Hoisting infectious patients: Helicopter hoisting in the current COVID-19 environment
Brad Matheson of Priority 1 Air Rescue in the US shared his insights into how to safely hoist patients that present with a respiratory infection, whether it be COVID-19 or anything else, keeping crew safety considerations paramount. The outcome of severely ill and injured patients can depend on the time to transport them to definitive medical care and access of the patient from their location, either from a confined area or offshore, may require the response of a SAR helicopter with hoist capacity to perform patient extrication with a rescue litter or other hoistable device.
Priority 1 Air Rescue provides patient care and transports via helicopters licensed as state air ambulances with three medical staff who are all state licensed working under a physician medical director and capable of providing EMT up to FP-C level critical patient care. These specially trained and integrated crews provide an advanced level of care not only during regular medevac flights but also during hoist rescue missions. Like many other air ambulance services in the last couple of months, P1AR crews have been responding to numerous cases with suspected COVID-19 as a possible diagnosis, some of which have recently required the use of a hoist for extraction in an offshore environment. The operational issue and question that is regularly being asked is, “Can we hoist a sick patient that presents with respiratory infection and underlying disease process that is symptomatic?” This goes for any type of patient that requires droplet- precautions due to suspected disease process such as Tuberculosis (TB), Meningitis, INFLU-B, etc as these patients present some unique challenges. A proper risk assessment on whether to conduct the hoist in this circumstance would be on a case by case basis as determined on the severity of the patient.
Relevant to the COVID-19 pandemic, these types of hoist missions bring with them many ‘new’ risks potential with regards to transmission of the virus to the search and rescue (SAR) crews. Due to the nature of the hazard (virus) these hoist evolutions cannot be approached in the same manner as previously conducted without protecting crews with proper personal protective equipment for droplet-precautions.
Critical to proper hazard mitigation, the SAR crews must first be able to adequately access and assess the patient, identify other probable patients that may have been exposed to the virus (considering the confined aspect in an offshore environment) and manage these risks with proper precautions, failure to do the above steps may result in consequences, all while keeping in mind that we are time limited due to having our aircraft overhead waiting to hoist extract us.
To compound the issue, there are no direct CDC guidelines for healthcare professionals that are faced with incorporating droplet precautions with helicopter hoist operations (HHO). These two specific and separate issues have raised valid concerns from our numerous training customers, government SAR operators and oil and gas customers. P1AR wanted to offer some points of discussion to assist other operators and guide them through some considerations in developing policies and procedures for their current operational environment.
Consider methods of extraction
It is clearly imperative to have a comprehensive and standardised approach to patient care, this includes universal precautions, decontamination policies and procedures, as well as appropriate care guidelines for the patient.
The concern for hoisting a known infectious patient is an exposure to the rescuers, as the effects of winds/rotor wash are unknown and uncertain with exposure. We are clearly seeing a continual increase with the number of cases and we would strongly recommend avoiding hoisting suspected patients with COVID-19 if possible and looking at alternative means to patient transport. In the early stages of the disease process these patients are generally not critical (unless respiratory failure is present) and can be transported by other means. If all other possibilities are ruled out and it is necessary to proceed with a hoist extraction, crews should procced with mindful caution.
For these specific hoisting situations, our standard precautions apply with using our current relevant PPE to include the use of N95 respirators, gloves (flight and surgical protective gloves) and eye protection ie goggles and helmet visor possibly in addition to safety goggles) as these items do not impede the ability to otherwise perform normal and hoist operations.
Gowns that are normally something that would absolutely be worn when encountering such a patient, provide a unique challenge when you add hoist rescue into the mix. Functionally to even wear a gown the SAR flight paramedic and rescue swimmer would have to don the gown under their harness which provides challenges and could easily result in the gown becoming torn or otherwise compromised. Because of these challenges, we typically consider it a higher risk to the crews to try and wear the gowns while hoisting, so we forgo that with the plan that the crews will don their gowns once hoisted down to their work environment, no longer under the helicopter and prior to making patient contact.
Once in contact with the patient all standards of care and medical protocols would be followed. This would include providing PPE items to the patient themselves as per standard isolation protocols. These can include an N-95 respirator as well as gowns, gloves and double sheets (above and below) to help isolate the patient and provide as much barrier as possible between them and the entire crew.
When it comes to packaging the patient for the actual hoist, we prefer to use an extrication device that offers the ability to provide further layer of protection and isolation between the patient and rescuers during HHO. The P1AR PEP bag can assist in this matter as it is encapsulated by its design. The PEP bag was designed with several modular face shield options. The most common method in normal hoisting conditions is to have the patient’s face exposed; however, with the modular face shields you can elect to cover the patient’s face with the clear plastic face shield. This in conjunction with the aforementioned isolation protocols can help increase the barrier between the patient and the crew.
Since the patient is encapsulated inside the PEP bag, the chance of rotor-wash disrupting their gown or double medical sheets is highly improbable and because of the design of the PEP bag it is also possible to have the patient on medical oxygen while packaged inside the PEP bag if deemed necessary based on medical protocol. Once the SAR flight paramedic and rescue swimmer have the patient fully packaged and prepared for hoist extraction via the PEP bag, they would then remove their gowns as previously discussed. Typically, in cases for droplet precautions, we would not encourage a double up extraction. Our extraction sequence for these types of patients may involve a single extraction of the SAR flight paramedic, followed by a tagline assisted single PEP bag extraction, and then completed by an extraction of the rescue swimmer. Once the SAR flight paramedic and rescue swimmer are recovered in the aircraft and before opening the PEP Bag to access the patient, all three medical crew members don medical gowns, while also ensuring that their medical gloves, eye protection, and of course N-95 respirators are still well intact.
Consideration always needs to be given to ensure that crews are not operating beyond their training, safety capability, and not performing outside of their approved medical protocols. Every agency has their own requirements and this approach is not limited to other procedures and considerations we currently employ and further recommend; however it is a baseline in response in response to recent requests for our opinion on where to start. Always follow your medical protocols and training and seek guidance from your medical oversight first. Also maintain awareness of any guidance that is being published by the CDC as that may help as well. Keep in mind that in some states if a crew is exposed to COVID-19 without the CDC recommended PPE, that crew is removed from duty for 14 days and quarantined. Losing an entire crew to quarantine could be debilitating to some agencies, so as always, the safety of the crew should always be the paramount priority.
Source: Priority 1 Air Rescue (P1AR)