, police, military, helicopters, ambulance
Test comms: radio, mobile telephones

All this information should be reviewed by the whole team and copies distributed to all team members.

Running a casevac
Difficult casevacs can be utterly exhausting but generally rewarding experiences requiring commitment from all team members. For the medical officer it can be a trial, clinically isolated in a difficult environment, with a sick patient. Things rarely go to plan!

The list below contains a few valuable suggestions on running a successful casevac.

USEFUL SUGGESTIONS
Never do a casevac alone
Carry enough money or credit cards; you can always be reimbursed later by the insurance company
Carry insurance details for expedition and casualty
Carry comms, either radio or mobile phone
Carry medical details of patient, and travel documents, passport, air tickets, details of next of kin
Carry casevac plan and all contacts
Take translator if needed
Take medical kit
Try never to leave the casualty, do not always trust medical staff and facilities in country, be aware medical practices differ in developing countries, and be open minded but protective.
Take snatch bag: spare clothes, money, treats, wash kit, anything which you feel will make casevac easier for you, should be easy to get to and easily identifiable
Keep records
Treat yourself if all goes well!!

Remember stay calm, be over cautious, don't mind spending money, use all the support you can, always be there to protect the casualty, and enjoy yourself, they may provide many an entertaining anecdote in the future (confidentiality allowing).

source: Across the Divide Expeditions & Dr Sean Hudson

 

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