Medical Helicopters in Wilderness Search and Rescue Operations

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1 Medical Helicopters in Wilderness Search and Rescue Operations Colin K. Grissom, MD, 1, 2 Frank Thomas, MD, 1, 2 and Brett James 2 Abstract Medical helicopters may be asked to assist in wilderness search and rescue (SAR) operations to quickly reach patients in remote areas and provide medical care and transport of sick or injured persons. The number 1 priority for any medical helicopter involved in an SAR operation is safety, which is considered at each decision point. The involvement of a medical helicopter service begins with a request from a local agency for support. Obtaining key information about the SAR operation from the local agency is essential for deciding whether to accept the mission and for making appropriate preparations for the mission. While en route to the SAR location, the medical crew can review the information regarding location and patient status. Once on location, the crew can survey the scene from the air before landing at the command post to brief with SAR personnel regarding the mission. An initial survey of the scene from the air is important for identifying landing zones and evaluating the terrain where the rescue will occur. A face-to-face briefing with SAR personnel is preferable to learn specifically what type of mission is requested. The medical helicopter crew is empowered to decline the mission for safety reasons at any step. The actual rescue may be done by inserting the helicopter at the scene in nontechnical terrain or by having SAR personnel extricate the patient and deliver him or her to the medical helicopter crew at the nearest safe landing zone. Medical care and transport of the patient as indicated by injuries or illness then occurs.finally, a postmission debriefing is essential for identifying problems that occurred during the mission and implementing corrections for improvement. Introduction Typically, medical helicopter services (MHS) are requested to transport the critically ill or injured from referral facilities or highway accident sites to tertiary medical centers. Requests to assist in search and rescue (SAR) operations are much less frequent but occur because medical helicopters can be an important adjunct to SAR operations. They provide several advantages 1,2 : the ability to perform air searches for lost victims; a rapid method of shuttling rescue personnel, equipment, or supplies to the victim; the delivery of early on-site sophisticated medical care; a decrease in the number of rescuers required for ground evacuation and their exposure to hazards associated with hostile environments; and a reduction in patient transport time to a treatment center. Given these benefits, an MHS may be asked to assist in an SAR operation. This article presents guidelines for a service performing a support role in an SAR operation. This article focuses on wilderness SAR operations; thus it is particularly appropriate for MHS located within or near remote back country wilderness areas. Many of the issues discussed, however, are also relevant to MHS involvement in SAR operations in more urban environments, such as after catastrophic accidents or natural disasters. Algorithm for Medical Helicopter Assistance With Wilderness SAR Safety is the primary critical issue for any MHS involved in an SAR operation, and safety will be emphasized throughout all aspects of SAR operations. Specifically, this article describes a seven-stage algorithm approach to wilderness air medical helicopter rescues (Table 1): Requesting medical helicopter support in a wilderness SAR Obtaining key information Conducting a pre-liftoff check 1. Critical Care Division, Department of Internal Medicine, LDS Hospital, Salt Lake City, Utah 2. Life Flight, LDS Hospital and Intermountain Health Care, Salt Lake City, Utah Address for correspondence: Colin K. Grissom, MD, Pulmonary and Critical Care, LDS Hospital, 8th Ave and C Street, Salt Lake City, UT 84143; X/$30.00 Copyright 2006 Air Medical Journal Associates doi: /j.amj / Air Medical Journal 25:1

2 Table 1 Important Questions for Search and Rescue Medical Helicopter Operations 1. Request for Medical Helicopter Support in a Wilderness SAR Does the request meet the criteria for using a helicopter in an SAR operation? Is the request consistent with the air medical service s SAR and safety policies? Is higher administrative approval within the air medical transport service required? (Request Accepted) 2. Obtaining Key Information Who is requesting help and who is at the scene? Is anyone injured? Where is the injured party (GPS coordinates and verbal description)? What agencies are involved? Where is the command post (GPS coordinates and verbal description)? What are the primary and back-up communication contacts (telephone number or radio frequency) for the party needing rescue, SAR team, and the local EMS or law enforcement agency? Is there a need for specialized equipment or personnel? 3. Pre-Liftoff Check Has the pilot provided clearance for flight regarding weather? Has the medical crew checked for all appropriate equipment (medical, specialized SAR and survival)? Is there a need for specialized equipment or personnel? 4. Air Evaluation of the Rescue Site Has the team done an initial evaluation of the scene from the air? Where is the nearest safe landing zone (GPS coordinates, altitude)? What is the terrain? What are the objective dangers for ground travel (water, rockfall, avalanches, ice, steep terrain)? Is there a need for specialized equipment or personnel? Who is on the ground to provide assistance during ground travel? 5. Face-to-Face Briefing with Search and Rescue Personnel What is the air medical transport team asked to do and is it safe? What is the ability of the crew and aircraft? What are their limitations? What are the alternatives to helicopter support for rescue? What is the nature of the injury or illness requiring care? Is there any support at the patient location? How can they be contacted? Is there a need for specialized equipment or personnel? Have the phases of the SAR operation been verbally rehearsed? 6. Performing the Rescue Are the critical points for safety and performing the SAR (TOMAS) being continuously monitored? (Tables 2 and 3) Are all phases of an SAR (LAST) being properly monitored? (Table 4) 7. Postmission Debriefing and Quality Improvement (Informal and Formal) What went well? What went wrong? What are we going to do to correct problems that occurred during the mission? Who should be notified of the problems? Evaluating the rescue site by air Briefing SAR personnel face-to-face Performing the rescue Holding a postmission debriefing and quality improvement Request for Medical Helicopter Support in SAR Utilization Criteria. Most requests for medical helicopter assistance with SAR come through the dispatch operations center, where initial contact information will be obtained by dispatch personnel. Written SAR utilization criteria are important in clarifying the role of medical helicopters in responding to these requests (Table 2). 1 Accepting or declining the SAR mission is the responsibility of the air medical crew or more senior administrative personnel in the service. In addition to the appropriate utilization of medical helicopters in SAR operations listed in Table 2, the mission profile for the medical helicopter must be consistent with SAR safety and the operational policies of the transport service. The initial acceptance of an SAR mission is conditional, because further information is obtained en route, at the scene, or during briefing with SAR ground personnel that confirms January-February

3 Table 2 Criteria for Utilizing a Helicopter for Patient Evacuation in a Wilderness Rescue 1 Helicopter rescue can be done safely. The patient has a life-threatening injury or illness in which time is critical. The patient has a non life-threatening injury or illness, but functional outcome depends on immediate care. Ground evacuation may be more dangerous and place a greater number of people at risk. Ground evacuation would be excessively prolonged. Ground evacuation is not possible. the mission as appropriate or indicates that the mission is inappropriate and other alternatives are pursued. Safety and SAR Policies. Starting with the initial request for helicopter support by SAR personnel and continuing throughout the operation, safety is the number 1 priority for the MHS. Part of a safety first attitude for the air medical crew is to repeatedly assess the safety risks versus the SAR benefits of the mission. For safety, SAR guidelines and policies must specifically address acceptable and prohibited aircraft maneuvers and limitations and the level of involvement of the air medical crew in ground operations. These guidelines and policies vary among MHS depending on aircraft type, location, personnel, training, and available SAR support. Helicopter maneuvers and limitations to consider include hover loads, hoist operations, one-skid landings for loading or unloading, cargo lowers, nighttime SAR operations, and altitude ceilings. Air medical crew operational issues include the level of involvement of crewmembers in a technical rescue situation. A conservative approach is to create a safety policy that excludes certain high-risk activities unless the MHS specifically provides training in those activities. For example, a hover load is an aircraft maneuver that might be specifically excluded for safety reasons during a rescue. A cargo lower might be an approved procedure. Similarly, air medical crewmembers might be excluded from insertion into any situation in which a rope and climbing harness are required to ensure safety, and instead SAR personnel are shuttled by helicopter to the scene for technical rescue. In all cases, written safety and SAR policies are important in defining the role of the MHS in each of these scenarios. Senior Administrative Approval. Even if the request meets the criteria for helicopter utilization, senior administrative approval may be required before the mission can be accepted. Administrative approval may be contingent on what type of SAR operation is appropriate to support. For example, assisting with SAR operations during the initial search phase, before a known patient needs rescue and medical care, is costly and may not be an efficient use of helicopter resources. Each individual MHS needs to decide how to handle such requests. Request Accepted. If the request meets the MHS criteria for helicopter SAR utilization, SAR and safety policies, and clearance by administration, the request can be accepted. At this point the dispatch center collects further key information necessary for initiating the SAR mission. Obtaining Key Information Clear, direct, and unambiguous communication is a key element of safe participation in an SAR operation, and good communication starts with the initial information obtained when the SAR request is first received. Information begins with who is making the request, the person or persons requiring help, ages, known injuries, and the presence of any on-site agencies. Communication is critical during SAR operations and requires knowledge of all cellphone numbers, radio frequencies, and designated call-in times to ensure ongoing communication with the scene. Foremost is an accurate description of the SAR location site. Inclusive are available global positioning system (GPS) coordinates, a verbal description of visible and prominent landmarks, the last known location of the lost party, and the locations of SAR personnel and the incident command center. The exact location of the injured person is not always precisely known. This commonly occurs when a group in a remote area has called by cellphone and requested a rescue for an ill or injured person. The initial call often is received by an emergency medical services (EMS) dispatcher and relayed to the local sheriff s office to mobilize SAR personnel. The sheriff may request that a medical helicopter respond directly to the patient, even if ground personnel are not yet on scene. In these circumstances, the medical helicopter may arrive at the SAR site well before ground rescue personnel. If the location of the injured person given to the local EMS dispatch is imprecise and contact with someone at the scene is not possible, the medical helicopter is forced into a timeconsuming air search for a known patient on the ground. This is why gathering as much information as possible about the location of the patient, radio frequencies or cellphone numbers, and subsequent contact times by cell phone before departing for the SAR site is important. 20 Air Medical Journal 25:1

4 Table 3 Critical Points in Optimizing Search and Rescue Safety Emphasize safety first, above patient care requirements. Maintain the option of declining the mission or aborting the mission at any time. Use direct, clear, and specific communication to verbalize the plan and ask questions. Do not allow air medical crew to perform technical rescue unless properly trained. Have SAR personnel extricate the patient from technical terrain to a safe location for the air medical crew. Pre-Liftoff Check Weather Check. As part of the pre-liftoff preparation, the pilot must initially give clearance for the flight regarding weather. Wilderness SAR operations may take hours to days to complete, so weather forecasts are important to evaluate. Weather patterns and local mountain weather can change and influence the mission. Weather is a critical safety factor throughout the operation. Even if an initial weather clearance is given, weather is continually re-evaluated and the mission aborted if safety is compromised. Specialized Equipment. Special equipment may be required for a wilderness SAR operation. Before liftoff, the air medical crew considers the known information regarding the mission and decides what special equipment to check and load on the helicopter. Additional hand-held radios may be required. Personal and group survival packs are modified for winter versus summer environments. Clothing and footgear are also modified according to season and environment. Additional specialized equipment for a winter environment includes snowshoes, shovels, and avalanche transceivers. Anticipating these special equipment needs is part of the operational plan for wilderness SAR missions. Specialized Personnel. Special personnel also may be required for a wilderness SAR operation. This depends on the crew configurations available and whether outside personnel with particular expertise are added to the crew. For example, paramedics generally have more training pertinent to wilderness SAR operations than flight nurses, although this is not universal. Ensuring that a paramedic is on the air medical crew is a consideration. Also, SAR personnel may be trained for specific types of missions with an MHS and may be added to the air medical crew for specific missions. Whatever the crew configuration, recognition of the limitations of each crewmember is critical to safety. Air Evaluation of the Rescue Site Initial air evaluation of the SAR site is critical to gathering information and performing an ongoing evaluation of the mission. This should occur first, whether the air medical crew arrives at the scene before or after ground rescue personnel. Keep in mind that observing technical terrain from the air can be misleading, and conservative judgment is used in evaluating the possibility of overland travel or in identifying an adequate and safe landing zone. When it is not possible to land next to the patient, a remote landing zone is identified, and the terrain between the remote landing zone and the patient is evaluated. If the terrain is not safe for the air medical crew, then it is the responsibility of a trained SAR crew to retrieve the patient to a secured site. An air medical crew first on scene does not attempt to extricate a patient from an unsafe area just because they arrived before SAR personnel. The better decision is to wait until appropriate ground rescue personnel arrive. Face-to-Face Briefing With SAR Personnel After the air medical crew does an initial evaluation of the scene from the air, face-to face discussions occur between SAR and the air medical crew at the command center. This briefing takes place before initiating any SAR mission and is one of the most important elements in safely completing the mission. During the briefing, safety is emphasized as the number 1 priority, direct communication is stressed, and the rescue operation is discussed relevant to the safest method for extracting the patient. Safety First. Safety always remains the top priority during the mission and takes priority over the medical needs of the ill or injured. The final decision regarding involvement of the medical helicopter during an SAR operation must remain with the pilot and the air medical crew and is independent of the SAR incident command structure. The air medical crew never engages in any activity that they think might be unsafe or they are uncomfortable in performing. Critically evaluating the safety of each mission, exercising conservative judgment, maintaining the ability to decline the mission at any time, and suggesting safer alternatives to the SAR incident command are keys to optimizing mission safety. This is especially important in the United States, where requests for MHS in wilderness situations may come from local county SAR organizations that may differ dramatically in quality and experience. With the first priority of crew safety, the option of refusing the request may be exercised at any point during the mission. Critical points in optimizing SAR safety are repeatedly evaluated during the mission (Table 3). This occurs as the air medical crew approach the location, evaluate the scene from the air, land at a command post, and interact with SAR personnel, as well as during the rescue operation. An important consideration for the air medical crew is whether other non-air transport options may be better SAR alterna- January-February

5 Table 4 Critical Points in Planning and Performing the Search and Rescue Mission TOMAS Terrain (exposure, cliffs, water, forest, vegetation, hiking trail, snow) Obstacles (trees, loose rock, debris, wires, daylight, rotor wash, blade clearance) Method (type of insertion and location, landing near or remote from patient, hover load) Alternatives (wait for SAR, ferry SAR personnel, relocate patient, no go/abort mission) Safety (first, last, and always) tives. Sometimes SAR agencies will call for helicopter support because it is an obvious easy alternative to a ground rescue and evacuation. Sometimes the request is justified because it will save many hours required for a ground rescue and place fewer people at risk of injury. Sometimes helicopter support is justified because of the time-critical nature of an injury or illness. Other times, however, helicopter support may be the easiest alternative requested, which does not mean it is the safest or best choice. The air medical crew is the best judge to critically evaluate whether helicopter support for the mission is justified. SAR personnel do not always understand every issue involved in a helicopter rescue in a wilderness situation. Critically evaluating the mission, asking questions, and suggesting alternative methods of rescue are the responsibility of the air medical crew. Communication. Communication is a key element of safe participation in SAR and is critical when trying to accomplish a common goal with another party. One must understand how the other agencies communicate and the decision-making hierarchy. Important information is required to plan the mission. This information includes the identification and location of the injured party and the previous events surrounding the accident or search. Knowing the other agencies involved in the SAR operation, the command structure (ie, who is in charge), the relevant radio frequencies for communication, and the coordinated plan are important. As much detailed information as possible is gathered to help the MHS evaluate the requested mission. Some of this information may have been obtained previously when the initial request for assistance was received by the air medical transport dispatch, but more detailed information may be available at the incident command center. Patient Location and Terrain Considerations. If the helicopter cannot land at the patient location, assessing the terrain between the patient and the nearest landing zone is critical to planning the rescue. Terrain issues may include steep slopes, cliffs, forest, vegetation, water, or snow with dangers of avalanche. Decisions regarding overland travel require conservative judgment by the medical crew at the scene. For example, it may be reasonable to use snowshoes to travel on flat or low angled terrain through deep snow to reach a patient but unreasonable to travel with snowshoes in deep snow on steep slopes greater than 30 degrees that may be avalanche prone. Likewise, it would be reasonable to land a helicopter at the scene of an avalanche accident if a ground avalanche rescue team is present at the location and has declared the area safe and the crewmembers are wearing avalanche rescue transceivers. In a summer mountainous environment, it may be reasonable to walk across steep nontechnical terrain but unacceptable to secure air medical crewmember personnel using a rope system put together by unknown SAR personnel. It is unsafe and unacceptable for an air medical crewmember to descend or climb on technical terrain on their own to reach a patient (terrain in which a rope system is required for safety). In general, if special equipment is required to safely negotiate terrain, the air medical crew should not travel across that terrain unless adequately trained or skilled or accompanied by known and skilled SAR personnel. All critical points in planning and performing the search and rescue must be evaluated before initiating the air SAR (Table 4). Performing the Rescue Phases of an SAR Operation: (LAST Locate, Access, Stabilize, Transport). SAR operations may generally be defined as organized efforts to search for and rescue persons in a remote wilderness area or in less remote areas during or after natural disasters. Every SAR operation goes through four consecutive phases known as LAST: locate, access, stabilize, and transport 3 (Table 5). Understanding the distinctions between the four phases of an SAR operation helps the air medical crew identify what support role they may provide. Locate is considered the search element, and access, stabilize, and transport are the rescue elements. The access phase starts when the patient s location is known but rescue personnel need to reach the patient. The stabilize phase starts when the air medical crew is at the patient site and involves stabilizing the environment first, then the patient, medically and emotionally, before the transport starts. The last phase, transport, selects and then proceeds with the best mode of transportation that balances the various risks and benefits. Each phase may vary in time and complexity, depending on the circumstances and environment. An MHS may be requested to participate in any or all phases of an SAR operation. 22 Air Medical Journal 25:1

6 Table 5 Search and Rescue Operational Phases 3 LAST Locate (search portion, lost person not yet found, no definite patient requiring medical care) Access (process of reaching the known patient, may require technical rescue) Stabilize (ensure that scene is stable and safe, then approach patient and provide medical care) Transport (extraction of the patient from the scene and air medical transport to a medical facility) The Locate Phase. During this phase there is no definite injured or ill patient who requires medical care. The level or extent of medical care required will not be known until the search is completed and the person found and rescued. If assistance is requested during the locate phase of an SAR operation, the air medical transport crew will serve only an air search or support function until the lost person is located. Helicopter operations are costly and therefore must be judiciously used. Air searches also may be conducted by county, state, federal, or private nonmedical helicopters or fixed-wing aircraft. In some areas of the United States, however, where air support from government agencies is not readily available, private MHS may be requested to assist in search operations. How to handle such requests is the prerogative of each service. The Access Phase. In this phase, SAR requests to the air medical transport service will be directed at using the helicopter to reach the patient and to shuttle rescue personnel to the site. The access phase may be as simple as landing next to the patient in a remote back country area, or it may be as complicated as extricating the patient from technical terrain. Distinguishing between these two types of situations is important. In the former, the helicopter may land safely next to the patient with minimal risk to the flight team. In the latter, in which the patient is in technical terrain, a ground rescue may be required to bring the patient to an area where the helicopter may safely land. If the terrain is not safe for the air medical crew, it is the responsibility of a trained SAR crew to retrieve the patient and bring him or her to the air medical crew. The Stabilize Phase. This phase begins when the air medical crew has access to the patient. Safety is still the number 1 priority before medical care, because the patient is still in a wilderness scene situation, and environmental dangers may need to be addressed. The stabilize phase has three components: physical, medical, and emotional. The first priority is physical stabilization of the environment by identifying and stabilizing any dangers. In some situations, the best way to stabilize an environmental danger in a hostile environment is to remove the patient from the area as quickly as possible. The next priority is to provide medical care and stabilize any injuries. The last component is to emotionally stabilize the victim. This reminds the air medical crew to provide calm reassurance to a conscious victim. This is not only good medical care; it also can improve safety for the crew during the transport by relieving the patient s fear and anxiety, which reduces the chance of unpredictable behavior in the aircraft. The Transport Phase. In this final phase, the patient is removed from the environment and transported to a medical facility. The patient may be transported by the medical helicopter, but in a wilderness SAR operation, this is not automatic. The medical helicopter may have been used to extract a non critically ill patient from a remote location where ground evacuation was not possible or was deemed to be too risky or time consuming. When the helicopter brings the patient to the command post, the medical injuries are re-evaluated, and if ground transport to a local medical facility is appropriate, that may be a safer and less costly option. This possibility reflects the varied utilization of medical helicopters in wilderness SAR operations compared with the usual scene response in which the primary purpose of the medical helicopter is to transport the ill or injured patient. Postmission Debriefing and Quality Improvement Any air medical transport service that chooses to be involved in SAR operations will optimize future activities by debriefing each mission, using a formal structure. Immediately after the mission, an informal debriefing occurs among the air medical crew to discuss aviation and medical issues. At a later formal debriefing with all staff, the mission is described in detail and critiqued so that all crewmembers, not just those involved in that particular mission, may learn. Throughout the debriefing, crew members and available SAR personnel discuss decisions and actions. These decisions and actions are then assessed in terms of how well safety first, medical care second, and then cost were prioritized. January-February

7 Pilot Training Considerations Pilot training for mountain and canyon flying is an essential component for safety of an MHS that supports SAR operations in wilderness terrain. Extensive helicopter experience (greater than 3000 hours) and previous mountain flying experience are often new pilot hiring requirements. In addition, program training in mountain and canyon flying should be an ongoing component of aviation operations. It is also essential to include the pilots in debriefing missions that supported an SAR operation. This includes informal debriefings immediately after a mission and formal flight reviews from which other members of the service can learn from the experience and improve operational safety for future missions. Both medical and aviation operational aspects of a mission are discussed at informal and formal debriefings. Crew resource management is a critical component in SAR operations, and during debriefing emphasis is placed on whether repeated discussion of objectives and concerns among the crew occurred during the mission. Open communication is key, and debriefing that involves both aviation and medical personnel builds relationships that enhance communication and safety during future missions. Aviation and SAR operational issues are one component of the debriefing, and medical care is the other. Separate recording documents may be used for each of these components. Some issues discussed are strictly aviation or SAR operations issues, some are purely medical issues, and some relate to both. Some issues are discussed and educational points made during the formal debriefing and no further action is required. Some issues, however, may require follow-up contact with an SAR group for discussion of operational aspects, and someone is delegated to perform that follow-up. Some issues may require further discussion and investigation. These would be referred to appropriate aviation, rescue, or medical personnel. Special Helicopter Considerations: Hoist or Short Haul Operations Helicopter hoist or short haul are external human load operations in which a person is carried outside of the helicopter suspended by a rope or cable for purposes of either insertion or extraction. A hoist is a mechanical system in which a steel cable with a hook is lowered or raised with the person attached in either a harness, a basket, or a litter. A short haul is a fixed length of line attached to the helicopter with a hook where the person is attached. Either system can be used to insert a rescuer at the site of a victim or accident, extricate a victim from a site, or extricate a victim and a rescuer together. A helicopter with hoist or short haul capability adds another dimension to the wilderness SAR operation. These systems allow the helicopter to extricate a patient from terrain where no nearby landing zone is available and thus have the potential to efficiently rescue a victim by air rather than by a lengthy, complex, and possibly dangerous ground evacuation. The risk-versus-benefit profile must be evaluated when these rescue capabilities are available. For example, the risk of a hoist or short haul operation must be balanced against the risk of a ground rescue. Additionally, a patient with a time-critical illness may justify a quicker hoist or short haul rescue, even if the ground rescue is safe. Medical Crewmember Training Considerations MHS that routinely assist SAR agencies should establish specific training directed at flight crew engaged in these operations. Such training may include: Hazardous environmental factors that are often encountered during ground and air rescues Actions to take in the event air evacuation is not possible and a medical flight crewmember is forced to remain at the patient s side until additional help arrives The key elements of a survival pack for summer and winter conditions and why a survival pack is essential for a crewmember who may be inserted into a wilderness area to provide patient care Specialized winter training, such as use of avalanche transceivers and the identification and avoidance of avalanche terrain Proper methods for landing zone selection in wilderness terrain (mountains or canyons) Methods to safely transport SAR personnel or avalanche dogs in the medical helicopter Treatment of wilderness-related medical conditions (eg, high altitude illness, lightning strikes, snakebites, hypothermia, or heat-related illness) The benefits of helicopter versus ground rescue based on hazardous environmental exposure time, the severity of injury or illness, and the need for rapid transport to a tertiary care center Often injuries that might not be considered indications for air medical transport in an urban setting may benefit from air medical transport in a wilderness setting because a lengthy ground evacuation may increase the potential for complications. Flight crew personnel often attain additional benefits from outside SAR expert training. Experts can educate the air medical crew about the subtleties of methods, the role of trained 24 Air Medical Journal 25:1

8 ground personnel, and more importantly, the limitations of the air medical crew in performing ground rescues. In general, most medical crewmembers are not trained to perform technical ground rescue. Trained ground personnel, not the medical helicopter crew, should perform technical ground rescues. The intent of training in SAR for a helicopter medical crew is to help them understand their role and, most importantly, their limitations. Conclusion As with all medical helicopter operations, safety remains the number 1 priority for any helicopter service engaged in wilderness SAR. By using appropriate screening questions, established acceptance criteria, planning and performance guidelines, and effective crew resource management during a mission, medical helicopters can be a valued resource in this operation. References 1. Forgey, WW, ed. Wilderness Medical Society practice guidelines for wilderness emergency care. 2nd ed. Guilford, CT: The Globe Pequot Press; p Tomazin I, Kovacs T. Medical considerations in the use of helicopters in mountain rescue. ICAR-MEDCOM guidelines number 18. High Altitude Med Biol 2003;4: Cooper DC, LaValla PH, Stoffel RC. Search and rescue. In: Auerbach PS, editor. Wilderness medicine. 4th ed. St. Louis, MO: Mosby; p January-February

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