Emergencies

What To Do In An Emergency

So what do you do when there’s an emergency? Hey, it happens. The best thing you can do is be prepared.

River Emergencies

The following pointers about river related emergencies include a lot of great information found in the four page paper “Responding to Critical Situations, An Incomplete Guide to River Emergencies” (Boatmans Quarterly Review, Grand Canyon River Guides, Vol. 20 #3 2007) by Ken Phillips. A National Park Service (NPS) Ranger and Paramedic, Mr. Phillips is the Chief of Emergency Services at Grand Canyon National Park. The article he wrote for the River Guides journal was focused on professional river guides, and didn’t acknowledge the do-it-yourself community of river runners, or the commercial passengers who travel with river guides. We have tried to present here a more holistic approach to river emergencies.

The NPS photo to the right was taken in February 2010 during a helicopter rescue of stranded boaters from the Crystal Rock garden.

Evacuation Insurance

The National Park Service at Grand Canyon National Park has a rescue helicopter. Your taxpayer dollars support this operation. If you need to be evacuated from the Canyon by NPS helicopter, that flight is free. If the helicopter takes you to the South Rim helibase, or on to a trauma center, that flight is free. Once the ship lands, the billing starts and you will be responsible for ground ambulance costs.

Most United States health insurance policies cover ground ambulance transport. You can purchase short term medical insurance if you need to.

The NPS helicopter does not fly at night. If the NPS helicopter is busy or there is need for immediate evacuation at night, the NPS may call in another Helicopter. Arizona Department of Public Safety (AZDPS) is a taxpayer supported rescue helicopter. Like the NPS helicopter, you will not be charged for an AZDPS helicopter flight. There are private air ambulances that certainly do charge. Depending on the severity of the person being evacuated, the NPS helicopter will either take a patient to the South Rim Helibase or direct to the nearest major trauma center.

From the South Rim Helibase, a ground ambulance to the South Rim Clinic is used. If the NPS Helicopter transfers the patient to a private medical helicopter, the private helicopter is going to charge your insurance. If you are transported to Flagstaff Medical Center from the South Rim Clinic, that takes two ambulances. You will be charged for those ground based ambulance rides.

Depending on your private health insurance, the trip from the rim by rubber tired ambulance may be covered. You are encouraged to read the fine print in your policy. In western Grand Canyon and for emergency night rescues, the AZDPS helicopter out of Kingman is also used. Again, there is no charge for emergency evacuation with the AZDPS helicopter.

Preplanning and Teamwork

One of the things you’d like to do before an emergency occurs is to have a plan. Phillips notes “A proven approach to handling any emergency effectively is to have mentally pre-planned it beforehand.”

This may seem difficult, like practicing wrecking your car. If you think of it in the terms of scouting a rapid, pre-planning what you will do in an emergency is a good idea. Who is your trip's “chief medical officer”? Who is the “technical rescue” person with the ropes and knowledge of how to use them? With a pre-plan, you can kick into emergency mode with calm, cool, collected thoughtfulness, putting your focus where it needs to be. This way, when under “pressure”, you’ll be able to make critical decisions with ease.

Phillips notes the “following checklist is used by Grand Canyon National Park Search and Rescue personnel prior to launching a helicopter medical evacuation:

• 1. Here’s what I think we face.
• 2. Here’s what I think we should do.
• 3. Here’s why.
• 4. Here’s what we should keep our eye on.
• 5. Now, talk to me.”

That’s a good checklist. You might not have the calm, cool time in the helibase hanger to go through this when an emergency is happening to your trip on the river, so before you leave Lee’s Ferry, some trips will identify a rescue team. That team should review the above checklist before your trip launches.

Emergencies should never be ignored until they happen. In fact, it is important to have discussed potential problems and assigned individual responsibility in advance. A common rule in disaster planning and recovery efforts is to "never go where you have not been before". Hospitals practice handling disasters and train so that everyone knows what to do, who stands in when one team member is not available, and who makes decisions. Likewise, one can avoid much of the risk in a river emergency by discussing real scenarios and working thru the role of each team member. By doing this in advance, the emergency is not a surprise to individuals but just one more team exercise. By the way, this is like insurance/just better - buying insurance is often associated with not needing it and no return on the investment, but your emergency exercises help build a team that will be friendlier, easily work together on day-to-day activities, and be more effective for the whole trip.

Your trip will be a small team of people. Teamwork will smoothly get you out of camp in the morning, get you through a rapid safely, and assist you in handling emergency situations.

Your trip might want to identify a rescue team leader and alternates. These folks would ideally be on different boats.

When there’s an emergency, the team leader (e.g. River Trip Leader, incident commander, assigned rescue commander, etc) must adequately communicate their intent and plans to other rescuers.

Good communication is essential. Anyone practiced in emergency rescue already knows the benefit of short clear communication.

The NPS uses “these five communication responsibilities for all personnel;

• 1. Brief others
• 2. Communicate hazards to others
• 3. Acknowledge messages
• 4. Ask if you don’t know
• 5. Debrief your actions”

As mentioned above, this is another good checklist for your emergency river team to have reviewed before the trip starts.

Take Care of Yourself

Have you heard this before?: “It’s an emergency, RUN!” We all need to keep in mind that when there’s an emergency, hasty decisions and shortcuts may endanger both the rescuer and the person needing to be rescued. If you don’t know how to swim, and you dive in to save someone without putting your life jacket on first, there may be two folks needing near drowning rescue breathing. It’s in these times of an emergency that you most need to take care of yourself.

Phillips cites the following river incident as “a case in point.”

“In the early morning of October 18, 2005 a Diamond River Expeditions concessions trip was camped at River Mile 192. At 4:45 A.M. a 78 year-old female commercial river trip passenger, accidentally fell in the Colorado River and was washed downstream, as she was attempting to return from the toilet in the dark. She had become disoriented, and fell in the river grasping the “help” cushion for the toilet and was immediately carried downstream in the swift moving 54-degree water.

“Miraculously her daughter-in-law, who was checking on her at the time, spotted the victim in the river with a headlamp on her head and began screaming for help. As the victim’s headlamp disappeared downstream, four employees of the Diamond River Adventures crew rushed to provide assistance”.

“Adam Bringhurst immediately donned his life-jacket, rushed downstream and dove in the river. Adam swam downstream arid got hold of the victim, while Mike Bork and Mike Wood responded by launching a raft downstream after Adam, in order to provide rescue support. The two boatmen located Adam and the elderly victim, after twenty minutes, one mile downstream. With the assistance of the other crew members, the victim was brought ashore and treated for possible hypothermia. Meanwhile boat man Mike Sampson had gone into the river in order to physically assist the distraught daughter-in-law.”

While you might want to have a pee container by your tent to avoid the midnight stroll to the river altogether (read more about this on the Hygiene and Personal Care page), it’s clear that quick action by all involved, especially the daughter-in-law, helped to save a life that night.

We can’t help anyone if we get injured or killed in the rescue attempt. Remember, it takes discipline to pay attention to your own safety first. Your safety is what’s most important. The second most important thing is the safety of your co-rescuers. When you and your co-rescuers are set and safe, then you can proceed with the safety of the person in distress.

Being Aware of the Situation You Are In

Phillips notes “As human beings we retain our prehistoric instincts that allow us to perceive when something “does not feel right.” Exactly what cues we are detecting through our subconscious is difficult to assess, but listening to our instincts can be a healthy survival tactic in emergency situations.” Trusting your gut feeling and proactively communicating with the other members of your emergency team requires an effort that may be lacking during an emergency.

Being aware of the situation around you is an important skill. Your awareness of the situation may be effected by your personal physical condition (when was the last time YOU ate or drank some fluids?), poor communication, and micromanaging a situation where you try to maintain control of too many things.

Phillips notes “Emergency operations are dynamic events. A patient’s condition may deteriorate or improve. High-risk environments, such as rescue operation, require us to gather information on a continual basis so that we can update our mental image of the mission. Failing to incorporate information from our surroundings causes us to employ a faulty mental image that could result in bad decisions. With an accurate mental image we are able to project into the future and play the mental “what if” of a current situation. This projection permits us to stay ahead of the situation being proactive rather than reactive.”

Be A Task Delegator

Have you ever seen a team leader during an emergency situation? The good ones are calm and cool, and delegate tasks to others. The emergency team leader is the “brains” of the operation, not the brawn. These team leaders will only rarely “reach the point of task overload.” These folks never place themselves in the role of primary care provider, technical rescue person, and communications commander. The emergency team leader oversees others, who do specific tasks. It’s like the conductor in an orchestra and the orchestra members. Everyone has their part, and the tuba player doesn’t try to play the tuba and the violin at the same time.

Phillips stresses that “There are limits to how much one person can do in a critical situation.” Take the time to assign tasks, make sure the assignments are clearly understood, and delegate, delegate, delegate when appropriate.

Communicating with the National Park Service

Grand Canyon National Park has a number of phone numbers that river runners will find helpful. If you are on the river and have an emergency and have access to a satellite phone, the Emergency NPS Dispatch number is (928) 638-7911. Remember, cell phones do not work on the river. The South Rim Park Dispatch number is (928) 638-7805, the Lee’s Ferry Ranger number is (928) 355-2232, and the Meadview Ranger Station number is (928) 564-2918.

For a one page Critical Communications Handout, click on this Critical Communications Handout link.

Does Your Medical Emergency Need A Helicopter?

On this topic, Phillips notes “Does the injury warrant a helicopter evacuation? If you find yourself struggling with the answer to this question, then you already have your answer. Do what is in the best interest of the patient. Some apparently minor injuries (e.g. eye injury, infection) simply must be evacuated to prevent aggravation. Err on the side of being conservative and evacuate early, rather than regretting your decision later.”

While the above advice is good sound advice, what should you do when you are not sure? How many days or hours are you from Phantom Ranch, Diamond Creek or South Cove? The decision to bring in a helicopter or not is one that ideally should be made by your medical team leader, with input from the others involved.

In serious medical emergencies, you will need to provide for immediate care of the patient. Phillips notes it’s important to “Stabilize their injury and document the care given. It is important to understand that if Cardio Pulmonary Resuscitation (CPR) is being performed on a patient at a remote scene, NPS paramedics will reach the site and conduct resuscitation attempts right there. The fact that the patient is not immediately moved toward the helicopter may cause concern, however the best chance of resuscitation will occur without unnecessarily moving the patient.”

When you contact the Grand Canyon National Park by satellite phone ((928) 638-7911) the dispatcher will get your initial information and then transfer you to the ranger who is coordinating Search and Rescue (SAR) incidents for the day. The single most important piece of information to give the NPS, in the event the call is lost, is your location. Phillips notes that “If the injury/situation is not time sensitive, then make phone contact during business hours when all personnel, including the pilot are in service.”

Helispot Tips

Phillips has the following to say about helispots: “Select a functional helispot. The helicopter requires a fairly level touchdown pad 15 feet by 15 feet and a safety circle 75 feet in diameter which is clear of major obstructions for approach and departure. If possible, wet down sandy areas just prior to the aircraft landing. Deploy orange panel markers in an “X” on the landing zone. In spite of the best intentions to secure these with rocks, there have been some close calls with panel markers being blown loose by the strong rotor wash from the helicopter. Remove the panel markers once the aircraft is beginning its final approach to your location. If you have a ground-to-air radio, advise the park during your sat phone call and agree on what frequency you will be monitoring (121.5 MHz is the standard emergency frequency).”

Once the helicopter is on the ground, work with the NPS crew, and always follow the instructions of the NPS helicopter team leader. You will need to transfer authority for the situation to someone outside of your group. If you have pre-planned for this, it will go smoothly. NEVER approach the helicopter. Let the occupants come to you.

For a one page printout on helicopter tips, click here on Helicopter Tip Handout.

Patient Transport

You may find you need to move an injured individual from an accident site to another location, say, closer to a landing zone. You will have to use your best judgment in deciding if you need to do this, but remember, don’t put yourself and or others at risk to move an injured person, especially over rough terrain. Phillips notes “An option for extrication of the patient from technical terrain may involve a helicopter short-haul rescue. This involves the use of a fixed rope attached beneath the aircraft.”

The NPS helicopter crews train in just this sort of thing. They have the skill and practice to get someone away from cliff edges, so your best option may be to make sure your injured individual is stable on-site, and let the professionals do the heavy lifting, or supervise you doing it.

If your injured person is stable and can be easily moved, by all means, you can travel downstream to a better evacuation location. You may find in speaking with the SAR shift team, the NPS may be delayed in arriving, and the NPS may direct you to transport the individual to another location if possible. Phillips notes that flying “out companions of a victim during a medevac mission is typically not an option. However, if weight and space permit, juvenile patients need to be accompanied by a parent or guardian. In the event of truly life-threatening injury or in the case of a fatality, a follow-up flight may be conducted to fly out the companion(s).” Remember, there is no hard and fast rule here, and every case is different.

You may find that your trip needs to evacuate a boat rower. If your trip can still proceed downstream, Phillips notes “ the evacuation may be delayed until a replacement boat rower can reach the South Rim, and be flown into the trip during the initial evacuation flight.” This is a common occurrence on concessions trips, where passengers without a guide's license are not allowed to row a boat with other people on it. You may want to cross-train folks on your trip, so that there’s a pool of rowers ready to help if a boat rower is injured.

Remember that, as Phillips points out, “NPS aircraft are only permitted to fly between one half hour prior to sunrise until one half hour after sunset. There is a dramatic increase in the risk associated with conducting a night flight into Grand Canyon. Although very infrequent, a night flight would be considered in the event of a “life-or-death” situation. In order to appropriately assess the situation, with consideration to the risk for the flight crew, NPS personnel will request very detailed information in order to make the best decision possible. Due to their capability with night-vision goggles, Arizona Department of Public Safety (DPS) Air Rescue would be the preferred resource to conduct such an evacuation. If the nature of the injury permits, a night flight will be deferred till “first light” in order to reduce the associated risk.”

On River Fatalities

Yes, it happens. Fortunately, you are at much more risk of dying every time you get into your car than rafting in Grand Canyon. Unfortunately, an on-river fatality will have a huge psychological impact on all trip members, acknowledged or not.

Phillips notes “Grand Canyon National Park SAR personnel go through a Critical Incident Stress Management (CISM) defusing session immediately following exposure to a fatality. Park personnel, who are trained as “peer counselors”, conduct such sessions. In the event of a river trip fatality, an offer will be made to bring a peer counselor to the scene in order to conduct a defusing session. This will help initiate the healing process.”

Please keep in mind that as with all fatalities, a fatality investigation will need to be conducted at the scene. This includes, according to Phillips, “bringing an investigator to document the incident and interview witnesses. If appropriate, consider keeping an accident scene as intact as possible. Prevent tracks, personal property and involved equipment from being disturbed or removed.”

In the event of a drowning where the individual goes missing, the NPS will conduct both an on-the-water and over-the-water (helicopter) search. Phillips notes this “will be conducted over several days and planned to coincide with the statistically likely days post-accident for a body to surface. If you are on a trip that encounters a body floating on the river, secure the body to the shore with a line and contact the NPS. This should be done in a manner that limits the visual exposure of trip participants to such a scene.”

This is important. In 2004, commercial passenger Paul Smith disappeared from his campsite at River Mile 118 on the Colorado River on Wednesday evening, September 8th. On September 14th, a concessions motorized tour-boat trip saw Smith’s body floating in an eddy. The trip notified the NPS of the body’s location, but did not secure the body to the shore, as the trip participants found the visual exposure upsetting. A non-commercial river trip arrived on the scene later, discovered the body, secured it, and notified the NPS. The non-commercial trip was surprised to find they were not the first ones to notify the NPS about the body. Unfortunately, this same non-commercial trip had suffered a fatality among their trip on September 5. To minimize the trauma of visual exposure to your trip, park in an eddy below if needed. You can then boat or walk back to the location and secure the body.

Psychological Emergencies

The NPS, who tracks these things, notes that the frequency of river-related psychological emergencies is going up. Phillips notes this may be due to individuals “with a preexisting condition (e.g. bipolar disorder) who stops taking their medications.” Regardless of what the cause is, if you have someone in psychological distress on your river journey, it is a medical emergency. You will need to keep in mind all the issues already discussed, like looking to your own safety and the safety of the other trip participants while staying as calm as you can. You will also need to decide if a medical evacuation is required. Keep possible weapons away from anyone experiencing a psychological emergency, including lifejacket and kitchen knives.

When and if it becomes necessary to helivac anyone from a river trip in an altered psychological state, Phillips notes that prior “to loading such a patient on a helicopter, they will be well restrained and secured to a backboard. This is to prevent a violent event from occurring in-flight. In the situation warrants, the patient can he sedated with medication prior to an evacuation.”

Let’s recap what we’ve covered. Remember to:

• Pre-Plan.
• Work as a Team.
• Communicate.
• Take Care of Yourself.
• Be aware of what’s going on around you.
• Delegate.
• Transport folks only if you must and it’s easy.
• Helivac if you need to.
• Train people on your trip to be able to handle multiple skills.
• If you have a fatality, peer counseling is a great idea.
• Remember that a psychological emergency is an emergency.

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