Technical Rescue Interface: Off-Road Vehicle and Helicopter WEMS Response

Brian M. Scheele

INTRODUCTION

Wilderness emergency medical services (WEMS) providers do not have a choice where accidents and disasters occur. When their traditional fleet of ground vehicles can’t reach a patient, the needed supplies are too difficult to transport by pack, or the distance by foot is too far in a time-sensitive situation, they may be required to employ nontraditional transport options. In this case, “transport” can refer to transport of gear or providers to a patient or transport of a patient from a scene. All-terrain vehicles (ATVs), utility task vehicles (UTVs), all-terrain ambulances, WEMS response vehicles, and helicopters are among those nontraditional transport options. ATVs and UTVs are capable of traveling over terrain impassable by traditional ground emergency medical services (EMS) vehicles, carrying stretchers and additional gear, and can be modified to enable room to provide care with patient transport in the wilderness setting. All-terrain ambulances and WEMS response vehicles provide a rapid means of bringing lifesaving care and a provider to a patient that may outperform the response of traditional ambulance response in a time-sensitive environment. Helicopter use in WEMS is an unmatched means of covering large areas quickly, grossly increasing direct vision for a scene or search from the sky, and able to perform an active role in search and rescue (SAR) and EMS response. Helicopters in WEMS, when employed appropriately and safely, can enable initial patient stabilization, treatment, and transport to definitive care hours to days faster than any other methods of patient transport (Figure 28.1). The application of off-road vehicles and helicopters in WEMS response enables an added advantage to prompt lifesaving access to our patients, but it must never be forgotten that the emergency is the patient’s and deliberate attention to provider safety be practiced.

FIGURE 28.1. AS350-B3 A-Star helicopter landing at ˜4,300 m (˜14,000 ft) camp in Denali National Park to provide WEMS support for an ongoing SAR mission. Courtesy of Brian M. Scheele.

Scope of Discussion

In this chapter, we will discuss the following:

What defines ATVs versus UTVs and all-terrain trailers
Introduce all-terrain ambulances and WEMS response vehicles
Air medical and helicopter-based WEMS operations in comparison with traditional helicopter air ambulance (HAA) operations, regulations, and risk management
Where EMS agencies are utilizing ATVs, UTVs, and helicopters for rescue
How WEMS providers can operate and understand ATVs and UTVs and work as a team member on a helicopter during WEMS response
How using these vehicles may affect your particular practice and what to know before getting aboard

Definition

Off-Road Vehicles

ALL-TERRAIN VEHICLES

ATVs are small, nimble vehicles, fast and versatile with limited storage capacity, and can be upgraded for patient transport and towing options. They are off-highway motorized vehicles designed to travel on four low-pressure tires, having a seat designed to be straddled by the operator and handlebars for steering control, and intended for use by a single operator and no passenger or by an operator and a passenger with a designated seating position behind the operator. ATVs are often referred to as “quads” due to their four wheels. Typically, ATVs have a combustion engine, although there are models with electric-powered motors. Sport models are built for high performance and recreation with two- or four-stroke engines, manual or automatic clutch, and gear ratios for quick acceleration. In contrast to the sport model, utility ATV models are more often employed for work such as pulling loads or shoveling snow, although often used in recreation as well. Utility ATVs are more rugged and typically have larger tires, stiffer suspension, skid plates, cargo racks, towing hitches, fourstroke engines, lower-end torque, and a driveshaft (Figure 28.2).

FIGURE 28.2. Two Burke County (NC) ATVs being prepared for deployment. Note saddle seats and handlebars distinguishing these as ATVs. Courtesy of Wes Taylor.

UTILITY TASK VEHICLES

UTVs are tough; rugged; able to carry personnel, patients and gear; and capable of crossing terrain and distance too difficult for cars, trucks, or ambulances. They are sometimes referred to as recreational off-highway vehicles or multipurpose off-highway utility vehicle and “side-by-sides.” The common “side-by-side” term comes from the UTV‘s nonstraddle seat, where the operator and a passenger sit side by side in a bench or bucket seat, in comparison with the solo-operator or front-and-back seating arrangement of the ATV. UTVs are off-road, off-highway vehicles with four or more tires, two or four tracks or a combination of four or more tracks and wheels, steered via a steering wheel, a nonstraddle seating, seat belts, and occupant-protective structure with engine displacement up to 1,000 mL. Unlike ATVs, UTVs can have more than four wheels, a steering wheel instead of handlebars, nonstraddle side-by-side seating, greater safety features in place such as seat belts and an occupant-protective structure, and a minimum cargo capacity of 350 lb (Figure 28.3).

FIGURE 28.3. (A) Ocean rescue UTV with Medlite©. Courtesy of Kimball Johnson, Kimtek Corporation, Orleans, Vermont. (B) Argo 8 × 8 Frontier 650 UTV being prepared for deployment. Courtesy of Matt Chandler, ARGO XTV, New Hamburg, Ontario, Canada.

ALL-TERRAIN TRAILER

All-terrain trailers (ATTs) or rescue trailers are two- or four-wheeled off-road trailers designed to safely transport sick or injured persons from off-road locations behind a UTV to an ambulance, helicopter, WEMS response vehicle, or definite care. ATTs offer an option for patient transport when a UTV is not configured for patient transport and the patient must remain in the supine position, or a UTV is configured with medical or rescue gear in the bed. ATTs require two personnel at the minimum, one operating the UTV and trained in the use of ATTs and the other attending to the patient.

LEGALITY OF ATVs AND UTVs

ATVs from the factory rarely meet state law standards for operation on paved roads, although in certain states modifications can be made to meet those standards. In comparison to UTVs, although generally not meant for the highway, these are closer in design to vehicles meant for paved roads, and simpler modifications may meet the standards for travel on paved roads. Laws and agencies that regulate ATVs and UTVs vary greatly state to state. Variations include laws regarding registration and licensing certification, title requirements, plates and decals, age restrictions, helmet and eye protection use, passengers, public versus private property use, paved roads or highway use, state park or forest land use, road crossings, and headlights and taillights, just to name a few. Finding your state’s laws on ATV/UTV use can generally be found by contacting the state Department of Motor Vehicles or locating the United States Consumer Product Safety Commission website on state ATV information.¹

ALL-TERRAIN AMBULANCES

All-terrain ambulances are four wheel drive (4WD) vehicles modified to incorporate the core components of an ambulance while maintaining the dynamic properties of their base vehicular chassis (eg, Ford Ranger, Toyota Land Cruiser). Dynamic properties like 4WD, all-wheel drive, stability protection, and antilock brakes retained from their base vehicle and smaller width allow for travel where traditional ambulances may be limited secondary to size, terrain, or weather. Modifications of a chosen base vehicle may include light-emitting diode (LED) lighting, exterior design, and sirens for recognition. In some models, the chassis may be mounted with custom aluminum box body design similar to traditional ambulances for patient care or the rear of the vehicle ergonomically designed and equipped to care for patients in a more confined space (Figure 28.4).

WEMS RESPONSE VEHICLES

WEMS response vehicles are all-terrain ambulances designed to provide emergency rapid response by enabling the arrival of personnel and equipment to a scene in the unpredictable wilderness environment. WEMS response vehicles are civilian 4WD vehicles that can be modified for EMS work specifically. Lightbars, navigation systems, exterior lighting and spotlights, radios and communication equipment, medical storage compartments, patient care areas, and even solar power can be built to create a customized WEMS response vehicle. EMS response times have been shown to impact mortality,² and challenges faced during certain WEMS response may be addressed by appropriate application of nontraditional WEMS response vehicles.

FIGURE 28.4. WEMS response vehicle. Courtesy of John S. Payne. In Hawkins SC. The Green Machine: development of a high-efficiency, low-pollution EMS response vehicle. J Emerg Med Serv. 2008;33:7.

Traditional ambulances cost, maintenance, and environmental impact in the modern setting of government regulations and environmental legislation may draw financial burden and undesired scrutiny if not addressed by EMS agencies. It has been suggested that fuel efficiency and decreased environmental impact of hybrid suburban utility vehicles, electrically powered vehicles, and the use of biodiesel fuel may decrease cost, maintenance, and the environmental impact of EMS resources when compared with traditional ambulance services in the wilderness or rural environment. This cost and impact, however, must be viewed in contrast to the different operational capacity of energy-efficient response vehicles and traditional EMS vehicles.³

Helicopter WEMS

Helicopters have directly powered main rotors, usually a jet engine with a transmission linkage to the rotor blades, and some helicopters have internal combustion engines as their power supply. Some have single engines and some have dual engines for redundancy. Helicopters are lifted by horizontal rotor blades
rotating around a mast and are referred to as rotary-wing aircraft. Grasping their primary advantage via their blades, helicopters can lift into the air without moving forward, enabling takeoff and landing vertically without the need for runways. Helicopters have either a single horizontal rotor and a tail rotor to compensate for torque or a dual horizontal rotor system with torque compensated by rotor rotation in opposite directions. Landing gear in a helicopter comprises of skis, skids, wheals, or floats (Figures 28.5 and 28.6).

Helicopters can operate over open ocean, at high altitude, and environments at the extremes of temperature on Earth although not without challenges. Aviation is a highly regulated industry secondary to the risks associated with flight. Density altitude has a significance effect on helicopter performance. Helicopters are used throughout the United States across multiple institutions involved in the application of WEMS. Risk management strategies decrease risk in aviation and aid in the decision-making process during planning and operations. There are numerous technical considerations while working with helicopters and specific considerations with mission types that are applicable during WEMS response that we will discuss.

FIGURE 28.5. Rescue helicopter landing in Whistler, British Columbia, at a snow-covered landing zone. Courtesy of Brian M. Scheele.

FIGURE 28.6. CH-47 “Chinook” at the Kautz helo-base within Mount Rainier National Park. Courtesy of Brian M. Scheele.

HELICOPTER USE, REGULATION, AND RISK

Helicopters are a platform for urban and rural HAA operations, SAR, firefighting, and broad-reaching military operations. When the capabilities to provide medical care in the wilderness setting are coupled with those of a helicopter, their versatility becomes unmatched in WEMS response. Helicopters do, however, have limits; although helicopter accidents in civilian SAR are rare, fatalities are significantly higher in civilian SAR helicopter accidents when compared with commercial helicopter accidents in the United States.⁴ In response to an unacceptable amount of civilian helicopter accidents in the United States the Federal Aviation Administration (FAA) in February 2014 issued a final rule that requires helicopter operators, including air ambulances, to have stricter flight rules and procedures, improved communications, training, and additional onboard safety equipment. The FAA examined HAA accidents from 1991 through 2010 and determined 62 accidents that claimed 125 lives could have been mitigated by the new ruling.⁵ Helicopter crews operating in the wilderness environment include qualified pilots, technical crew, medical providers, engineers, and ground crew. Appropriate training, continuing education, up-to-date qualifications, and the practice of risk management are required to make wilderness helicopter operations safe and reliable. Helicopters are an outstanding EMS response, evacuation, and rescue tool, but helicopters and humans have limitations, and consequences for pushing the limits can be quick and fatal.

HELICOPTER OPERATIONS—RISK MANAGEMENT AND THE DECISION TO FLY

Numerous models of calculated risk management are practiced across federal agencies and the aviation industry. Risk management during an operation is a continuous, cyclic, and systematic process. Ongoing communication and situational awareness exercised by all members throughout the duration of an operation are paramount. A risk management model is used to identify and control risks during planning and operational execution of a mission. Unnecessary risks are never acceptable, and necessary risks are potentially acceptable when benefit outweigh calculated risk. Preflight risk analysis is mandatory and must include, at a minimum:

flight considerations, to include obstacles and terrain along the planned route of flight, landing zone conditions, and fuel requirements;
human factors, such as crew fatigue, life events, and other stressors;
weather, including departure, en route, destination, and forecasted;
a procedure for determining whether another HAA operator has refused or rejected a flight request; and
strategies and procedures for mitigating identified risks, including procedures for obtaining and documenting approval to cancel a flight when a risk exceeds a predetermined risk level.⁶

Risk management models are varied and agencies have predetermined models that must be utilized. An example risk management process is given below:

Identify mission/tasks
Identify hazards
Assess risk
Identify options
Evaluate risk versus benefit
Execute decision
Monitor situation WEMS helicopter assets are valuable when:
Conventional EMS response is impractical, intensive, or arduous
Patient status is time critical and expedited management is necessary to preserve life, limb, or eyesight
Patient location is remote with critical injury or illness
Benefits of WEMS helicopter asset outweigh calculated risk (Figure 28.7)

FIGURE 28.7. Risk management must be performed continuously throughout your mission. National Park Service ranger looks over the terrain out the window of a CH-47 “Chinnok” while involved in a search and rescue on the slopes of Mount Rainier. Courtesy of Brian M. Scheele.

PREVALENCE

ATV/UTV Prevalence

Anecdotally, after the observed FDNY EMS use of UTVs and ATVs during their response to the attack of September 11, 2001 in combination with increased funding by the federal government, and the creation of the Department of Homeland Security, ATV and UTV use among EMS agencies has grown nationwide. Although data regarding the prevalence of ATV and UTV use across EMS agencies is not widely available, the number of their units sold in the United States is significant. ATV sales in the United States from 2012 to 2015 were steady at around 230,000 units per year. That contrasts to the 2015 UTV sales of around 400,000 units, of which 55% were intended for commercial use. The greatest number of UTVs is purchased in the southern United States followed by the midwest, west, and finally the northeast. Users in Texas, California, and Ohio purchased the greatest numbers by individual state.⁷

Helicopter WEMS Assets

Helicopter WEMS assets function within commercial organizations such as air ambulance services or local, tribal, state, and federal government in addition to the military. Private, for-profit, and not-for-profit organizations provide HAA operations in the wilderness setting with contractual relationships with hospitals and government agencies across the United States. Fire departments, local city, county, and state law enforcement agencies are also involved in WEMS as part of their HAA programs or SAR services. Federal agencies have developed a National Search and Rescue Plan (NRP) for the United States for coordinating SAR services to meet domestic needs and international commitments.⁸ Helicopter WEMS assets are often fundamental to the operation of SAR and make excellent SAR platforms for insertion or extraction of personnel, visual and electronic search, ground personnel direction, and equipment and personnel transfer.⁹

The U.S. National Search and Rescue Committee (NSARC) is responsible for the NRP and its member agencies include Department of Homeland Security (eg, U.S. Coast Guard, Federal Emergency Management Agency), Department of Transportation (eg, Federal Aviation Administration, Maritime Administration), Department of Defense (eg, U.S. Air Force, U.S. Pacific Command), Department of Commerce (eg, National Oceanic and Atmospheric Administration), Federal Communications Commission, National Aeronautics and Space Administration, and Department of the Interior (eg, National Park Service). The NSARC members all have unique responsibilities with a combined objective to
improve cooperation in providing expeditious and effective SAR services.⁸

Federal military arrangements with civil agencies provide their fullest practicable cooperation when military helicopter assets are requested provided these maintain noninterference with their military duties. The Air Force Rescue Coordination Center (AFRCC) serves as the agency responsible for coordinating on-land federal SAR activities in the continental United States carried out by the Civil Air Patrol primarily, and the Alaska Rescue Coordination Center (AKRCC) coordinates inland Alaskan SAR activities carried out by their Air National Guard Units primarily. Both the AFRCC and the AKRCC coordinate response, and the missions themselves are carried out by available deployable assets. The United States Coast Guard (USCG) is the SAR coordinator for other maritime areas governed by the federal government as well as the State of Hawaii. Upon civilian request for additional helicopter assets, the coordinating center will determine a mission go/no-go on the basis of whether there is a threat to life, limb, eyesight, or undue suffering and arrange assistance with available local, state, regional, and national assets.⁸

TECHNICAL DISCUSSION

ATV/UTV/ATT Technical Discussion

ATV and UTV use is technically similar. For that reason, we will discuss both simultaneously here while pointing out the differences when applicable. ATV and UTV use for wilderness, fire, EMS, law enforcement, and federal agencies require training and certification before official use, and that training is agency dependent. In this section, we will describe the basics of operating ATVs and UTVs, with emphasis on use in the wilderness setting.

Again, agency certification before use of ATV/UTV should be required by all personnel. Additional training and certification is recommended for any personnel towing an ATT behind their ATV/UTV before official use. ATT accidents can occur while loading or offloading patients and during towing over rough terrain. Both ATV/UTV and ATT certification should be checked before deployment on a rescue mission or EMS response. Annual recertification for personnel who respond to wilderness emergencies should demonstrate their off-road ATV/UTV operating skills on an approved course. This recertification should include loading and unloading from a trailer, assembly and coupling of the ATT to the tow vehicle, and safe towing of the trailer with rescuer and patient on board over rough terrain.

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