General principles

 

On board a sea-going vessel the medical care usually rests in the hands of the first deck-officer, although everything remains under the final responsibility of the ship’s captain. Many sorts of ailments and injuries can be handled by the officers on board, possibly after first having sought additional advice of a TMAS. There are evident limits to the capabilities of ship’s officers to diagnose and treat medical conditions, in addition there are limitations to the medical facilities and equipment on board. These limits will differ to some degree, depending on a number of individual factors: the medical training of the crew, the equipment on board as well as the vessel’s position and its distance to the nearest port.

 The decision to evacuate a patient from a vessel and secondly, which mode of evacuation is chosen, is sometimes evident but can also be a difficult choice. This decision is the result of a number of factors such as probable diagnosis and prognosis as well as the facilities available.

The initiative for a medical evacuation will be taken either by the captain or by the TMAS doctor. Most often the two parties will agree on the decision to take but there may be differences of opinion, each party sometimes having different aspects in view. The nearest RCC (Regional Coordination Centre) and the organisation that is actually going to conduct the evacuation will also have a say in the matter, if not the final one. In cases where differences of opinion arise, these arguments should be clearly brought forward, each respecting each other’s professional (medical versus nautical) arguments and come to an understanding whether an evacuation is necessary and what mode of transport offers the best prospectsModes of evacuation

 

Ship-shore

 

If the medical situation of the patient allows and the distance towards a shore-based medical facility is within acceptable reach in distance and time, the safest and most comfortable mode of evacuation is by the vessel itself delivering the patient. This may imply that the vessel changes its course/ itinerary towards a nearer port than the one that was scheduled. Via the RCC or the vessel’s shipping agent medical transportation on land (usually an ambulance?? ) will need to be arranged separately to transport the patient to a medical facility ashore.

Ship-ship

 

 If the above is not feasible, the vessel may arrange a rendezvous with another vessel and transfer the patient. This may have two different motives.

Most often the patient will be transferred on to a vessel ?such as a lifeboat or ambulance boat? serving primarily for the transport to a medical facility ashore, these boats being faster and more manoeuvrable than the vessel itself. These boats, often of the all-weather type, are evidently confined to coastal waters and have a range of a few tens of nautical miles. They mostly have personnel on board with medical training often equaling or surpassing that of the ship’s crew, so they can be of help in stabilizing the patient before transferring him onto the lifeboat. Pilot’s vessels or sometimes shipping agents’ craft may be needed to transport a patient ashore.

 Sometimes the patient may be transported to a vessel offering more advanced medical care. Naval vessels, passenger cruise vessels and hospital ships are some examples of ships that will offer help in case of medical emergencies, sometimes far out at sea. These different options will be described in more detail further on.

Picture 61              Picture 62

 

 

 Figure 3 Ship/ship medevac

 

The risks of transferring a patient from one vessel onto another at sea must not be underestimated. Even if the sea is calm, walking down the gangway for a sick or injured person, and hopping onto a smaller vessel always has its potential hazards, regardless of the willing help offered from all sides. If the patient needs to be transported on a stretcher, this stretcher will need to be lowered by ropes down the side of the vessel (in cargo ships this may be as high as twelve metres, viz. the third storey of a building), to be subsequently landed on the deck of the smaller craft below.

 Two large vessels adjoining at sea may sometimes be unfeasible. Transfers at sea onto larger ships as mentioned earlier (naval vessels, cruise ships, hospital ships) then require an intermediate transfer in one of the vessel’s dinghies, thus implying two transfers ship-to-ship.

 

  Ship-helicopter


Evacuating a patient by helicopter is sometimes the only option given the circumstances. Helicopters are a swift and efficient means of transporting the patient towards more advanced medical help. A helicopter’s range, however, is limited to an average of 150-200 nm outside the coast, this being primarily a question of fuel supply.
SAR helicopters are normally manned with a doctor or medic who are well trained in medical emergency treatment and transportation. This implies that in getting help from a helicopter to evacuate the patient, expert medical personnel are also called in. This can be vital to assess the situation, come to a preliminary diagnosis, give advanced first aid treatment and stabilise the patient. Besides advanced medical know-how, the helicopter crew will also bring in advanced medical equipment such as Propaq (monitoring equipment) and a defibrillator.

 

 Picture 67

 

Figure 4: Ship/helicopter medevac

 

Getting expert medical help on board through a helicopter and transporting the patient need not be an inevitable sequence. For instance it may well be that the doctor decides, once the patient is sufficiently stabilised, not to transport the patient by helicopter, but to have him transported by the vessel itself to the nearest port. If the patient cannot be stabilised, it may be hazardous to have him undergo the extra physical and emotional stress of a helicopter evacuation. It may also happen that a critically ill or injured patient cannot be saved, and that it is best for the body to remain on board.

 

 

 Picture 63

 

Figure 5: Hoisting the stretcher and patient

 

A helicopter evacuations is a costly operations and not without dangers in itself. When the weather conditions are adverse, the risks involved increase markedly. The helicopter crew put their own safety at risk in these undertakings, so it is evident that their decision whether or not to fly must be a well-balanced one. This firstly implies that the indication for the “Helivac” to be conducted must be medically sound, and that the benefits for the patient outweigh the risks that will need to be taken.

 In ideal cases, the vessel will have a helicopter platform on which the aircraft can land, offload the doctor and possibly a helper, wait until the patient is stabilised and secured on a stretcher, and load everyone back on the craft. In most instances the conditions are not that ideal. If there is no landing platform, the doctor and other crew will need to be lowered by a line for the helicopter, and the aircraft will need to wait in the air, with evident consequences for its fuel reserves. Sometimes the helicopter may choose in the meantime to return to shore or possibly to an offshore oil-rig to refuel and return to pick up crewmembers and the patient.

 Lowering and hoisting persons from a vessel can be hampered markedly by cranes, masts, antennas and objects on deck. The procedures for lowering and hoisting persons from a helicopter may differ. It is essential that the ship’s crew are fully aware and acquainted with the procedure. There are examples of dramatic accidents caused by differences in protocols involving these procedures. The US Coast Guard has issued a concise list of recommendations for the ship’s crew to keep in mind when requesting and conducting a helivac. See the table at the end of the chapter.

One should also realise that, once aboard the helicopter, in spite of a doctor being nearby, the possibilities for further stabilisation and / or treatment are minimal due to noise, lighting, movement and restrained space.

It is important to realise that transport of a patient from a vessel either by the vessel itself, via another vessel or by helicopter sometimes needs to be followed by yet more transport by road ambulance to reach an on-shore medical facility.