Education is fundamental to the future of helicopter emergency medical services (HEMS) and how it is received is critical to the individual learner (Bassett, 2018). Some of us learn best through reading, watching videos, reviewing PowerPoints, or listening to podcasts, etc. I learn best through doing, putting my hands on a patient, using the equipment, and performing an intervention regardless of how I receive it, for example, high-fidelity simulation or a cadver lab. This blog will highlight the first hand, hands-on approach to education while learning survival and safety training in Guatemala.
The last several weeks have opened my mind to the things that cement education into our memory. For instance, a Heavy Lies the Helmet (HLTH) podcast recently discussed the benefits of high-fidelity simulation and how it translates into better clinical practice when performed correctly (Kiernan, 2018). Another podcast that explained how we exchange information and learn from one another. Finally, a better way to write blogs so that the people reading stay focused and get the most from our hard work.
Guatemala and the Why
The point of all this is that over the next five days I am going to be in Guatemala City for an educational aircrew retreat we are calling Guatemala Educational Aircrew Retreat (GEAR) 2019. This is expected to be an experience in education like nothing I have ever done before, and I am so excited.
HLTH podcasters and owners, Mike and Bryan Boone invited me to come along with them as a part of their team to learn helicopter safety, survival training, external cargo operations, rappelling, and underwater egress. We are fortunate enough to get this training from one of the most influential names in the business – Chris “Razor” Sharpe of Black Wolf Helicopters a man with gobs of real-life experience and an understanding of what it takes to do this job not only safely but efficiently and effectively.
“Razor” has been a helicopter aircrewman for decades. He has likely forgotten more about the business than many of us will ever know. Moreover, is his connection with HLTH as their Chief Safety Officer and blogger. Furthermore, his safety record has been highly regarded by some of the biggest names in helicopter aviation, including the Helicopter Association International Safety Award.
“Razor” was an aircrewman for the British Navy and has been kind enough to teach us the skills he learned over the years in the next few days to ensure we are safer crew members within our own programs but are also more competent and confident crew people. I want to take a moment to thank him personally and look forward to more adventures in the future.
I want to provide you, the reader with my experience and what I learned as a part of this opportunity. My goal, to illustrate a play-by-play if you will, of how this experience provided me with new ideas, new skills, and lessons that can only be learned by doing; and maybe teach them back to my colleagues so that they too have an understanding about how safety and survival education is necessary, skills just like airway and ventilator management we learn in the HEMS and critical care transport world.
Countdown to GEAR 2019
Tomorrow we depart for Guatemala, and so far, I feel like it has been an excursion even before leaving. I have had to prepare in so many ways. For instance, purchasing a flight helmet to use while down there. Locating a physician to provide me with the vaccination needed to prevent typhoid. And preparing for the moment, I first rappel from a helicopter. Very exciting and anxiety-inducing are the only way I can describe the feeling. Similar to ones I had the first time I worked as an EMT in an ambulance, or the OR attempting my first intubation.
That said, it’s day one – travel day. I’m up early (4 am) preparing coffee and going over my list one final time (I’ll go over it again twenty more times before I walk out the door). I plan to wake my wife up and have a cup of coffee with her and make our way to meet up with the HLTH team for the drive to Chicago. We fly from O’Hare to Dallas and then to Guatemala City. Altogether approximately 12 hours travel time; so much fun, not really. Long flights almost always make me a little more tired than usual.
Wow! I have been to many places around the globe, but Guatemala City is set in what appears to be a high valley, surrounded by towering hills, maybe mountains. A lot and I mean a lot of traffic. We saw at least one motor vehicle crash and perhaps another on the way to our house for the week I will call the “casa,” when in Rome.
After arriving at the casa, we settled in and performed a live feed video to preface our trip down here. Razor discussed our training, which will include basic helicopter safety, rappelling, survival, and underwater egress training. He implied we might not like him after the survival portion of the training. We stayed up chatting about education platforms for a couple of hours, brainstorming ways to improve our collaborative and disseminating education. It was a bonding experience.
Day One August 22nd
This morning I woke to the sun beaming through my window at 0551. Outside the window, the sun coming up over the mountains and homes off in the distance. It is a beautiful view. Keeping quiet not to wake everyone else I cleaned up so I could get to writing this blog. The plan is to leave around 9 am and head toward to heliport for our first day of training. The goal absorb as much safety-related education as possible and try to find ways to use it in practice. This is going to be a fun, engaging, life experience.
Training day one was eventful. We started by “trying” to learn the lay of the land. Eventually, made it to HeliSOS and spent the morning, long into the afternoon discussing topics related to crew resource management, ditching, survival, physically went over the helicopter and its gear, and finally fundamentals of rappelling and short hauls/external human cargo operations. Great experience again, and what I am taking from this will be beyond beneficial.
What was unofficially learned was the meet and greets with our Guatemalan City colleagues who staff ambulances but also motorcycles equipped with essential gear like and in some cases better than what I currently have access to on an ambulance in the states. These men and women were highly trained and passionate about the EMS profession the same way we all are it was a humbling experience.
I also chatted with Jason Stopper, a paramedic who works in rural North Carolina and enjoys prehospital education as much, if not more than I do, turns out he and I became fast friends. His goal is to be a flight medic one day and took it upon himself to come down to Guatemala for this experience. At dinner Jimmy “Jungle” (also a friend now) a remote search and rescue technician (SAR) who lives in the jungles of Peru showed me his chest rig that he carries on the helicopter and in the jungles while on SAR missions; needless to say, I was impressed.
What I was more impressed with was his knowledge of medicine and his understanding of providing prolonged field care to patients days (some cases more than four) away from any truly defined hospital. Both people are providers who continue to push the boundaries of prehospital medicine while continuing their education by collaborating with others and taking the time to listen and learn about the profession from all angles.
Day Two August 23rd
The next day we woke up early and preparing for external human cargo operations. This was to be the highlight of our trip, and it was worth the hype. Once we ate and made our way to the Land Rover Defender painted in EMS colors with the Servicios Medicos Emergencia logo on it, we rode approximately 20 kilometers to the staging site where the helicopter was to meet us.
The Land Rover struggled in the heat due to some mechanical issues but ultimately got us to our training location. The site was gorgeous, a hacienda with the Guatemalan mountains set in the backdrop. Once the helicopter arrived (a Bell 206 perfectly maintained and painted with a canvas of colors) we got right into our briefing and safety training for the rappel. This is included the basics and the repetition of what needs to be done to rappel from a helicopter 150 meters above the ground safely. Oh, and I have to say Capt Edras Barrera, Chief Pilot, is fantastic, his skills were phenomenal.
A few dry runs, the order of who would go with who, and a lesson on harness safety and we were all ready to go. We watched Chris Gibson (Gibo), a flight paramedic with a laundry list of skills in (SAR), a critical paramedic, and more things than I can count, perform the first rappel and then it was our turn. Gibo is also the founder of the SOS Medicos Servicios in Guatemala, an ambulance company that staffs critical care ambulances with registered nurses and paramedics.
Somehow, I ended up in the second group but managed to be the first trainee to rappel. All I can say is that you think differently after being in a helicopter with the doors removed lifting knowing that you are about to jump with just a rope holding you to the aircraft. A ground skid is no longer a ground skid 150 meters hovering above the Earth.
We all made it, and our adrenaline spiked, morale was high, and everyone felt terrific. We learned about extracting patients from difficult to reach areas and performed a short-haul with a simulated patient in the litter. You do not realize the importance of communication until you are hanging ~1000 feet above the ground flying over mountains and not having the ability to talk. It was a great experience, and I look forward to learning more about this in the future.
Day Two, Part Two, Survival Training
The survival portion of our training came in two forms, classroom (which occurred during day one), what I discussed earlier and the actual hands-on training in a “jungle.” We literally had just finished the external cargo operations portion of our training and moved to the jungle for a brief, gear check, and the expectations from us during our survival training. We started with about an hour a daylight remaining and the potential for rain. We could carry whatever we usually carry in our flight gear and ten additional items we were allowed to choose before we walked into the jungle.
List of items:
- Rappelling Rope (13mm, I think – about 50 feet in length)
- Plastic bags
- Blue tarp
- Chlorine tablets
- Pot (for cooking and shuttling water)
- Mylar blanket
- Duct tape
- I might be missing one
And the gear we carried, if any at all.
Then we were off! Making our way through the hills covered with volcanic rock debris and high brush. We simulated where the aircraft was hypothetically landed for a “mechanical failure.” The instructors then left us to the jungle. This is where we realized that surviving is not as simple as it sounds. Simply locating shelter close enough to the aircraft was difficult. We needed to find a location that would protect us from rain and wind but also insect and snake population on the jungle floor.
Once we decided on a tree to shelter next to a plan was made to begin building and start a fire. There were six of us, and we split into teams of two. Two worked on the shelter — two on fire and collecting kindling and wood. And two on finding water. The plan went okay, but we ended up changing course slightly to ensure that we had left a signal with the tarp we chose from the list provided to us, for our to be rescuers. Bryan Boone made a fantastic signal from the tarp we elected to use for shelter but failed to inspect, it was rotted and unusable, so he decided it would be utilized as a signaling device. He fashioned an arrow from the tarp, pointing in the direction of our shelter.
We gathered firewood, worked on the shelter, and searched for a water supply. The fire was started quickly with survival items from Chris Smetana’s survival equipment. He supplied some petroleum-soaked cotton balls and a simple lighter that worked perfectly. Without that, I am not sure we would have made fire as fast as we did. And we needed it, bad. Not only does fire boost morale, but it also provides heat, a cooking source, a natural insect repellent, and a signaling device.
The shelter came together quickly with the dedicated work of Jason Stopper, Bryan Boone, and Jordan White. They used the machete to cut down wild cornstalks (probably not native) and laid the leaves and stalks across the rappelling rope tied between two trees. In between the stalks, they placed the Mylar to decrease heat loss and a secondary layer from rain and insects.
After the shelter was up, we focused on finding a water source which ultimately came from puddles of rain that had occurred hours earlier. It was not clean to drink straight. We discussed filtering, chlorine, and boiling. There are some nuances to when to use the different methods that can be addressed later, but the most important thing to do is locate a source, macro filter it, and boil it.
We were fortunate that we had the corn we also found limes and prepared a concoction of corn chowder with lime. It was cooked with water we had in our gear, but mainly corn and lime juice. Definitely not a five-star meal but it did the job. Not only did the meal help with morale, but it gave me a little more energy to keep working through the night. After dark, the insects started to get heavy, and our moods began to worsen, the fire helped, the conversation was helpful, but all things said, it was not pleasant. Eventually, we were rescued and allowed to take down our survival camp and depart the jungle. We debriefed and made our way back to the casa.
Day Three August 24th
Shallow water egress training (SWET) or as I prefer to call it “sweat” training was the final exercise in our training. We had expected a break between the jungle and the trainer, but “Razor,” who was assisted by Mario a Guatemalan Airforce Huey pilot and Jimmy Jungle, had different plans.
The day started with a short wrap up from the night prior, and then we headed to the pool. The trainer was a custom-built contraption that mimicked a helicopter seat made from polyvinyl chloride (PVC). It looked as if it would do the job. If I understand, correctly, the purpose of the trainer is to prepare aircrew people for the possibility of a water landing and improve their chances for survival. I am an above-average swimmer with experience in water egress training, yet it still induced anxiety in me. This anxiety could be the reason people fail to egress and ultimately drown, and this fear is not uncommon, at least according to one case report (Brooks, Gibbs, Jenkins, & McLeod, 2007). But I digress and feel like I should elaborate more on the training we received.
We started with simple techniques that were repetitive to get us familiar with our gear and the pool. The water was not warm, and this was a swimming pool so I can only imagine was it would feel like to land in a body of water colder and suddenly be immersed, talk about mammalian dive reflex. First, we jumped into the pool with all our gear on and treading water for approximately 5-10 minutes. After we were instructed on floatation devices and again sent back into the pool to tread water and swim with the personal floatation device, after that, we discussed larger flotation devices, like inflatable rafts and then back into the pool for learning to right the raft and board it properly. Like I mentioned previously, I have done this many times, but it still is never as easy as you think it will be. We struggled a bit and the raft filled with water, and this was great because I believe that people believe a raft will appear and save them, not the case, practicing is what builds the “currency, competence, and eventually confidence.”
The trainer was placed into the water, and one by one, we took turns being flipped and dunked only to attempt an escape from the trainer. This looks easy, but with water rushing up your airways, it can be quite an event. That said, we seemed to make it through okay and learned that the most important one could do when faced in an egress situation is to remember to remain calm, brace for impact, close your eyes, find a reference point, and once all movement has stopped remove your buckle and egress the helicopter. I found that reference point and never let go, it was literally life-saving. I am not more confident than ever, and I feel like this training has helped my mindset. We went through a series of 180-degree twists, 360 turns, and then a washing machine style dunk, which was exciting but amazing for training.
We were allowed to a short break and then educated on helicopter emergency egress devices (HEEDs), also referred to as STASS bottles. These are devices that will enable the crewperson a minimal amount of oxygen to get to the surface of the water and save lives (North Atlantic Treaty Organization, 2001). One thing I did not realize was that breathing through one takes practice, merely placing it in your mouth and breathing is not a piece of cake. To effectively breath through it, you must be able to close off your nose and breathe only through your mouth, well, that is not so easy. However, after some practice and encouragement from “Razor,” we were ready for the egress portion.
Back into the trainer for a final washing machine dunk with the HEEDs bottle and we were done. What I noticed was a little less excitement and more anxiety from the group. However, every single one of us made it through. My personal experience was to repeat the steps that “Razor” so eloquently stated throughout the drilling; brace, reference point, wait for no movement, and egress. I added one thing, and that was to hold my nose to keep water from rushing in, but other than that, I made it through the training and felt terrific. One thing that is fact, this training improves survivability regardless of how often it occurs, I do not want to be a statistic and if I am a survivor (Hussin, Wang, & Hipnie, 2012: Callahan, 2014; Black, 2018)
We debriefed, cleaned up the gear, and decided to have a meal. Which I felt was well deserved. We were on top of the world. Everyone had made a massive leap from being just a passenger to becoming a crew person. This may not mean a lot to the average reader, but a crew person is a critical component of the flight team, and according to our instructors, make pilots feel more confident in sticky situations. This was one of my last nights in the city, so we enjoyed ourselves, and the team helped me to celebrate my 40th birthday.
Day Four August 25th
The next morning, we woke up later than usual (everyone else did) I woke up at my routine 5 am. We hung around the casa until noon and took a local bus to meet Jimmy and Jason for lunch. After lunch, we returned to the casa, and the Boones, Jordan, “Gibo”, Jimmy, and Smetana got to podcasting. Jason and I decided to walk around and talk shop we discussed the similarities of rural and urban paramedics and how we would love to come back to Guatemala for follow on training. The night ended earlier than usual so that 4 I could catch a ride with Jordan and “Razor” to the airport. Jordan’s flight departed before mine, so I slept for a couple of hours at the ambulance station and called an Uber for a ride to the airport. Saying my final farewells to the city that I learned so much about survival, safety, teamwork, and myself.
Day Five August 26th
My plane departed around noon, and I finally landed in Indy 10 hours later ( a brief customs layover in Miami). My wife met me at the airport and had prepared a meal for me, which was terrific. We ate, I showered, and went to bed without any worries about the next day but still missing the comradery of the trip. Now I had to focus and get a blog out for all you to read. What started as an adventure ended with “currency, competence, and confidence,” I look forward to passing this information on to my colleagues and preparing them for the unknown.
Wrap up, so in conclusion, here is what we learned. Accidents do occur, and they are almost always caused by human error (Taber & McCabe, 2006). They are avoidable with proper preparation, which includes quality prechecks, checklists, and training. If they are unavoidable, preparing for the worse increases the chance for survival; whether that be on land or water. Carry a survival kit, remember to stay near your aircraft if on land, start with building shelter or finding protection. Remember the rule of three’s ; three seconds to make a bad decision, three minutes without oxygen, three hours without appropriate protection from the elements, three days without water, and three weeks without food, so stop and think about priorities. Build a shelter and do not expend too much energy doing so, a simple lean-to will suffice. If you have water and food use it, it helps with morale and provides energy. Rationing food and water is not a bad thing it is something to discuss and consider when determining how long you will be stranded.
Focus on the priorities, prepare for all situations, and never be afraid to slow down and think through your decisions. Three seconds is fast and making a wrong choice might end up with you being dead. I now know that this trip was more than just a vacation it was an educational experience that taught me about mitigating risks but also surviving on the most basic principles, and I suggest if you have not taken a course like this, you do so. Remember “Razors” quote “currency, competence, and confidence.” I will not explain the meaning, but instead, allow you the opportunity to think through what it means. That said, I have had the currency, now I have the competence and far more confidence than I have ever been.
Education is a critical component of our jobs in the HEMS environment, and it does not always revolve around vents and blood gas interpretation. Being a part of the crew can prove instrumental to your success and maybe one day your survival. However, I hope what you take away from this is that mitigating risks by preparing for the unknown you can build an active safety program. Discuss what is essential to carry in their flight suit and remember terrain, weather, season, and resources all matter. However, never be afraid to say no to going on a flight you feel is less than safe.
I look forward to hearing from you all and hope that the impact I received has been impressed upon you as well. One final note, pre-briefs and debriefs are essential components of the process, so please utilize them in your day-to-day missions (Allen, Reiter-Palmon, Crowe, & Scott, 2018).
Shout Outs to the Crew
One final thanks to Mike and Bryan Boone the brothers who took me in as one of their own and allowed for me to participate in this great excursion. Chris “Gibo” Gibson the legend, you will just have to meet the man to see what I mean (SOS Medicos Servicios and RED MED Podcast). Chris Smetana the business man with a heart of gold and a paramedic with more knowledge than I care to admit (IA MED). Jordan White the former EMT-I and current Flight RN who seemed to be plagued by bad luck the entire trip, his new nickname “Spider Bite” (HLTH’s After the Call Podcast). Jimmy “Jungle” for being a friend, survivalist, educator, and more importantly, saving us from my poor Spanish nearly every day. Jason “The Crime” Stopper, my new found amigo and paramedic, he has an uncanny ability to befriend everyone. Mario a Guatemalan national and Airforce pilot who was essential to our SWET activity. Last but not least, Chris “Razor” Sharpe for everything he did for us over the last week, without him none of this would have ever happened. “Razor” thanks friend, shipmate, and all around good guy for being the sport you are.
Allen, J. A., Reiter-Palmon, R., Crowe, J., & Scott, C. (2018). Debriefs: Teams learning from doing in context. American Psychologist, 73(4), 504-516.
Bassett, J. (2018). Air medical services: What does the data show? EMSWorld (August 2018).
Black, D. (2018). Army’s underwater egress training aims to improve survival rates. Retrieved from Army: https://www.army.mil/article/208314/armys_underwater_egress_training_aims_to_improve_survival_rates
Brooks, C. J., Gibbs, P. N., Jenkins, J. L., & McLeod, S. (2007). Desensitizing a pilot with a phobic response to required helicopter underwater escape training. Aviation, Space, and Environment Medicine, 78(6), 618-623.
Callahan, M. (2014). Marines increase survivability with SWET. Retrieved from Marines: https://www.mcbhawaii.marines.mil/News/News-Article-Display/Article/540255/marines-increase-survivability-with-swet/
Hussin, M. F., Wang, B., & Hipnie, R. (2012). The reliability and validity of basic offshore safety and emergency training knowledge test. Journal of Kind Saud University – Engineering Sciences, 24(2), 95-105.
Kiernan, L. C. (2018). Evaluating competence and confidence using simulation technology. Nursing, 48(10), 45-52.
North Atlantic Treaty Organization. (2001). The requirements for an emergency breathing system (EBS) in over-water helicopter and fixed-wing aircraft operations. Cedex: NATO.
Taber, M., & McCabe, J. (2006). Helicopter ditching: Time of crash and survivability. Safe Journal, 34(1), 5-10.