Chapter 20. Patient Transport/Evacuations

In austere circumstances, a functioning emergency medical system (EMS) may not exist or an existing system may not function as it should. In these circumstances, you may not be able to reach patients or they may not be able to get to you using normal methods (e.g., the roads are impassible). This chapter discusses improvised methods to transport patients or medical personnel.

The first question, however, is whether to transport the patient. In resource-poor settings, the decision whether to transport a patient is a delicate balance between patient benefit and the appropriate use of available resources. It comes down to asking two vital questions: CAN we transfer and SHOULD we transfer? The detailed parts of each question are listed in Table 20-1. All the parts must be answered "Yes" for a transfer to take place.

If the patient has an IV in place, keep it flowing during transport: either put a pressure cuff (or blood pressure cuff or elastic bandage) around the bag or place the bag under the patient to maintain pressure and flow. The danger of this practice is not paying attention to the now-hidden IV bag, which results in letting the bag run dry, thus ruining the IV access port.

If the patient has an IV but doesn't currently need fluids—or needs them only intermittently—use a saline lock and put the IV fluids through it in boluses, as necessary. That also accommodates stopping the fluids and restarting them at a later time without having to restart an IV. Improvised saline (or heparin) locks are described in Chapter 5, Basic Equipment.

If a litter is not readily available or if one cannot be improvised, rescuers can choose from a variety of methods to transport patients, including carrying or dragging the patient. Evacuation from a multistory hospital is discussed later in this chapter.

One-Person Drags

Patients can be dragged head or feet first for short distances to remove them from a dangerous, time-critical situation or when they are in a confined space and no other method is practicable. If the time and circumstances allow, wrapping the patient in a sheet, blanket, or similar cloth makes it easier to drag them. This also provides more protection from any debris the patient may be dragged over.

One-person drags are particularly useful when it is necessary to go under low obstructions. The downside is that there is no way to support the victim's head. Place the patient in a supine position. Cross the patient's wrists and tie them together with any available material (e.g., belt, rope, hose, scarf), then kneel over the patient and lift the tied wrists over your head so they rest on the back of your neck (Fig. 20-1). When crawling forward, raise your neck just high enough so that the patient's head does not bump against the ground.

One-Person Carries

Most people can carry a person in their arms for a short distance, as long as they are relatively small and lightweight compared to the rescuer.

Larger patients can be transported more easily across the rescuer's back (Fig. 20-2). If the person is standing or can be lifted into a standing position, the rescuer drapes the patient's arms over his shoulders and holds the wrists with one hand (pack-strap carry). Once upright, the rescuer should lean slightly forward so the patient's feet are just off the ground and then begin to move.

To get an adult on your back takes extra effort if a patient is supine and no one is available to help the patient stand. With the patient supine, lie on your side alongside the uninjured or less-injured side. Position your shoulder next to the patient's armpit, and pull his far leg over your own, holding it there if necessary. Grasp the patient's far arm at the wrist and bring it over your upper shoulder as you roll and pull the patient onto your back. Get up to your knees, using your free arm for balance and support. Hold both the patient's wrists close against your chest with your other hand. Lean forward as you rise to your feet, and keep both of your shoulders under the patient's armpits.1 If this carry is to be used for more than a short distance, tie the patient's wrists together with any available material to secure a better handhold on the arms.

Two-Person Carries

It is much easier for two people to carry a patient, especially for long distances.

The most basic two-person carry has both rescuers squatting on the same side of the patient, with one at chest level and the other at the thighs. The person at the chest passes both arms under the patient while the other rescuer puts one arm under the knees and his other arm over the pelvis, gripping his partner's wrist. They then pull the patient toward their own chests and move forward (Fig. 20-3). This carry, as well as some of the others, can be used for bed-bound patients by first moving them to a sitting position in the bed and then having the two rescuers sit on either side of the patient to begin their lift.3

Another method that can be used for longer distances starts with rescuer A squatting at the victim's head. Then rescuer B lifts the patient to a sitting position by pulling on the patient's arms, if necessary. Rescuer A grasps the patient from behind around the midsection, holding his own wrist with the other hand for security. Rescuer B then squats between the patient's legs and grasps the knees. This rescuer can face toward or away from the patient (Fig. 20-4); for longer distances, the rescuers should face in the same direction and walk forward. Both rescuers then stand while holding the patient.

The two-person chair carry is more useful over longer distances. The two rescuers squat on either side of the patient and slide their arms under the patient's back and thighs. Although Fig. 20-5 shows the two rescuers holding onto the patient's side, it is more secure if they hold onto each other's arms in the back and grab each other's wrists under the thighs. They then stand and begin walking forward.

Chair Carry

Two rescuers can also sit a patient in a chair, with one grasping the back of the chair and the other the bottom of the chair's front legs. Starting from a squatting position, they tilt the chair backward and stand, both facing in the same direction (Fig. 20-6). The rear person (the more strenuous position) must also support the patient's head and shoulders. A key to success is finding a sturdy chair that is not too heavy.

Litters can be used either as the only means of transporting patients or to get them to another form of transportation. At that point, they often are used as the patient's "bed" while in transit. When no litter is available, improvise one from available materials. This is an emergency measure; always use standard litters when available.

When using any type of litter, designate a team leader to keep those carrying the litter synchronized. Once the team is squatting in position holding the litter, it is customary for the leader to announce, "Ready to lift on the count of three: One, two, three, lift." Once they are standing, the leader should say, "Ready to move on the count of three: One, two, three, move." The team begins moving. The leader gives the same directions for "Ready to stop" and "Ready to lower."

Be kind to the patient if using a rigid litter—pad it. Use any available soft material, such as clothing or sleeping bags. For a head or neck rest (assuming the person does not need to be in a cervical collar), use a roll of toilet paper. Stand on it to squash it. It is the right size and softness for a head/neck support. If it is too thick, unroll some of it.4

Improvised Litters

Litter Without Poles

If material for poles is not available, a blanket, sheet, poncho, cloth sack, or similar item can be rolled from both sides toward the center so that the rolls can be gripped for carrying a patient. Bunch up a blanket lengthwise next to the patient. Push one side under the patient; the patient may need to be log rolled to get the blanket underneath. Roll the edges as close as possible to the patient. All rescuers should squat facing the same direction, three on each side. They each grasp a rolled-up portion of the blanket, and the team leader instructs the team to lift in unison (Fig. 20-7). They stand and begin carrying.

Rescuers should pull out sideways on the blanket as they lift, which avoids straining their backs and prevents the blanket from sagging too much in the middle. This type of litter is useful for carrying a patient only for limited periods, since it is much more tiring than using one with poles. At least six people are needed to safely move an adult patient.

Rope Litter

Make a rope litter by passing a strong rope back and forth beneath the patient, with the loops extending past the patient's body. Rescuers on each side use these loops and each end of the rope as handholds to carry the patient (Fig. 20-8). Another rescuer supports the patient's head. These litters are useful only over relatively short distances.

Flat-Surfaced Objects

Most flat objects that are not too heavy can be used as a litter. These include doors, slabs of wood or light metal, benches, ladders, and cots. This type of rigid stretcher is excellent for patients with suspected spinal injuries. An ingenious litter can be fashioned from two chairs by tying or wiring them together with one back overlapping the other.5 The two back legs serve as handles (Fig. 20-9). In a similar manner, some backpack frames can be linked together to form a stretcher.

Blanket and Poles

To improvise a stretcher using a blanket and two poles, lay one pole lengthwise across the middle of the blanket. Then, fold the blanket over the pole. Place the second pole across the middle of the folded blanket. Fold the free edges of the blanket over the second pole so the edge is almost at the first pole. The patient's weight on the litter will keep the blanket from unfolding when carried (Fig. 20-10). Poles can be fashioned from strong tree branches, tent poles, skis, pipes, and so forth.

Shirt/Jacket Litter

Use two long-sleeved shirts or jackets. Button the shirts or jackets and turn them inside out, leaving the sleeves inside. Pass the poles through the sleeves. Two to four shirts or jackets will often be needed to make an adequate litter (Fig. 20-11).

Sleeping Bag/Cloth Sack Litter

A sleeping bag may also be used as a litter. Zip it up completely and make a small hole at each of the two corners away from the opening. Put carrying poles through the bag's wide opening and then through the new holes. The patient lies on top of the sleeping bag. Gunny sacks, grain bags, or similar containers made of cloth may also be used in this manner, although two or more will be needed, depending on the height of the patient.

Standard Litters Not Used in Hospitals

Military Collapsible Litter

The US military's standard collapsible litter (Fig. 20-12) will probably be available in large-scale emergencies when organizations, including hospitals, begin using their disaster resources. The collapsible litter is commonly used in conjunction with military transport vehicles, including fixed-wing aircraft. It folds lengthwise and has a cotton cover to hold the patient. There are four wooden handles for carrying it and four metal stirrups (one bolted near the end of each pole) to support the litter when it is placed on the ground. Two spreader bars (one near each end of the litter) are extended crosswise at the stirrups to hold the cover taut when the litter is open. Two straps secure the litter when it is closed. Most also have straps to secure the patient. The litter weighs 15 pounds, and is 90 inches long by 22.88 inches wide. The patient area is 72 inches long and 22.88 inches wide.

Stokes Litter

The Stokes litter provides maximum security for the patient when the litter is tilted, such as during ground-to-helicopter, ship-to-ship, or vertical-ground transfers. Its steel or aluminum tubular frame supports wire mesh netting on which the patient lies—after the basket is padded with blankets or other material. If it doesn't come with patient straps, they can be improvised using webbing or rope secured to the end of one side rail and passed back and forth over the patient—first toward the head and then back toward the feet, forming a crisscross pattern. It may also have carabineers and cables for attaching to helicopter long lines or ship-to-ship transfer cables. Some baskets are fitted with handles so they can also be used as a litter. A search and rescue improvisation is to attach a large wheel to the underside to assist in moving the patient long distances. The standard basket is 84 inches long, 23 inches wide, and, without attachments, weighs 3.5 pounds.

Specialized Litters

Litter with Skis

Many types of litters can be fitted with skis. The formal type is known as an Ahkio. This Alaskan sled is particularly useful where patients must be evacuated through deep snow.

Litter for Paralyzed Patients

An improvised method of making prolonged litter extrications more tolerable for paralyzed or immobile patients is to use two stretchers. The first stretcher has a hole for the patient's face and a hole for urine output when the patient is in the face-down position (Fig. 20-13). The second stretcher has a hole for stool output, to be used when the patient is in the face-up position. Turn the patient every 2 to 4 hours, by first sandwiching the patient between the two stretchers and then flipping them over. This also prevents the patient from developing pressure sores or autonomic dysreflexia from a distended bladder.9

Vertical Intra-Hospital Transport

Non-ambulatory patients may need to be moved down stairways or lowered out of windows when a hospital needs to be evacuated.

Lowering Patients

In some circumstances, such as when normal hospital exits are blocked, patients may need to be lowered out of the windows to safety. For this risky maneuver, get the most experienced people to help, such as fire department and rescue personnel.

The basic technique, without normal litters and ropes, involves securing the patient as well as possible into sheet slings and using additional sheets as "ropes." Bed-sheet ropes can be anchored to hospital beds, or the rigid "standpipes" in stairwells can be used to belay the patients.

Down the Stairs

It may be necessary to move non-ambulatory patients down the stairs when the elevators do not work. This has traditionally been an extremely slow process, involving fire department stretchers and many teams of strong people.3,10

However, this method, which can be used in nearly any situation, is much faster, takes only a few people of normal strength to operate, and requires no specialized equipment.

1. Check the entire length of the stairwell to be certain that it is clear and that an exit is available at the bottom. For safety, station someone at the bottom of the stairway to ensure that the exit stays open and to warn the team if it doesn't.

2. Place patient mattresses end-to-end on the stairs. Cover each flight of stairs (the stairs between a flat landing) with mattresses by putting a mattress even with the top stair and having mattresses extend to the landing. Push all the mattresses against the wall side of the stairway so there is a narrow area for personnel to walk.

3. Repeat the process for the entire length of stairs to be traversed.

4. Prepare the patients to be transported by wrapping them with two sheets (Figs. 20-14 and 20-15), leaving their faces uncovered. Both sheets should be tied individually at the head and foot ends with square knots. Wrapping the patient in two sheets provides extra support and allows the two rescuers at the head end to each hold a different sheet (for safety). The rescuer at the foot end holds both sheets.

5. To get the patient off the bed, turn the mattress 90 degrees on the bed, with the foot end on the floor. Using the sheet for control and one or two people holding the sheets on each end, slide the patient off the mattress and onto the floor. With most smooth hospital floors, two health care workers can easily slide most normal-sized patients to the head of the stairs.

6. Once at the stairs, lift the patient's foot, using the sheets, onto the end of the mattress at the top of the stairs. The person holding that (foot) end begins walking down the stairs, sliding the patient. The person holding the head end of the sheet follows, simultaneously holding onto the stairway handrail and slowing the patient's slide as necessary. If available, it often helps to have a third person hold the top (head) person's belt to steady him (Fig. 20-16).

7. Once at the landing, slide the patient to the next set of mattresses and repeat the process, continuing to the bottom of the stairs.

8. Once each team clears a landing, the next patient can be started down the mattress ramp from the flight above.

Any type of vehicle or transport method can be used to get health care workers and equipment to patients, and to get patients to initial or better-equipped health care facilities. For example, in Kenya, current methods of emergency transportation include canoes, bicycles with trailers, tricycles with platforms, tractors with trailers, reconditioned public vehicles, and ox carts. (Charles O. Otieno, MD, in a letter to the author, received June 22, 2008.) Bicycle EMS services have been used in many locales for special events involving large numbers of people, for wilderness search and rescue operations, and for disaster response.11

Domesticated Animals

Riding

Any domesticated animal can be used to transport either health care workers or patients, and are especially good in rugged terrain.12 However, experience has demonstrated that (a) a patient's fear can make using a pack animal dangerous, (b) some individual animals that are typically used for transport (including horses or donkeys) may not have the calm temperament needed to carry patients, (c) having experienced handlers available for the animals helps greatly, (d) patients may need to be removed from the animals when going over especially difficult terrain, and (e) putting a safety strap around the patient helps.

Travois

A travois (Fig. 20-17) is a crude sled lashed to a horse or similar animal. The animal drags the travois along the ground. A travois may also be lashed between two animals in single file and carried level. A travois is made from two long poles fastened together by two crossbars and a litter bed fastened to the poles and crossbars.13 The patient is secured on the litter bed. If the travois is pulled by only one animal, the bearers should lift up the end from the ground when going uphill, fording streams, or crossing obstacles.

Motorized Vehicles

All-terrain vehicles (ATVs) equipped with advanced life-support supplies have been used to decrease response times at mass gatherings.14 Golf carts, motorcycles, snowmobiles, mopeds, motorized bicycles, and similar vehicles also can be equipped for medical purposes.

Flat-bed trucks are particularly useful for transporting morbidly obese patients who cannot fit into a standard ambulance or on a standard ambulance stretcher. The "stretcher" can be the patient's own mattress or a large canvas sheet. Trucks can also be used to transport multiple casualties, although one must take care to see that there is adequate light, ventilation, and protection from the elements (if an open-bed truck).

Trains

For the past two centuries, trains have been used to transport large numbers of casualties. For trains not specially configured to transport casualties, seat ambulatory patients in normal passenger cars, in box cars (provided there is adequate light and ventilation, perhaps with doors fully or partially open), on flat cars (although there is no protection from the elements), or on top of passenger or box cars (if there is no other space and the risk of injury or death from falling off the train is less than from leaving patients behind).

Litters can be placed over the backs of the seats in passenger cars and firmly tied down, put in passenger cars after the seats have been removed (or in box cars, again providing there is adequate ventilation), or put on flat cars, exposed to the elements. To stack litters in a car, make improvised fittings using strapping, ropes, or wood (like bunk beds). These must be firmly affixed to the wall of the train compartment, since the load on them—due to the patient's weight compounded by the train's movements—will be significant.

Ships/Boats

Rafts, canoes, inflatables, jet skis, and similar small boats can be used for rescues and to transport both medical personnel to patients and patients to medical facilities.

Small ships, such as ferries and military landing craft, may be requisitioned either to transport patients or for use as medical facilities. Ships are self-contained units, and so can often provide food, shelter, air-conditioning, and other amenities that are lacking in a devastated locale.

Hospital ships are set up to care for patients. The primary issue will be getting to them, or getting them to you.

Those responsible for medical care aboard a ship must know the ship's exact capabilities and limitations, as well as what situations will trigger medical evacuation of patients off the ship. The ship's captain must also be aware of these, especially if the ship is to travel beyond the reach of air transportation or to areas where on-shore hospitals offer limited care.15 Plans must be in place to evacuate patients under specific circumstances.

Medical Evacuation at Sea

Medical evacuation at sea should be considered only after predetermined medical criteria are met, telemedicine consults have been fully exploited, and the risks of evacuation are outweighed by the patient's needs. Improvised transfers can be accomplished by using a smaller boat to carry the patient from one ship to another, but this can be very dangerous. The best way to transfer a patient to a medical facility is from a ship docked at the pier.16

Air transport is often the optimal method to deliver advanced medical supplies, and to transfer patients for initial treatment during medical emergencies or to tertiary care centers, especially when the patient is far from medical facilities or, even, civilization. Yet, aeromedical transport is a costly, often scarce commodity, so practitioners must use it wisely.

Two general types of aircraft are used for aeromedical transport—fixed-wing planes and helicopters—each is discussed separately.

General Problems

Major adverse events occur in about 12% of aeromedical evacuations. These are often the result of high altitude, rushed patient assessments, hurried evacuation of unstable patients, a patient's long immobilization during flight, health care worker fatigue, the difficulty of in-flight evaluation and treatment, and the unpredictable availability and length of evacuation.17,18

Special problems arise when arranging for international nonmilitary air transport. The cost, which may be $100,000 or more for a transoceanic air ambulance, must be paid, or guaranteed by an insurance agency, in advance. Other problems may include communicating with the transferring and accepting physicians, obtaining visas, and obtaining transportation for the patient at both ends of the flight.18

In all aeromedical transport, preparation lessens the chance for untoward events. Preparation includes completing all the paperwork before taking the patient to the plane and carefully envisioning any medical problems that may occur en route. The medical preparation should include placing any tube or doing any procedure that may become necessary during the flight. If possible, have sufficient battery power and oxygen, medications, functioning IV lines, and any other equipment you may need—even if the trip is delayed.

Specific Problems

The major problems in air transport stem from the decreased barometric pressure at altitude and transporting contaminated patients. Additionally, the noisy environment may interfere with the ability to hear monitors, use stethoscopes, and communicate with the patient, other staff, and the aircraft's crew.

Decreased Barometric Pressure

The diameter of a gas bubble in liquid (such as blood) or in tissues doubles at 5000 feet above sea level, doubles again at 8000 feet, and once again at 18,000 feet. Cabin pressure in most passenger planes is maintained at 5000 to 8000 feet; on military aircraft, cabin pressure is between 8000 and 10,000 feet. Not all aircraft can increase their internal pressure to simulate sea level. At a cabin altitude of 8000 feet, a normal person's oxygen saturation drops to 90%: Correct this by using 2 L/min of oxygen to raise saturation levels to between 98% and 100%. During the flight, the lowest possible "cabin altitude" should be maintained; if necessary, that may mean flying at a lower altitude, which will increase both the flight time and fuel consumption.

Maintaining the lower cabin altitude (ask the aircrew if this can be done) is most important when transporting patients who have penetrating eye injuries with intraocular air, free air in any body cavity, or severe pulmonary disease. It may also be necessary if gas expansion would cause a tension pneumothorax, surgical wound dehiscence, intracranial hemorrhage, or irreversible ocular damage. Patients at greatest risk for this are those who have had recent surgery or head or chest trauma. Unfortunately, problems related to gas expansion can be difficult to diagnose or treat aboard an aircraft.

It is vital to maintain a constant ground-level cabin pressure throughout the flight when transporting patients with decompression sickness or arterial gas embolism. If there is no aircraft that can maintain this, the cabin altitude should not exceed 800 feet (242 meters), especially with helicopter evacuations. These patients must also be on 100% oxygen (by aviator's mask, if available).19

Before they are transported in any aircraft without ground-level (1 atmosphere) cabin pressure, prepare patients by17:

• Inserting a chest tube with a Heimlich valve or collection system, even for small, asymptomatic pneumothoraces.
• Venting ostomy collection bags to prevent excess gas from dislodging the bag from the stoma wafer. Use a straight pin to put two holes in the bag above the wafer ring.
• Using rigid splints, rather than air splints, since the air within them expands at altitude and they would need to be readjusted frequently.
• Doing fasciotomies or escharotomies if they could conceivably be necessary in flight.
• Bivalving casts if the cast is over a surgical wound site. This "window" permits tissue expansion and emergency access.
• Adjusting ventilator settings in neurosurgical patients to meet increased oxygen demands at altitude.

Situations Requiring Decontamination

Aeromedical transport may be limited or delayed in environments contaminated with radiological, biochemical, or infectious agents. These situations may limit or delay air resources due to (a) the time needed to decontaminate aircraft after the flight, (b) the availability (or lack) of an aircrew that is not contaminated and is willing to fly, (c) the need to batch similarly exposed patients, and (d) the ability to isolate patients on the aircraft.17 Prior to transport, decontaminate any patients with external contamination. During the flight, isolate any patient with a communicable disease.

Fixed-Wing Aircraft

Military Aircraft

When large numbers of patients require transport, military planes generally are used. In such situations, prioritizing patients is a concern. Load the sickest ones first; they should be off-loaded first as well. Plan for cabin temperatures ranging from 15°C (59°F) to 25°C (77°F) in the winter and from 20°C (68°F) to 35°C (95°F) in the summer.

Safety

Safety is a major concern when using military fixed-wing aircraft. Unlike commercial passenger planes, which are normally entered through a controlled point in the terminal (even for litter patients), military planes usually sit on the tarmac without an obvious approach path.

A "circle of safety" exists around the aircraft. It is an imaginary circle 10 feet from the plane's nose, wings, and tail (Fig. 20-18). Vehicles and people must not enter the safety circle unless instructed to do so by the flight crew. Vehicles within that area (such as those carrying patients) must have a spotter when in motion and use chocks when parked.

When entering the aircraft, use a flashlight, preferably one with a low light intensity and a red or blue filter, to avoid compromising the aircrew's night vision.

On an aircraft equipped with webbing along the sides (primarily military), a bandana or cravat can be tied through the webbing and around the patient's forehead to provide support when sitting for long periods.

Other safety caveats are as follows: (a) do not run near any aircraft; (b) do not walk under the wings or propellers, even when the engines are not running; and (c) wear eye protection near the aircraft, especially when the propellers are in motion.

Passenger Airlines

The most common situations involving passenger airlines are using them to transport patients or confronting medical emergencies during a flight.

Transporting Patients?

Transporting patients via a regularly scheduled commercial passenger airliner is cheaper and, usually, more readily available than is an air ambulance. If the patient can sit, simply purchase a seat for her and for the medical attendant(s). Airlines may get a bit nervous, however, about accommodating medical equipment; check with them in advance.

Getting a stretcher-bound patient onto a commercial aircraft may be difficult, since the aisles are too narrow to accommodate standard ambulance stretchers. Patients must be taken aboard using a soft (scoop) stretcher or an improvised stretcher. The stretcher is then usually placed in the back of the plane across several seats; the medical team sits across the aisle. Some airlines permit stretcher patients only in the first-class cabin. Some airlines specifically prohibit access to the aircraft's electrical systems. This requires operating any equipment on battery power, which may be difficult on long flights. The airlines generally do allow hanging IV solutions from overhead bins, as well as taping flow sheets and other medical information to them.18

Hypoxia can be treated with supplemental oxygen. Bring extra oxygen in case of delays in air travel or another unexpected need for additional oxygen. Aircrews prefer not to provide oxygen from their medical supplies.

Even on commercial aircraft, airframe vibrations may interfere with monitoring devices, and the high ambient noise level can interfere with using a stethoscope or communicating with the patient, other team members, or the aircraft crew.18

Medical Emergencies During a Flight

Few locations are more isolated than the small tube of an airliner 35,000 feet above the ground, with limited space and medical equipment. Fortunately, medical emergencies on board aircraft are relatively rare. Recent estimates are that between 1 in 10,000 and 1 in 40,000 passengers will have a serious medical event, and between 1 in 3 million and 1 in 5 million passengers will die while in the air.20

The goal of in-flight medical assistance on commercial airline flights is to stabilize the patient's condition until the aircraft has landed. The most common in-flight emergencies on commercial aircraft are vasovagal, cardiac, neurologic, gastrointestinal, and respiratory events, and trauma.21 Alcohol consumption and more stressful flying conditions have increased the need to restrain passengers for disruptive and violent behavior.22 While this may seem like a medical emergency, it is best to let restraint experts, such as police, security personnel, an air marshal, or a psychiatric worker, intervene. Health care professionals can be useful if sedation is necessary.

The option to ask for advice from ground-based health care providers is now commonly available. Many commercial airlines have links to physicians with experience in on-board medical emergencies.

Treatment options include providing oxygen and using the patient's medications, medications (labeled) from other passengers, or the medications and supplies in the plane's emergency medical kit. You can also request that the plane fly at a lower altitude to increase cabin pressure. That may alleviate altitude-related chest pain, dyspnea, and abdominal pain by resolving relative hypoxia and decreasing the expansion of gas that resulted from the decreased pressure at altitude.21 The final option is to ask that the plane be diverted to the closest airport, if possible.

Ask the captain to land at the closest airfield if a passenger (a) has chest pain, shortness of breath, or severe abdominal pain that does not improve with basic interventions; (b) is persistently unresponsive; (c) has cardiac arrest that has responded to initial treatment; or (d) has an acute coronary syndrome, severe dyspnea, stroke, refractory seizure, or severe agitation.21 Note that if a patient does not respond to CPR, initial attempts at defibrillation (many planes are now equipped with automatic external defibrillators [AEDs], especially those flying internationally), and the administration of cardiac drugs (e.g., epinephrine, atropine), the patient will not survive, so diverting the plane will not help the patient.

In-flight medical incidents are stressful. There is not much light, it is hard to lie someone flat, the seats are cramped, and it is noisy. Hearing anything through a stethoscope is nearly impossible. Personal experience demonstrates that resuscitation in a plane's narrow aisle can be challenging. The widest space is near the galley; if possible, get patients who need to be supine to that area. There may even be enough room to spread out the plane's medical kit and, if necessary, to position the AED. Use a pillow under your knees—a plane's floor has paint-thin carpeting. Also, ask the flight attendant to help steady you during landing if you absolutely must stay with the patient. On miniscule regional planes or in small private planes, there may be no place to position a patient supine except near the exit.

Helicopters

Working with a Medical/Rescue Helicopter

Helicopters are often used in austere medical environments both to transport health care professionals to patients and to extract patients who need a higher level of medical care. When extracting patients, the health care provider may need to prepare and direct ground operations. This is outside the training for most health care workers, so they need to be aware of how (a) to set up a landing zone and (b) to work safely around a helicopter.

Special Situations

When the helicopter used to transport patients is neither medically configured nor staffed (most commonly military helicopters in disasters), patients do not receive medical care during the flight.17 Patients may be dangled in a basket (horizontally) or in a restraint device (vertically) at the end of a "long-line" attached to the helicopter. When patients will experience any of these exciting/scary excursions, tell them what will occur. Then, secure them tightly into the basket or follow the crew's instructions about using the vertical restraint device. Be careful to let the long-line touch the ground before touching it yourself, to avoid getting hit by a static electricity charge; it's not pleasant.

Establishing a Landing Zone

It may be necessary to establish a landing zone (LZ) before you can evacuate a patient from a difficult environment. While action movies often show helicopters hovering or doing one-skid landings to offload people (and skilled pilots can do that in emergencies), loading a patient normally requires a stable platform—the LZ. There are five major considerations in locating an LZ23:

1. Surroundings. Ideally, it should be free from overhead wires, trees, poles, structures, or anything else that could damage the aircraft.

2. Size. An LZ should be 100 feet by 100 feet to permit safe landing and lift-off. Pace off an "X" of 50 steps in each direction from a central point. Assuming that an adult's pace is about 2.5 feet, that provides at least the needed space. The center of the "X" is the landing spot.

3. Slope. Find a relatively flat site. If the slope is >15 degrees, there is a chance that the aircraft could roll over.

4. Surface. Dust or snow will reduce the pilot's visibility. Some surfaces may not support the craft. Clear the LZ of debris. Any loose debris can be blown up into the air and, if struck by a rotor blade, can seriously damage the blade.

5. Access. Place the LZ at least 200 feet away from the medical facility, so that the facility won't be damaged by rotor wash. But remember that you need easy access for patients, personnel, stretchers, and equipment.

Other considerations for the LZ are as follows24:

• If the LZ will be used multiple times, find a way to prevent unauthorized people from entering it.
• Mark the LZ's corners to identify it for the pilot. Do not use material (e.g., cones, cloth) that can blow around; fluorescent surveyor's tape is excellent. At night, use red- or yellow-colored lights or strobe lights (not flares) to mark the LZ perimeter.
• Protect the pilot's night vision by not using bright white lights.
• If the LZ must be on a highway or in an area where vehicles are present, use their headlights to illuminate the LZ.

Wind conditions are extremely important for helicopter operations, so be prepared to signal the wind direction, especially if the pilot asks that you do so. Several methods may be appropriate, including using flares, hand signals, ribbons, and kicking dirt into the air (Fig. 20-19).25

Safety

Safety is a huge concern when working around a helicopter. Horrific accidents have occurred when these rules have been violated.

1. Do not approach the craft until instructed to do so by the flight crew. If you must approach the craft for a "hot on-load" or "hot offload," approach only from the front, between 3 o'clock and 9 o'clock (Fig. 20-20).

2. Danger can come from the main rotor blades or the tail rotors. The tail rotor, which can be as low as shoulder height, is difficult to see when it is spinning. Stay away from the rotors!

3. Wear eye and, preferably, ear protection. Secure any loose items that the blades could pick up (clothing, supplies, equipment).

4. Do not radio the helicopter during the last 30 seconds of the landing, except to warn of an immediate hazard. If there is an immediate hazard, radio "Abort Landing" or "Wave-Off." Repeat the message until you see them lifting or hovering. If you have no radio, use the hand signal shown in Fig. 20-21.

Patients must be prepared for safe helicopter transport. Insulate the patient from cold—especially when under the spinning rotors. If traveling over water, put the patient in a survival vest that does not need inflating. Secure patients to the litter with quick-release straps, if possible. Any oxygen or IV tubing must be secured so it cannot become entangled with aircraft equipment. Most patients should receive supplementary oxygen, if it is available.16

A major part of disaster planning is preparing for the evacuation of hospitals and other health care facilities. Facilities should be assessed in advance for their ability to survive disasters and to safely shelter-in-place their patients and staff.26

Should/Must Patients Be Evacuated?

A major question, either after a disaster strikes (Fig. 20-22) or when one is expected (Fig. 20-23), is whether to evacuate or to shelter-in-place. Making this decision is difficult and its implementation can be costly. Who makes this decision may be as important as how to make the decision (see Appendix 1, Hospital Disaster Plan, for "triggers" that force decisions and how to identify the decision makers). The question of whether to order an evacuation relies on the infrastructure assessment, which includes knowing how long the hospital can maintain a safe clean environment without city water during hot months and how long the facility can maintain essential backup power with only the current on-site fuel supply (Table 20-2).

If the critical infrastructure still functions (or it is assumed that it will function after the event), the hospital's ability to shelter-in-place will depend largely on whether the supply of critical consumable resources can meet the needs of patients and staff without relying on outside supplies.

How Long Will It Take to Safely Evacuate?

If the decision to evacuate the facility is made, how long will it take? Table 20-3 lists factors to consider. The most important of these are the number of patients, the mix of patient acuity, available staff, exit routes within the hospital, patient transportation requirements, available transportation resources (personnel, vehicles and equipment), road and traffic conditions, and the locations of the receiving care sites.

Time is the major issue in hospital disaster evacuations: the time needed to empty the building and to transport the patients safely. In planning, one must distinguish between an orderly, planned evacuation that maximizes safety for patients and staff, and a "drop everything and go" evacuation, such as during a major fire. In emergencies posing an immediate danger, you may need to abandon optimal procedures for safely moving patients in favor of getting everyone out as fast as possible.

The time to empty the building includes the time required to move patients from their location inside the hospital (e.g., rooms, OR, emergency department, clinics) to an ambulatory area in which they can be assessed and discharged or an area for non-ambulatory patients from which they can be loaded into ambulances and other vehicles for transport. One factor that determines how elegantly and quickly this can be done is whether the facility has a means of tracking patients and generating patient discharge summaries. In addition, evacuation time depends on whether elevators are operational (or staff have practiced using the evacuation method described under "Vertical Intra-Hospital Transport" earlier in this chapter), and how quickly additional staff can arrive to help with the evacuation.

Evacuation time also depends on the time needed to transport patients from the assembly/staging areas to receiving hospitals or other appropriate health care facilities.

When Can the Facility Be Reopened?

Subsequent decisions about whether, how, and when to move back into a damaged and evacuated health care facility is a complex decision involving many people. A US government publication, Hospital Assessment and Recovery Guide, describes the process and provides detailed checklists.30 It is available on-line at http://archive.ahrq.gov/prep/hosprecovery/.