First published by Grant Rayner on 22 Jun 2020
14 min read
Remote expeditions present a complex risk management problem.
If an incident happens, you’re a long way from good help. It could take days to reach a point where you can meet a vehicle and possibly even more days before you can get to an appropriate medical facility.
If you do have an incident, how do you get the casualty out safely? What are the types of things you need to consider during your planning?
Expeditions to remote places are defined by a team’s apparent willingness to accept risk. Expedition leaders and team members have all made a conscious decision to push beyond existing safety nets in their desire to accomplish an objective. This wilful acceptance of risk is how expeditions achieve great things. At the same time, remote expeditions also demand great things in terms of planning and risk management.
There are, of course, risks that simply can’t be fully mitigated. These risks must be accepted for the expedition to continue. Nonetheless, building a safety net is important in case someone on your team is either too seriously injured to move (preventing the team from continuing) or could die if not given proper medical treatment within an appropriate timeframe. Field medics can only do so much without access to specialised equipment and medication.
After giving you a little background and context details, I’ll explain how to effectively plan and execute the evacuation of a casualty from an expedition in a remote location. I’ll also give you a quick breakdown of the different evacuation approaches, and highlight the challenges involved with each approach.
I’m a specialist in planning and executing small-scale, low-profile evacuations. I provide this support in very specific situations. Here’s an example that relates to the focus of this article: after the Nepal earthquake in 2015, I helped to evacuate dozens of trekkers by vehicle and helicopter from remote parts of the country. This evacuation included several locations that had been severely impacted by the earthquake and had been cut off from Kathmandu.
Obviously (and thankfully) such an evacuation is not something that needs to be done every day. However, I also support organisations operating in remote and higher-risk locations by helping them develop detailed and workable evacuation plans.
I’ve mostly done this for large organisations, from the perspective of armed conflict, civil unrest, terrorism and natural disasters. More recently, I’ve been working with expedition teams operating in remote and higher-risk parts of the world. This work has pushed me to look for different solutions to more complex problems.
For the purposes of this article, I’ll define remote as follows:
On paper, such locations may not seem all that remote, but if you’re a small team with a casualty, with no immediate access to vehicles or helicopters, you’re in for a very challenging time.
Being outside the reach of helicopters is a major factor — you can’t simply sit tight where you are and call for help. You must instead move your casualty to a trailhead, get them into a vehicle, and drive them to either a hospital or an airfield.
This article will focus only on injuries to team members, not fatalities. If someone on your expedition team dies, you will still need to evacuate the body, but there are different factors and considerations involved. Obviously, you wouldn’t be dealing with the same time imperatives as with a casualty who requires urgent medical care. In this article, I’ll focus on scenarios where you need to evacuate a team member to save their life.
With those details out of the way, let’s dive into how to plan and execute the evacuation of a casualty from expeditions in remote areas.
When first starting to plan an expedition, you should already be starting to think about how you will respond to different types of emergencies along the way. Specifically, you should be considering how you would evacuate one or more injured team members, including where you would evacuate them to. While working through the planning processes, you should be thinking about a number of factors. I’ll break these down below.
One key consideration is how far you’re willing to move from the trailhead or a trafficable road. This consideration effectively comes down to how far you want to have to carry a teammate (Murphy’s Law will ensure that the heaviest among you is the one who gets injured). The distance will ultimately depend on the number of people on your team and the type of terrain your team will be moving over. There’s a vast difference in how far someone can travel in an hour across a stony desert versus through a mangrove swamp.
Another consideration is whether roads actually lead somewhere. There are plenty of roads in remote locations that just go to even more remote locations. At the end of the road, you either want a decent medical facility or an airfield — ideally both.
The size of your expedition team significantly affects your ability to conduct a successful evacuation. It takes a minimum of four people to carry a stretcher. Even with four, it would be extremely arduous because there is no opportunity to rest.
If you decide to embark with a small team, you’ll need to focus on risk mitigation to reduce the probability that an evacuation will be required. Such mitigation will include being significantly more conservative regarding the type of terrain you move on so that you can prevent minor injuries that could result in a team member not being able to walk. You’ll also probably want to avoid travelling at night due to the higher risk of trips and falls.
The availability of helicopters was ruled out above, but that doesn’t mean you’ll be outside the range of light aircraft. Light aircraft are more widely available than helicopters and can operate at greater ranges and higher altitudes. In remote areas, light aircraft are often the only way to move people and supplies. There are therefore often airfields around, but they may be few and far between. Plus, they may not necessarily be marked on maps.
During your planning, identify the locations of airfields. Broaden the scope of your search to include private airfields and disused airfields. Some airfields may have aircraft (and hopefully a pilot) physically at the airfield, perhaps with a small fuel supply. Other airfields may just be long stretches of grass or dirt. If you can, speak to local pilots to find out how often airfields are used.
When planning your expedition route, consider how many hours of driving (or days of walking) you are from these airfields. The further away you are, the more difficult your evacuation will be.
You will also need to identify aviation providers willing to fly into these airfields. Check what aircraft they have available, and gather additional information on the aircraft configurations and characteristics. If you’re operating at higher altitudes (over 3,000 metres), a key concern will be whether the aircraft is pressurised. Many won’t be. If that’s the case, you’ll need to make a note to ensure that the pilot packs medical oxygen. If you don’t ask for it, they may not bring it, so be sure to check in advance.
Once you’ve identified airfields, start looking for medical facilities. Identify every facility in your expedition area that has a medical capability. Such facilities could range from a small clinic operated by a local nurse in a village of 30 people to a world-class hospital. There may even be military bases or mining camps with their own medical clinics. If there are no medical facilities in your immediate area, you’ll need to look further afield to larger towns or cities.
Try to get as much detail as possible regarding the capabilities of each medical facility. The key things to determine are the capability of the medical staff, the equipment they have on hand and the type of services they can provide.
As you go through your planning, you may identify a “medical facility escalation” process, whereby you bring a casualty initially to a nearby medical clinic for initial evaluation and life-saving treatment, before evacuating them to more capable facility.
Reliable communications are an essential component in executing an evacuation. An expedition team should carry at least two communications devices. If you’re operating in a very remote area without cellular coverage, then you should carry satellite phones and satellite communicators. Of course, you need to communicate with someone. That’s where your Field Support Team comes in.
Aside from the team members actually participating in the expedition, it’s a good practice to establish an Expedition Field Support Team. The Support Team can have a number of different roles:
The Support Team could theoretically be located anywhere. However, there are advantages in positioning the team in a hub location within the expedition area. Ideally, this location would have an airfield, a hospital or clinic, and vehicles available to support the evacuation (vehicles may be positioned in other parts of the expedition area as well). The location must also be safe and secure — there shouldn’t be a risk that the Support Team may suddenly have to pack up and leave.
The Support Team should also always include local people who can speak the language and have a good local contact network. Without good local support, it will be very difficult to coordinate an evacuation.
Once out on an expedition, you’ll be singularly focused on achieving your objectives. While hopefully all goes as planned, there’s always the possibility of incidents occurring along the way. If someone on your team gets seriously injured and cannot continue, you’ll need to activate the evacuation plan. The details in this section focus on getting the casualty to the trailhead. I’ll provide additional details related to evacuation by vehicle and air in the next section.
That said, here’s how you would handle the initial stages of an evacuation, in five steps.
Your first step is to send an evacuation request to your Support Team.
As a guide, the evacuation request should include the following:
Once the Support Team receives the request, they should start the process of coordinating vehicles, aircraft and any other local support required.
Should any parts of the evacuation require using vehicles, the Support Team should immediately contact their local transport provider, who will then prepare vehicles to go to the proposed pickup site. After coordinating with the vehicle provider, the Support Team should get back to the expedition team with an estimated time of arrival (i.e., when the vehicles will reach the pickup point).
As a rule, the Support Team should always dispatch a minimum of two vehicles for an evacuation. Doing so provides some redundancy in case of a breakdown or other contingencies. The Support Team should also be as selective as possible regarding what type of vehicles are used. If the casualty is on a stretcher, the vehicle will need to be able to accommodate a stretcher.
If additional medical supplies are required, these should be packed into the vehicle. If the remainder of the expedition team intends to stay in the field, they may need to replace the medical supplies used to treat the casualty. Vehicles should also carry any other items that were due for resupply, as well as additional water, food and stove fuel (might as well take advantage of the opportunity). Throw some blankets in as well. I’ll explain why shortly.
In many remote locations, it’s possible that the team will have no way to communicate with the driver of the vehicle. There may be no cellular coverage, and the driver may not speak the same language as the expedition team. Providing the driver with GPS coordinates may not work if they don’t have access to a GPS or if they don’t know how to work with GPS coordinates. All of these factors will make a linkup difficult. The best way to ensure a good linkup is to select a prominent landmark that both the driver and the team know of and can easily identify (e.g., a river crossing or a fork in the road).
If you have sufficient devices, it’s useful, no matter the situation, to include a GPS device in the vehicle. If you’re using a local team and they don’t have the necessary skills or experience to use a device, just turn it on, put it in tracking mode and leave it on the top of the dashboard where it has good line of sight with the sky. Having the device there will allow the Support Team to track the vehicle and provide the expedition team with updates about the vehicle’s likely time of arrival. The Support Team can also call the driver to inform them when they’re approaching the pickup point or inform the driver if they go off route for any reason.
If the Support Team is large (> 4 people) and locally positioned, it may be useful for one person from the team to accompany the evacuation vehicles. Having the person there will help to prevent any delays in the driver getting to the right spot and will provide a friendly face to the expedition team. The Support Team member may be able to take over the role of medical escort, ensuring the remainder of the expedition team can stay behind to continue working toward the team’s objective.
Remember that vehicle evacuations have a range of limitations. In some locations, vehicles may not be able to travel by night, so there may be significant delays. If there’s been an earthquake, roads may be blocked by landslides or fallen trees. In higher-risk locations, local militias may also block some roads, which would be a significant cause for concern.
Rough roads also present the risk of exacerbating the casualty’s injuries.
After receiving the evacuation request and dispatching vehicles, the Support Team should contact the casualty’s next of kin — from my experience, the sooner the better. If you delay, you’ll be asked ‘when did this happen?’ followed immediately by ‘why didn’t you call me sooner?’ On balance, it’s better to let the next of kin know as early as possible in the process and update them as the evacuation progresses. Be open and honest about the situation, but don’t engage in hypothetical ‘what-ifs’.
Plan the call to the casualty’s next of kin in advance. Write out your talking points, and rehearse the call before picking up a phone. Doing so will ensure you sound professional and coherent on the call.
At a minimum, in your first call you should include the following information:
If there are real challenges with the evacuation, let the next of kin know ASAP. This transparency will set expectations and give them time to mentally and emotionally process the situation. Unless the casualty is dying, it’s best not to allow communication between them and their next of kin because this can delay the evacuation process and use up battery life.
Your immediate priority is to get the casualty to safety.
Getting the casualty to a trailhead or road is the most difficult part of an evacuation. Having carried stretchers through jungles, mangrove swamps, and up and down hills of all types, I can assure you that it can be absolutely epic.
The ease (or not) of the process will depend on the casualty, the terrain, the weather and the team.
Weather and environment
If your casualty is not mobile, you’ll need to make a stretcher. You can either use a properly designed roll-up stretcher or improvise one out of your equipment (using ground sheets or tarps, for example). If you’re using a roll-up stretcher, cut saplings to make poles. If you’re in an area without trees, you may need to carry the stretcher by using handles on the side, which will require at least 4 people. Walking poles can potentially be used, but from experience, these don’t work very well. You also risk dropping the casualty. (If you think walking poles will work, I recommend that you try this at home first before leaving for your expedition.) I generally find stretchers with wrist support loops work better than stretchers with handles.
Make sure you place padding between the bottom of the stretcher and the casualty. Padding will help to prevent further injuries if (or when) one of the team members drops their corner of the stretcher.
Carrying stretchers in the field is hard, particularly when you only have a small team. There may be options available to make the move to the trailhead slightly easier. Here are a few such options:
Pack animals are a great option if they are available, but you’ll need to ensure the casualty’s injury won’t be made worse by riding on the animal. There are plenty of injuries that would prevent riding an animal — leg injuries, for instance. You’ll also need to carefully monitor the casualty to ensure they don’t lose consciousness and fall off, which could result in an even more serious injury.
When you get to the trailhead, if the evacuation vehicle isn’t there waiting, set up a shelter, keep the patient warm and dry, and maintain medical care. If you’re in a potentially hostile environment, stay a few hundred metres from the road in a concealed position until the evacuation vehicle arrives. Go through the casualty’s gear, and remove any team equipment. Such equipment could include a stove, fuel, team food or tent components (you will probably have split parts of the tent between team members to distribute the weight).
Pull out the casualty’s passport and any other permits, and place these in a waterproof bag inside their shirt pocket. This step will ensure the key documents stay with the casualty even if their pack or gear is taken away.
Remember to distribute some team cash to the person accompanying the casualty. Cash may be needed to pay for transport or medical care. Don’t put the cash with the casualty’s passport and papers, though; if they are unconscious and the cash is found, it may just be stolen.
There are special considerations in each method of evacuation. Below is a quick breakdown of additional aspects to consider for vehicle and aircraft evacuations.
Once the vehicle arrives, make sure it’s the right vehicle. In most remote areas, confirming this will be easy because the vehicle will probably be the only one around, but check nonetheless.
Don’t be in a rush to load the casualty. Take a few moments to set the vehicle up first; then load the casualty in, and ensure they’re secure. Don’t rush this part, particularly if the casualty is in for a long drive.
If the casualty is stretcher-bound, then you’ll need to be particularly careful to reduce jarring and vibrations. Remember the blankets I recommended packing in the vehicles? You’ll now see their purpose. You want to layer them below the casualty to provide a buffer against jarring and vibrations. Be careful about using inflatable mattresses because these can actually bounce the casualty off the mattress. Closed-cell foam mattresses are perfect as a base, followed by blankets. If needed, use the casualty’s sleeping bag to keep them warm.
Before you set off in the vehicle/s, consider the condition of the road. If the road is rough, as many are, it could exacerbate the trauma and could cause the casualty to feel excessive pain. You will need to give clear instructions to the driver to drive as quickly as conditions allow, without causing too much discomfort for the casualty. If it’s clear after setting off that vehicle movement is only going to make things worse, you’ll have to make a very difficult decision regarding whether to stop or continue. Make sure someone travels with the casualty in the vehicle as a medical escort. This team member will not only need to continue providing any treatment or care en route to the medical facility but also provide updates to the Support Team and the expedition team throughout the process. They’ll need to have communications gear and cash. As with the casualty, the medical escort should leave any team gear behind with the team.
If you’re lucky enough to be able to bring an aircraft into your expedition area, you have some major advantages. The biggest advantage of having access to an aircraft for evacuation is that you’ll be able to get your casualty to a major centre, and a major hospital, quickly — far quicker than by walking or driving. Bear in mind that having available airfields won’t solve all your problems, however. You’ll still need to get your casualty to the trailhead and then either walk or drive to the nearest airfield. This trek could still take several days.
Remote airfields are normally small and are unlikely to be paved. As a result, they are more vulnerable to weather conditions. For instance, the runway may be unusable during or after rain. It’s also very unlikely that the airfield will be able to be used at night. Weather conditions may preclude operations during certain hours (winds may increase in the afternoon, for example). When factoring in both the earliest time the aircraft can leave its base and the flight time to get to where you are, the limited operational hours may constrain you to a very narrow time window — perhaps only a few hours a day. Make sure you understand this clearly so that you’re able to set expectations for both your team and, more importantly, the casualty. Many locations don’t have air ambulances that can service remote airfields. You may only have access to standard light aircraft designed to carry passengers or cargo. These aircraft aren’t designed for medical evacuations. If the casualty is on a stretcher, make sure you inform the aviation provider in advance, so they can reconfigure the aircraft. At a minimum, they may need to remove some seats. Trust me, you don’t want to be pulling seats out at a remote airfield.
If possible, try to get a doctor to fly in with the aircraft to provide in-flight medical care. If this isn’t possible, you’ll need to provide a medical escort from the expedition team or from the Support Team. If the remainder of your team plans to continue with the expedition, you may not want the medical escort to be your team medic. Deciding who serves as the escort will be a judgment call based on the criticality of the casualty.
It’s unlikely that your full team and all of your equipment will be able to get on the same aircraft, particularly if the aircraft is small and the casualty is on a stretcher. Ensure that your plans cater for this possibility.
When you reach the airfield, find a location to the side of the airfield on the upwind end. The aircraft will land into the wind. While you wait for the aircraft, erect a small shelter to protect the casualty from the elements and continue treatment. Be prepared for a long wait.
Once the casualty reaches their destination, the medical escort can update the team and the next of kin regarding which hospital the casualty has been taken to and how they are being managed.
Through the overview above, you’ve learned the basics on how to plan and conduct an evacuation if you’re on an expedition in a remote area. This article is obviously not exhaustive — there are a lot of other aspects to consider. But hopefully I’ve covered most of the main points.
The bottom line is this: it’s imperative that you consider evacuations at the start of your expedition planning. Don’t plan everything, and then consider evacuations as an afterthought. You need to bake evacuation planning in so that, if and when you need to get an injured team member out, you can do so effectively and efficiently.
Sure, it’ll be hard. But at least it’s possible.
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